Placebo Rocks

Apparently, results of a recently published study* suggest that placebo works (sometimes) even when the patient knows he's getting (only) placebo.

So...

How did they measure compliance? serum placebo levels?
Maybe patients just have to THINK you're a doctor. This could end the physician shortage.
Can we compare placebo to psychotherapy?
Does it work with kids? at what age? by proxy via parents?
Works for what? If you give a patient placebo for one illness will it cure a concurrent illness a well?
Placebo effect apparently varies, eg I recall ~60% for Germans ~30% for Brazilians. Will these distinctions hold?
Have we discovered a "psychological marker?" Response to placebo means it was "all in your head?"
Will Medco require prior authorization for placebo prescriptions?
Will we have to wait seven years for generic placebos?
Will manufacturers of placebo pay leading physicians to use their names on ghost-written publications that exaggerate benefits and play down risks?
Will physicians consider it ethical to accept pens and free meals from placebo reps?
Will placebo sold on the street be cut with other materials to increase profits for dealers?
Will Teva generic placebos work as well as or better than other generics?
Will over-the-counter placebos work as well as prescription placebos?
Will emergency rooms be flooded with placebo overdoses?
Will placebos effectively treat drug addiction? Internet addiction? Addiction addiction?
Will placebos effectively treat drug withdrawal?
Will people become addicted to placebos? (Placebo Anonymous?)
Will placebo work if you don't know you're taking it? if someone puts it in your food without your knowledge? Will placebo become the new date-rape drug?
Will there be a new spate of DUI (driving under the influence of placebo) offenses?
Will spies carry suicide placebos to use if they get caught?
Will insurgent groups use money from illicit sales of placebo to finance overthrow of regimes?
Will we need a PEA (Placebo Enforcement Administration)?
Will natural placebo be safer than synthetic placebo?
Will we be able to treat allergic reactions to placebo with another placebo?
Will placebo work better if you smoke it instead of eating it in brownies?

*Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E, et al. (2010) Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLoS ONE 5(12): e15591. doi:10.1371/journal.pone.0015591

Is It Time to Give up on the Phone?

I wrote before that mental health professionals must not rely upon cell phones for handling emergencies. Now I wonder whether we can rely upon them even for routine communication with patients, and I have an idea that other technologies may provide a solution. In just one day, yesterday,

• after I thought I left a message for a patient who wants to schedule an appointment he called again to say he knew I called but did not get a message,
• after a patient failed to appear for an appointment I tried to leave a message but an automated voice told me the mailbox was full,
• when I tried to call a pharmacy to order a prescription for a patient who had just left the office I got a fax handshake: beeeeeeeeeep. I left a message on the patient's relative's voice mail asking for another phone number or some other way to identify the pharmacy, but 12 hours later there was no return call.

Then there's,

• Aliens abducted my cell phone.
• I dropped my phone in the toilet.
• My voice mail got wiped out.
• They turned off my phone service because I didn't pay the bill.

I have resisted using email to communicate with patients so far, but I believe the time has come for me to stop bucking the trend. Snail mail is too slow. We can't rely on telephones, cell and otherwise. I believe the solution lies in diversity. Sure, there are problems with email. There are also problems with videoconferencing and texting. But if I fall back on one when the other fails, I dramatically increase the likelihood of success. 

Here's an example. Often when attempting a video-conference contact with a patient we have audio problems. First we can use the texting capability of Skype to discuss the problem and arrive at a solution. Then we generally just pick up the phone while using Skype for the video only.

Technological complexity can cause problems, but it can also lead to solutions. Now for the hard part: getting it all set up and rewriting my patient treatment agreement to lay out all the rules. I'll need a new email address that uses the domain of my practice Web, which is on Google sites, which means I'll need a new POP account... Oy.

Who Wants to Be a Sporkiatrist?

As I joined in yet another debate over the extent of the tragedy of psychiatrists who have relegated psychotherapy to non-physician professionals and restricted their practices to the now infamous "med check," an analogy occurred to me. The spork represents the combination of two perfectly good eating implements, the spoon and the fork. Each of these does its job quite well, but by combining them you can achieve one-stop-shopping, at least a small advantage.

The spork compromise, however, leaves you with an inferior spoon and an inferior fork, not to mention that you can't take along a 3-tine vs. a 4-tine fork, or a smaller or larger spoon. You are stuck with the design of the implement. If you lose the spork, you've lost both implements, while if you had brought separate tools, you might still have one. You are not likely to ever need to use a spoon and fork simultaneously, but those tines make for a leaky spoon, and their stubbiness makes for a decidedly inferior fork.

And so it goes with psychiatry. Some patients and their psychiatrists will find the combined approach suits them best. For the rest, independent professionals offer decided advantages.

More ad nauseum:

The Sporkiatrist Tries to Do Psychotherapy

The Real Reasons Psychiatrists Want to Provide Psychotherapy

Unhinging Dr. Carlat

Personality Disorders Aren't

Before I comment on his article published in the New York Times, a word about psychologist Charles Zanor and how he is treated by the Times. His byline gives his name with no prefix or degree. In contrast, when he refers to John Gunderson, whom I believe has an M.D. degree, if not a few others, he writes "Dr. Gunderson." I had to Google Charles Zanor to confirm that he too has a doctorate degree, a PhD. Not only do I believe it is disrespectful of the New York Times to omit any reference to this, but I believe readers, myself included, also may want to know whether he has a doctorate degree or a lesser degree, perhaps even whether he has a PhD vs. an EdD or a PsyD.

Having said that, I disagree with much of what Dr. Zanor says in his article. He comments on another article reporting on the apparent direction of the committee addressing personality disorders for the upcoming DSM-V. He describes abandonment of the current 10 defined personality disorders in favor of a "dimensional" approach. He also describes Dr. Gunderson's opposition to this direction.

Dr. Zanor makes some good points, but he fails to adequately address two aspects of this problem. Personalities exist on a continuum of traits, and whether one's personality is labeled as disordered or not depends on where we decide to draw an arbitrary line. Under the current system a clinician makes a judgment call about the degree to which an individual's personality traits interfere with his functioning. Compare this to judging "how pregnant" a woman is. Unlike in "diagnosing" pregnancy there is no bright line.

Having decided to classify the patient as personality disordered one may then attempt to pigeonhole them in one category or another. All individuals with narcissistic (or other) personality disorder do not necessarily display the same pattern of personality traits. One individual may also display some dependent traits while another may display some obsessive compulsive traits. However, generally the narcissistic traits dominate the clinical picture. It's comparable to skin color. Nobody is really just black or white.

Dr. Zanor also errs in referring to "syndromes" of traits. Syndromes are collections of symptoms. Ill people complain of symptoms. Most people with personality traits (We all have them.), even the self-defeating ones, don't complain about them: "Help me doc. I've been feeling really generous for the last few days." or "Gee doc, I've noticed my speech is 'impressionistic and lacking in detail.' Do I need surgery?" Syndrome implies Axis I in the DSMs, at least from III on.

So despite what Dr. Gunderson says, a dimensional approach is more intellectually honest. And what difference does it make anyway? Nobody really believes any medication effectively treats a personality disorder. Imagine the FDA approving moxapoxatoxatine for the treatment of Avoidant Personality Disorder. Most don't believe psychotherapy works very well either. I suspect only the psychoanalysts care, and they probably approach every case the same way regardless.

Some addiction psychiatrist once said AA was the best treatment for personality disorder, and I tend to believe it, but you can bet that AA doesn't care how you classify them either.

Suicide by Any Other Name

The thought of suicide makes mental health professionals even more uncomfortable than it does lay people, probably because we associate the act with personal failure, having bought into the myth that we can and should somehow control this tragic behavior in others, that we are responsible. When you hear the word today you will most likely think of Muslim extremists on the other side of the world or mental illness in your hometown, yet if you consider the films listed on this suicide page you will be hard pressed to find more than a few that depict either context. And unlike the self-immolation practiced by the Vietnames Buddhist monk as filmed in Mondo Cane 2, Muslim extremists generally murder others in the bargain.

Suicide: Abstract, technical and clinical, the term suicide, like the term homicide, is a euphemism which distances us from the stark gravity and emotional impact of the act.

Committed Suicide: When we say "committed suicide" we imply killing oneself constitutes a sin or crime, stigmatizing the act, the person who acts, and mental illness, if it seems likely to have played a role. We should avoid this term.

Died by Suicide: If I play linguist it seems to me that the preposition "by" here requires an object that implies some kind of method or action. For example, died by drowning or died by gunshot. Similarly one cannot say "died of suicide." Use of the word "of" requires a disease as in "died of cancer" or "died of malaria." Use of the word "from" might work for either as in "died from heat stroke" or "died from a fall." An actor might also follow the word by, as in suicide by cop. But is that really suicide?

Ultimately, however, I believe redundancy prevents "died by suicide" from working: the word suicide already includes and implies death.

Suicided: Technically the word may be used as a verb, but I find this awkward. Imagine saying, "She homicided the man accidentally." Perhaps the fact that homicide requires a specified object while suicide implies the object explains the difference. One cannot suicide anyone else, but homicide requires a victim. Which brings us to:

Victim of Suicide: Somehow "victim of homicide" is more comfortable, but constructions starting with "victim of his own" occur commonly, in keeping with our all too frequent self-defeating behaviors. Still, we think of victims as passive, and the idea of killing oneself implies intent.

Completed Suicide: This term belongs only in discussions contrasting it with "attempted" suicide. Otherwise the word "completed" is redundant. Imagine a "partial" suicide. Similarly:

Successful Suicide: Is this not a contradiction in terms? We generally view suicide as a failure, perhaps the ultimate failure, but of course the word "success" refers only to the act itself.

End His (Own) Life: Another euphemism, like:

End Her Life by Suicide: This construction suffers from the same problems as died by suicide, although perhaps somewhat less redundant. However, it does imply active intent.

End It All: Even more of a euphemism.

Kill Himself: My favorite, this phrase is stark and direct. It pulls no punches.

Take Your (Own) Life: Introduces the idea of taking something away, but too often the life is taken away from friends and family. Although one can certainly take someone else's life, even omitting the word "own," in the absence of another specified actor we generally understand this to imply suicide.

Die By Your Own Hand: Quaint.

Suicide by any other name is still suicide.

DEA Buprenorphine Audit Animated

Digital Diagnosis Duo for DSM

I have found that turning ideas upside down often leads to truth. An example from my personal experience follows while another pokes fun at those who thrive (and even profit from) labeling any activity they deem excessive an addiction, then claim to offer treatment for it. (Nothing here should be interpreted as making fun of anyone who suffers from any psychiatric or substance use disorder or any professional or program intending to help such individuals.)

Digital Gaming Aversion Disorder (DGAD)

About two years ago, while sitting at my desk, I realized that there was really nothing I wanted to do. A friend had been playing solitaire on her computer, and that was all it took to get me going. Within a few days I was hooked. Almost every time I got done with whatever computer task I had been engaged in, I started playing solitaire. After a couple weeks I realized my skills were improving gradually. I began to develop winning strategies. Maybe I wasn't addicted yet, but I certainly might have been headed in that direction.

Then one day I noticed that some of the pleasure had gone. I almost had to force myself to finish a game. Next time I thought about starting another game I simply could not do it. I have not played solitaire since. When I see my friends playing, the screen looks totally two dimensional, unlike previously when it was as though I could see into the game. I cannot even imagine myself starting a game. The thought of how it works, the different suits, the different colors, the different numbers, all are blocked from my mind.

To be honest I cannot say this has interfered substantially with my social or occupational functioning. I cannot say that I am particularly distressed about this aversion to solitaire. However, should I want treatment, I have two approaches to propose, both probably requiring double blind studies to prove their effectiveness.

Psychotherapy of Digital Gaming Aversion Disorder

Cognitive behavior therapy will be the first line psychotherapy for this disorder. I believe a sufficient and appropriate reward will quickly overcome the aversion. I suggest rewarding the patient with $1000 for each game played to conclusion will rapidly reverse the aversion. I of course expect this to be covered by medical insurance.

Pharmacotherapy Of Digital Gaming Aversion Disorder

I believe a similar approach to that proposed for psychotherapy will lead to rapid resolution of this disorder using cocaine as the first line agent. A small dose after completing each solitaire game should lead to rapid resolution.

Digital Media Avoidance Disorder (DMAD)

For years now people have admonished those who, in their minds, use computers and/or the Internet "too much," calling these behaviors, like almost any other behavior they can label excessive, "addiction." It occurs to me, however, that those who engage in this "addiction addiction" simply want to deflect attention from their own dysfunction. This clever but pathological strategy, based on severe denial, has enabled them to avoid needed treatment, often for many years, for the condition I address below.

Today we must all face the fact that we can only experience true reality through digital media, using devices like computers, smart phones, and other devices, regularly, if not continually, connected to the Internet. Avoidance of this reality can be compared to intoxication with drugs or alcohol, which we all know provides an escape for the user who wants to avoid the realities of day-to-day life.

To address this problem first we must confront the denial, rejecting the notion that we can experience reality without digital media. This dangerous idea will certainly lead to impairment of social and occupational functioning and probably distress as well. In particular, avoidance of social media can lead to digital social isolation. A disturbing percentage of the population may have never communicated with another person via email or texting with resulting alienation from digitally connected friends and family!

Treatment of Digital Media Avoidance Disorder

Due to its similarity to chemical dependence, treatment requires admission to inpatient rehabilitation where a holistic approach involving staff of numerous disciplines will immerse the patient in (digital) reality with gradual elimination of escape into non-digital media euphoria. Cell phones with non-removable ear buds will start the detoxification process. Only in the first hours will staff allow patients gradually diminishing access to analogue devices such as harmonicas, nose whistles, and, for more severe cases, ukuleles to ease the transition. At first specially trained staff even engage in face to face conversations with them. Motivated patients will work the (binary) 1100 step program. They will gradually learn that  ordinary feelings associated with life in the real digital world are normal and they they can tolerate them or even to appreciate them, that feeling them affirms life. They will learn to turn them over to Google (as they know it, their higher power). Patients who can tolerate tweeting and blogging while simultaneously listening to streamed audio, playing computer games and shopping on ebay will participate in a ritual upload to YouTube of a digital video showing their dysfunctional pre-digital escapest functioning followed by scenes showing them leading a fully sober digital life one virtual day at a time. They are ready for discharge. Most will continue working the binary 1100 steps in video-conference meetings for years after discharge, starting with 1001010 meetings in 1001010 days. After working the program for a year or more, some individuals can play World of Warcraft non-stop for 11000 hours without face-to-face contact with another human. Rarely do such individuals relapse.

Short Psychotherapy

No, not "short term," short, as in short sessions.

Who says psychotherapy requires 45-50 minute sessions and a formal commitment? Although I cannot claim to know the history I suspect the almost-an-hour session originated with psychoanalysis, and the 45' session allowed psychotherapists to pack more patients into a day, and make more money. Modern psychiatric visits started out as psychotherapy sessions. The medication management piece snuck in slowly and now threatens to take over entirely. Despite the numerous advantages of independent provision of medication management and formal psychotherapy a compromise model offers a few advantages that might quiet some of its critics.

Since I ostensibly stopped offering psychotherapy I have noticed that the patient and myself often wander off the subjects of symptoms, medications and side effects, and almost as often I yield to the temptation to offer a systemic intervention, even when I know the patient is "in" psychotherapy in the more formal sense with a non-physician professional.

When I reflect, I realize this is nothing new. My family systems perspective lends itself to this less rigid approach to psychotherapy. I have done this all along. There is no real contract. Patients appreciate it, possibly partly because it's one-stop shopping and I charge no more for the added time.

There's always that dilemma over whether to charge a flat fee whether the visit lasts only five minutes or requires twenty five. The payer, whether a third party or the patient herself, likes to know in advance how much any visit will cost. I don't like to have to worry about whether the patient can afford an extra ten minutes with me. Besides, my fee always covers much more than actual time with the patient: office rent, staff, billing services, postage, telephone calls, malpractice insurance, contacts with other treating professionals, writing medical records, copying medical records, reading some other provider's medical records, ordering prescriptions, etc, ad infinitum.

CBT, which can be directed at specific symptoms and disorders also may lend itself to this model. Read High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide or the article in the October, 2010 issue of Psychiatric Times.

Pitfalls do exist:

• The psychiatrist risks working at cross purposes to the independent psychotherapist treating the patient formally.
• Without a contract patient expectations may exceed reality.
• It's a lot easier to say "time's up" when you both see the minute hand on ten. In this model you decide when to stop based on when you want to go home or how many patients are in the waiting room. There's no entitlement to the full 50'.
• Some patients may not feel permission to bring up a matter they want help with.
• That matter the patient wants your help with might require referral for formal psychotherapy. But you can figure that out with the patient and steer them in the right direction.
• Some interventions benefit from follow-up within a few weeks, but for medically stable patients the next regularly scheduled appointment may be months away.

The notion that psychotherapy must be an all or nothing proposition may prevent you from providing the best treatment to your patient. If you the psychiatrist include a psychotherapy intervention now and then, you may increase efficiency, cost-effectiveness, and your chances of success.

More Harassment from DEA

A few days after the audit I started getting voice mails (2) from a DEA auditor asking when I would like to meet to go over the "findings" growing out of The Audit. I ignored them and set Google Voice to block all numbers associated with the local DEA office. The auditor emailed me (He told me my number had been disconnected. Thanks for confirming the call blocking feature works!), this time asking if we could meet the next day (10.29). I faxed a terse letter to his boss that morning (last Friday) telling him he could send any comments or questions in writing.

That same Friday morning, as I waited for a new patient to finish her paperwork, my office manager informed me the auditor above and another male from DEA had just appeared in the waiting room.(They did not present a warrant.) Furious at this presumptuous invasion of my office  I called the Seattle field office. Apparently they got the message that he was wasting his time (and our tax money). After they received a phone call they left.

I filed a formal complaint with the US Attorney. I attempted to have them charged with criminal trespass by local police, but the police refused to interfere with an ongoing "investigation." I have contacted the ACLU. I figure at a minimum DEA has violated my right to freedom from unreasonable search and seizure and the privacy rights of both myself and my patients, not to mention the patients of my office mates.

I don't recall that it was a requirement of DEA registration that I allow these thugs unrestricted access to my office, which I regard as my castle. If that's the case they can so inform me, and I will decide whether I might prefer to continue my practice without DEA registration. (Other than buprenorphine I only prescribe controlled substances to 4 patients, one with schizophrenia who takes clonazepam to prevent seizures related to clozapine, a couple of patients with ADD who take methylphenidate, and one buprenorphine patient who takes pregabalin (Has anyone heard of addiction/abuse associated with that drug?). Partly because most of my patients are usually recovering addicts/alcoholics I have convinced myself that I can handle almost any case without controlled substances. Hey, it could even help me market my practice.

I'm fed up with the harassment I apparently must endure to prescribe buprenorphine, and have allowed my buprenorphine practice to shrink since early this year anyway. I could retire. I would have time to picket in front of the local DEA office. At least one other physician I no of has said he will stop prescribing the drug because of DEA harassment.

My plan if another auditor shows up in my office without a warrant: Depending on whether patients are present I will call 911 or ignore them and maybe leave. I don't know whether my office mates have enough nerve to demand they leave if they present when I am not there.

When I spoke to the auditor at the field office while the two auditors were in my office I made her aware that I expect DEA to communicate with me in writing. She told me that's not the way they do things. Fine. If DEA wants to have a meeting, "their way," they can meet without me.

Five days have passed since I faxed my request for the findings from my audit in writing. So far I have received nothing, but this makes the third time DEA has ignored my letters. These are public servants?

Who's the Doctor?

In my post Independent Treatment: The Whole Truth I believe I made it clear that I like the idea of independent providers for treatment of psychiatric disorders, a psychiatrist to prescribe medication, rTMS, ECT or whatever, and a non-physician psychotherapist to provide psychotherapy. I believe we can overcome the challenges posed, one of which arises when the psychotherapist advises the patient about medication.

I admit to irritation when my patient tells me her psychotherapist told her she should ask me about lamotrigine, or her chemical dependency counselor told her the acamprosate I prescribed for alcoholism really misses the mark for her particular drinking pattern. But I also must admit to considerably greater irritation when I have never worked with the psychotherapist before. If I know the psychotherapist and am familiar with his work, it just doesn't bother me as much.

Several key facts impact these situations. Psychotherapists may not be qualified to recommend or prescribe medications, but every now and then one of them has an idea that works, and I cannot claim to be perfect in my knowledge of psycho-pharmacology. Bottom line, if the patient gets better I'm glad for the help. Psychotherapists often express surprise that I, a physician, bother to contact them to coordinate treatment. This model does not require weekly or even monthly email or phone contact between psychiatrist and psychotherapist, but, especially when the two professionals do not know each other, either should initiate contact with the other on learning of the other's involvement in the case, and each should always respond promptly to attempts to contact the other. Without such open communication you cannot provide the best care to your patient.

Still, I wonder how a patient feels when his psychotherapist suggest, "Ask Moviedoc about clonazepam." I imagine my patient must wonder what's wrong with me if I didn't think of that, or what's wrong with the psychotherapist when I tell the patient what a horrible choice that would be and why. I believe we would all do better if the psychotherapist contacted me directly with the suggestion or question. I would also like to think I might not be too proud to give the psychotherapist credit for the idea if I endorse it and bring it up with the patient.

Usually such discussions between myself and the psychotherapist extend beyond a simple suggestion of a drug and thus likely lead to better treatment overall. Sometimes what's behind the suggestion of a drug is a symptom of which I was not aware, either because the patient didn't tell me, or because I didn't ask.

The independent practitioner model works, but we must do it right by working as a team. If you're a psychiatrist, always respond promptly when the psychotherapist tries to reach you about a patient. If you're a non-physician psychotherapist, consider contacting the physician directly about your idea of that medication you think might help the patient before you mention it to the patient. And if you don't get a response, consider suggesting the patient find another psychiatrist.

The Audit

The big audit. At last.

In my last post I told you I expected DEA agents to return, "Administrative Warrant" in hand, to conduct the obligatory audit of my buprenorphine practice. The entourage did arrive on October 14, conducted the audit, and I'm still a free man. Nobody got hurt.

Let me recap: When I applied for the special DEA number that allows me to treat opiate addiction with buprenorphine it was clear that I might have to submit to audit of my prescribing records. However, only about a year ago I discovered DEA had embarked on a project of auditing all such physicians. I only objected to a few aspects of the plan. DEA law enforcement agents, the sort that might carry badges and guns, would conduct the audits. This I could accept, but what really galled me was DEA's refusal to schedule the audits. I guess they thought they might catch me red-handed doing something illegal. I expected this to disrupt my practice unnecessarily, and I began to protest. Professional associations such as the American Psychiatric Association, the American Association of Addiction Psychiatry, and the American Society of Addiction Medicine, to my disappointment, focused their efforts on assisting physicians in complying rather than assisting us in assuring that our rights and those of our patients would not be violated. We all learned early on to expect agents to present physicians with Form 82 on arrival. This form permits agents to enter the office and conduct the audit. We were warned that if we refused to sign Form 82 agents would return with an "Administrative Warrant." (Yikes!)

Warrants, even the administrative kind, sound pretty bad, like something to be avoided at all costs, something that will brand you a criminal for the rest of your life. But it seemed possible there might exist some advantage in going this route, and that has turned out to be true. I asked DEA to provide me with a copy of such a warrant and detailed description of how they conduct such an audit. The description proved vacuous and useless, and DEA refused to send me a copy. I figured I would have to get it the hard way.

After agents Sanchez and Carter left my office on October 8 I wondered how long I would have to wait for them to return with the dreaded administrative warrant I had the audacity to demand from them, but I decided to use the time to prepare. I would not have wanted to do the audit on the 8th anyway. Although my office manager was there to help, it had been a busy morning, and I was running behind. The buprenorphine prescription logs I wanted to show the auditors still needed hours of work to remove patient names, so that night I copied all buprenorphine prescription records of patients I deemed active going back the requisite 90 days to a single spread sheet on Google docs. Then it was just a matter of keeping it up-to-date.

When I walked back into my waiting room October 14 after lunch and a haircut, a casually dressed man introduced himself, handed me my warrant (the moment I had been waiting for -- I wonder how long he had been waiting.), and told me to read it over and get settled while he summoned the rest of the troops. He staked out the waiting room for the rest of the audit. Agent Carter took charge. A big guy with a couple suitcases turned out to be their computer "expert" (his description). There was an African-American woman who didn't do much. And remember the attractive woman I mentioned from my own unannounced visit to the DEA field office? She's their secret weapon. I call her Ms. Waterboard. She can interrogate me any day. Anytime she wants to. I'll confess to anything. Making obvious assumptions about everyone's sexual orientation and marital status, if you're 10-20 years younger than me, and have not already found the woman of your dreams (like I have), and practice in the area covered by the Seattle field office, do whatever it takes to get interrogated by Ms. Waterboard. And she loves dogs, so arrange to have one in your office for the audit.

Just to speculate on DEA strategy: Have enough agents to keep the doc so busy that he won't really notice when they do something they probably shouldn't or that he might say something he might have preferred to avoid saying. I let down my guard with the interrogation. I can only blame Ms. Waterboard so far. I did confront the agents with the fact that there was no mention on the warrant of any interrogation. However, it seems fair to me that they should be able to ask me questions directly related to my buprenorphine records.

I do believe DEA exceeded the appropriate boundaries in interrogating me. Agent Carter asked me my observations about the relative numbers of heroin addicts versus pharmaceutical opiate addicts presenting for treatment. I had no idea. I was also asked how many active patients I was currently treating. When I asked for a definition of "active" none was forthcoming. When I made a wise crack about my experience testifying in court where a definition would be damanded, the African-American woman reminded me that she knew all about my background. So I hedged and estimated between 30 and 40 patients without a real definition. Ms. Waterboard asked me about my office hours. Rather than getting into a discussion of the fact that I don't really have set office hours, I evaded the question by reporting the days and times when my office manager is usually present. No one seemed to notice that I didn't really answer the question. (This often works in court, too, by the way.)

The auditors presented me with a single page printout of prescriptions from a local pharmacy, citing it as evidence that I stocked buprenorphine in my office, which I never have. When I explained that these were simply prescriptions picked up by patients before coming to the office to have their induction the auditors made a few phone calls and dropped the issue.

The real fun was with my log. The DEA computer "expert" seemed befuddled by the notion that my log resided on a server somewhere in cyberspace. The warrant simply did not contain any language to allow for seizure of such an abstract entity. I offered to print a copy, but I think he really wanted to snoop around in my hard drive. It appeared as though he had never seen a tablet PC before. He opened a case containing an impressive array of hard drives, and connected one to a USB port, but ultimately was unable to figure out how to download the elusive file. I offered to help. He accepted, and thus began the most time-consuming part of the audit. We are dealing with computers here after all. Unfortunately, I had not yet installed Adobe Acrobat Reader on my tablet since installing Windows 7. After 15 or 20 minutes I was able to download a copy of the file to the hard drive so he could make a copy, and I was also able to print a copy on paper.

Of course the whole notion of "seizing" evidence, whether on a computer or elsewhere, implies that the evidence will be incriminating. In this situation, however, the only evidence would likely exonerate me.

Early in the audit one of the agents confronted me that this all could have been so much easier had I just cooperated by signing Form 82 the week before. Although I will never be sure, I suspect they meant to imply that they subjected me to a more intimidating or disruptive audit to punish me for forcing them to get a warrant. In fact, though, because I had time to prepare, I believe things went more smoothly, and the timing disrupted my practice much less. Only one patient appeared in the waiting room while they were doing their dirty work, and he complimented me on my handling of the situation. (One of the agents seemed to be holding the door to the waiting room open during most of the audit.)

How would I handle the audit differently if I could do it again? First, I would not have volunteered access to my computer. As far as I can tell the warrant does not require me to allow DEA to commandeer my computer for its own purposes. Instead, I would have printed out a fresh copy of the log every day so I could simply present it to the auditors. I might also refuse to answer questions unrelated to my buprenorphine practice. I would really like to know whether DEA would revoke my license just because I refuse to confabulate office hours that do not exist.

What else did the auditors do wrong? When I did resist answering questions, citing absence of reference to interrogation in the warrant, I seem to recall at least a veiled threat of admonishment or revocation of my DEA number. When I sarcastically suggested that that might not be such a bad thing, agent Carter, a little too eagerly, offered to relieve me of the burden of the audit if I would surrender my special number. This same interaction has played out before around these audits elsewhere in the US, and I have seen at least one letter from a DEA field office claiming to deny any effort to discourage physicians from treating addicts with buprenorphine. Agent Carter's offer would seem to betray DEA's real position: By treating opiate addicts we threaten DEA job security. I believe the agancy would be very happy to have us abandon our efforts.

DEA also needs to get up to speed with computers and the Internet. I had provided agent Carter with access to my log at Google docs months ago. Let's compare the costs of two or more agents showing up only to be told they need to return with the warrant and five agents showing up the next week unnecessarily versus the cost of going online and peeking at my log at your leisure while sitting in your office downtown. Think about this next time you pay federal income tax. Maybe the auditors thought they would find a meth lab in my office. If so, they did not conduct a very thorough search. The whole exercise was a waste.

If you prescribe buprenorphine to treat drug addiction, I strongly suggest you place your prescribing log online. If DEA has not yet audited your practice, plan to refuse to sign Form 82 when agents arrive unless you are completely prepared, and they have arrived at a convenient time for your office. If we all   force them to obtain warrants, maybe they will back down and start scheduling.

I cannot speak from experience since I have never wanted to stock any controlled substance in my office. When the opportunity presented itself for me to stock buprenorphine, I declined. I suspect those of you who do stock that drug or others will find the audit considerably more difficult regardless of whether you sign Form 82.

I initiated a moratorium on accepting new buprenorphine patients almost a year ago with the idea that I would end the moratorium after my audit was completed. I do plan to accept a few new patients for buprenorphine induction and maintenance, but before I will want to accept significant numbers of new patients (like anywhere near my limit of 100) I would like the United States government to deal with its ambivalence. All the agencies need to get together and decide whether they want us to treat addicts or not. If not, I certainly have better things to do with my time than subject myself to this kind of harassment.

DEA can chalk up another victory in the war on drug treatment.

The saga continues.

DEA Suboxone Audit: The Wait is Finally Over. Or Is It?

This story started for me almost a year ago: DEA On-Site Investigation of Suboxone Prescribing Physicians

Sometime late last year I wrote a letter to the Seattle field office asking to schedule my audit as soon as possible. I asked DEA to provide a detailed description of how they carry out the audit after serving an "administrative warrant" on a physician who refuses to sign Form 82, giving permission for the audit. After several months without a response it occurred to me to give the DEA a taste of their (it's?) own medicine. I had to be in the city early for an orchestra rehearsal anyway, so I made my own unannounced visit to the Seattle field office last spring.

When I entered the office I explained to the polite guard that I wanted to hand deliver a letter and that I wanted to dispose of some unused samples of modafinil I brought with me. He asked me whether I was carrying any explosive devices. Fortunately that day I had left my C-4, dynamite, and IED's at home. He asked whether I had an appointment. The answer of course was no. He asked whether the agents might know who I was. The answer of course was yes. Sitting in the waiting room I was struck by a wall covered by portraits of DEA agents who lost their lives in the line of duty. I trust none of the deaths occurred while auditing physicians trying to treat patients suffering from addictive diseases.

After a short wait a very attractive young woman entered the waiting room and asked me whether I might wait for agent Carter since chief agent Thomas was on vacation. When I asked agent Carter to please proceed with my audit, she explained this would not be possible and told me how to dispose of my drug samples.

Once more there was no response to my letter.

I was pleasantly surprised when, on September 29, agent Sanchez left a message on my voicemail asking me to call him back on his cell phone. I in turn left a message on his voicemail suggesting when he might reach a person by dialing my office number, but I did not hear from him until Friday, October 8. I was standing at the reception window talking to my office manager and agents Sanchez and Carter entered the waiting room, introduced themselves, and told us they were ready to perform my audit. I asked them whether they had a warrant. They said no. (If only I could have obtained a photograph of the look on their faces.) I explained to them that I wanted to know what would happen during an audit performed under administrative warrant. They asked me if I had not received a letter from the diversion office in Springfield. I explained that the letter I had received was woefully inadequate. I asked if they wanted to schedule an audit later, but they repeated the mantra that that doesn't fit with their policy. I pointed out that I had shared my buprenorphine prescribing log, which resides in Google Docs, with Agent Carter. They told me they are not allowed to access the Internet.  They left. I completely forgot to ask whether they were carrying explosives.

So I'm back to waiting and wondering what will happen next. It would have been so much easier for everyone concerned if they had only honored my request for a detailed explanation of how an audit is conducted under administrative warrant. But I hope without too much further delay to be able to provide a first-hand description.

As a taxpayer I'm really OK with DEA agents having access to the Internet. Maybe we could arrange for the FBI to monitor their use. Or maybe we could establish another agency. We could subject them to unannounced visits to audit their browser histories.

Next: The Audit

APA vs. APA

Psychology vs. Psychiatry: What's the Difference, and Which Is Better?

Starts out, "Psychologists and psychiatrists tend to hate each other."

Metaphor or joke? Did this guy talk to even one representative of either profession? Is this just a wild extrapolation from his gross misinterpretation of the new APsychiatricA Guideline? Regardless, it's an opportunity for me and others to set the record straight.

Psychologists and psychiatrists not only should not, but do not, hate each other. In fact as fewer psychiatrists do psychotherapy we tend to refer our patients to psychologists for psychotherapy more than ever. Which reminds me of the biggest insult in this article, namely that the author seems to completely ignore the most numerous categories of psychotherapists and counselors, those who are neither psychologist nor psychiatrist, and who are, in my experience, often equally respected for their skills.

There is no "idea of psychiatry." Psychiatry is a profession, a medical subspecialty.  Psychology is a science. Clinical psychology is another profession. The first "chemical" treatment used on psychiatric patients was probably a group of drugs called mercurials which effectively treated neurosyphilis, leaving mostly patients with bipolar disorder and schizophrenia in the asylums. Morphine and barbiturates may have been the only chemicals available to help them at that time, and those drugs simply sedated them.

Contrary to what the author would have us believe, after Sigmund Freud (a neurologist) developed his very psychological theory of neurosis, psychiatry began to embrace talk therapy in the form of psychoanalysis, and circa the 1970's I believe psychologists had to sue to gain acceptance to psychoanalytic institutes that only admitted physicians. (I wonder whether the author realizes that the picture that accompanies the article portrays a "psychiatrist" -- not a psychologist -- psychoanalyzing a patient on a couch.)

So he thinks the Guideline "denigrates" CBT. Perhaps this best illustrates that such guidelines are just that, and are intended for trained professionals, not amateurs hoping to conjure up conflict where none exists. The real problem is that too many psychiatrists cling to psychoanalytic/psycho-dynamic methods. Those of us who restrict our practices to prescribing chemicals, however, regularly refer to psychologists, usually the real CBT experts.

The author accuses our leaders of acting like children for not relinquishing the acronyms APA, one organization to the other. Surely this must lead to confusion from time to time, but I have been blissfully unaware that anyone on either side ever wanted the other to change it's name. I wonder if the author would think the same of two SCCA's, the Seattle Cancer Care Alliance and the Sports Car Club of America.

I do agree with one statement: Combining medication with the right type of psychotherapy often works better than either alone. But "national guidelines that will shape the treatment of millions?" Most psychiatrists will not even read them, and those who do will probably keep practicing as they always have.

Which is better? Neither. Apples and oranges. They are just different.

I only have one (more) comment. Almost any psychologist or other psychotherapist could probably help John Cloud get in touch with reality and let go of his hatred for psychiatry.

Therapists on a Plane

A triple coincidence: I am replying to the email of a family psychotherapist friend with whom I used to share an office. She told me she sat next to John Gottman on the way home from attending the recent AAMFT meeting in Atlanta. I told her of my similar experience seated next to UW psychiatry professor David Avery, MD who was flying home to Seattle after this spring's APA meeting. And my partner shows me the article "Cornered: Therapists on Planes" in this morning's New York Times.

First, I would like to point out that the author, Liz Galst, undoubtedly used that term I dislike so much, "therapist," as shorthand for psychotherapist. Amazing how some seem to forget the existence of all the other kinds of therapists. But, too, this betrays the misguided popular perception of all mental health professionals as givers of "advice," professionals with whom you just talk to feel better, rather than people who treat mental illness or family dysfunction.

Kudos to Galst for sharing with readers the very legitimate concern of Rhode Island psychiatrist Scott Haltzman, MD, that seemingly casual interactions with a fellow traveler might lead to a lawsuit. She found an opponent to this notion in Gregg Bloche, MD who labels this an "urban myth." I hope he's right, but judges and juries -- not authors -- decide such matters. The notion that the patient's perception of the doctor-patient relationship rules still holds sway in court to the best of my knowledge.

Guest Blog: Dr. Douglas Landy on the Crisis in Inpatient Psychiatry

Psychiatrist Douglas Landy, MD, generously permitted me to publish his thoughts about the current crisis in inpatient psychiatry, which I suspect are not unique to New York State [links courtesy of BehaveNet]:

It seems to me that over the years the face of inpatient psychiatry has been changing.  It looks like we are seeing progressively sicker patients, and violence is more common than used to be the case.  These factoids are supported by statistics throughout New York State (length of stay, violence, disability secondary to violence, etc).  It seems to me that a number of factors have brought this about:

1.      More severe psychopathology is tolerated in outpatients.  Many of the people we see on an outpatient basis, at least in mental health clinics, would have been hospitalized when I was a resident, but are now more frequently treated on an outpatient basis rather than on an inpatient basis.
2.      Many of the people who (with the above taken into consideration) are treated on an inpatient basis are harder to place owing to their penchant for inappropriate if not frightening behavior, making them personae non gratae for most placements.
3.      Many of the people that society asks us to care for are more emotional misfits (who have been acculturated to using violence as a means of expressing dominance, social pecking order, and so forth) rather than having a mental illness such as bipolar disorder, etc.  An associated problem is our societal tendency to “pathologize” behaviors that the majority culture of the location dislikes or fears.  Another associated problem is our profession’s wholesale trade of contextual diagnosis for single symptom diagnosis (i.e., racing thoughts = bipolar disorder, end of discussion).  As a result, we are in part contributing to this problem by agreeing that someone who behaves in a way that is not acceptable to the majority culture is mentally ill; and that implies we can treat that mental illness; and so forth.  This is, of course, an entirely separate controversy, but you get the idea.
4.      Because our inpatient models are based on context-based diagnosis driving treatment – as opposed to mere symptom-suppression treatment along with (generally fruitless) attempts to use a model for a problem that is generally not amenable to the inpatient model of treatment (ie, many of the people referred to in paragraph 3) – we fail spectacularly at accomplishing any kind of effective inpatient treatment in this population.
5.      As a result, the inability to place this group, along with error-driven treatment, results in many people being more dissatisfied, and that does not mean the patients alone.  Staff gets overwhelmed by this as well.
6.      Staff dissatisfaction and hopelessness (as well as fear) leads to petty tyranny or abandonment of responsibility, either of which leave the situation rife with the potential for violence and loss of the therapeutic milieu owing to patient “take-over.”  This is exacerbated by continually decreasing money for mental health resulting in lowering staffing to unsafe levels, while bloating administration to ensure that the paperwork is all in order for our “friends” at the regulatory agencies.

My own conclusion is that we need to do a couple of things, some of which are clearly easier than others.
1.        We need to have adequate staffing.
PROBLEM:  Costs money
2.      We need to help society understand that:
  a.      Not all annoying behaviors, even those that are violent, are driven by mental illness.  Even the presence of mental illness does not ipso facto make it the cause of the unwanted behavior.
  b.      With mental illness in general (such as the major mood and thought disorders) and the “softer” diagnoses of personality disorders, impulse control disorders, etc, treatment is not always successful.  In such a case the questions for society are:
    i.      Do we block up the hospital system with people who don’t need to be/shouldn’t be hospitalized?
    ii.      In the case of a criminal act, should such a person be restored to health and then sent back to prison for the remainder of their sentence (ie, guilty but mentally ill)?
    iii.      What should we do with dangerous people who don’t, won’t or can’t respond to treatment and victimize peers and staff in the hospital system where their current lack of criminal behavior precludes incarceration?  Why should the mental health system be responsible for this group (I suppose that you can correctly infer that I object vehemently to the idea that sex offenders who have finished their criminal sentence can be sent to a psychiatric hospital for an indefinite period of time afterwards).
  c.       PROBLEM:  It’s like changing the course of a river.  It can be done but it takes considerable time, energy, and a lot of money.
3.    We need as a profession to be clearer about diagnosis, remembering that symptoms are contextual and not independent phenomena.  The current craze (and I use that word pointedly) for single-symptom diagnosis is merely a rationalization to use medications that perhaps needn’t or shouldn’t be used, considering the ramifications of so doing.  Additionally, the current diagnostic patterns make us all look like fools.  I’m sure that many of have heard (or even said) about a colleague something like, “It’s curious how all his/her patients are Bipolar.”

PROBLEM: It is not clear if the pharmaceutical companies promote this kind of diagnosis/treatment strategy because it’s good for the bottom line, or if their speakers promote this (I can’t say more for fear of libel) to boost their own earnings from the companies (doubtless in which they have already invested as well).  Additionally, we tend as a profession to use medications more than non-pharmacological treatment options, and as a result think more in that way.  I would love to see psychiatric training spend an additional year or so on how effectively to do combination treatment – psychotherapy and psychopharmacology together, which is something you don’t see any more.

Douglas A. Landy, MD
Chief of Psychiatry
Rochester Psychiatric Center

The opinions expressed above are those of Dr. Landy, and do not necessarily reflect the mission or opinions of BehaveNet, Rochester Psychiatric Center or the New York State Office of Mental Health.

Washington's Narcotic Analgesic Prescribing Rules

The State of Washington, plagued by record opiate overdose deaths, drew  national attention recently with the announcement of an initiative to address the problem by formulating guidelines for physicians treating pain. I offer my comments on the August 26, 2010 draft proposed rules submitted to the Pain Management Workgroup by the Medical Quality Assurance Commission's subcommittee on pain management as an outsider with no direct stake since I do not treat pain.

In fairness this is only a draft, so perhaps we can excuse the duplications, typos, and misplaced items. But better writing will not make for better policy, nor will more documentation by doctors, which seems to be the goal. Overall the effort is misguided and constitutes a waste of state funds during a budget crisis.

Risk Factors
One rule requires the provider to "screen for risk" by looking for history of addiction, "aberrant behavior and underlying psychiatric conditions." Aberrant behavior could cover a lot of territory. Without a definition this requirement fails to advance the cause. I find the term "underlying" psychiatric condition offensive and stigmatizing. Absent evidence that any psychiatric condition causes chronic pain or addiction the committee should substitute co-morbid or coexisting.

Informed Consent
Another rule addresses informed consent. This rule states that the provider should discuss with the patient the "risks and benefits of the use of controlled substances." Providers should probably discuss the risks and benefits of any treatment, certainly any drug, even if it is not a controlled substance.

One Provider, One Pharmacy
This rule goes on to suggest the patient should "receive prescriptions from one provider and one pharmacy" if possible, a nice idea but hardly within the control of the prescriber. I am not sure I see the connection to informed consent. Another loosely related rule suggests that the provider should document indication for opioid usage on the prescription. Perhaps this is so the pharmacist will know that the patient wants that OxyContin for pain rather than to get high. It will not prevent overdose deaths.

Patient Responsibility
Also included under this section is the suggestion of use of a written agreement "outlining patient responsibilities." I welcome this wording as in medicine in general I believe there is far too little focus on the responsibilities of the patient and too much on the responsibilities of the physician. Ultimately overdose death results when a patient takes too much drug on a single occasion. The physician cannot prevent such an occurrence. However, the committee could do us all a great service by providing at least a prototype agreement. Such agreements often fail to live up to their promise and frequently add to confusion. For example, the committee suggests requiring the patient to agree to "medication levels screening when requested." This may work well if the sample is collected when the patient is already in the office, but if the patient must provide a sample when ordered to do so at a random time between office visits, the physician must assume the role of arbiter when the patient delays appearance at the lab or office, forced to make judgments about the validity of the excuse. This is not an appropriate role for a physician.

The committee suggests a requirement that the patient provide consent to allow coordination of treatment between the prescribing physician and local emergency departments and pharmacies. Such authorizations, however, expire in 90 days in the state of Washington, so when such communication is required the physician must have access to the date of the authorization in order to confirm its continued validity in order for this provision to work. This problem also makes for difficulty and adherence to another provision of the proposed rules. In this provision is suggested that the patient must consent to reporting by the physician of "concern" that there may have been "illegal activity." Again, vague language limits usefulness.

Of course such an agreement or contract must specify consequences, most likely discontinuation of the drug, when the patient fails to adhere to its terms. The proposed rules also alludes to "tapering" before discontinuation, but this implies control over what the patient takes when the physician can only control what she prescribes, and, other than the unenforceable "one prescriber" notion nothing prevents the patient from seeking another physician.

Safekeeping of Drugs
The suggestion that responsibility for safekeeping of the drugs rests with the patient admonishes the patient to use "discretion" and keep medications in an "inaccessible" place. The only feasible way of addressing the issue of potential theft is to make it clear to the patient that replacement prescriptions will not be issued when the patient claims to not have enough to last until the next planned refill, regardless of the reason given, except perhaps if the drug has been confiscated by law enforcement and the patient can provide a receipt proving this to the physician.

Consultation
One proposal suggests that the provider should be "willing" to refer to the patient. I can imagine a prescriber documenting his "willingness" in a progress note. Willingness alone will not help. Not only must the consultation actually take place, but patient and prescriber must alter the treatment in response to the consultants recommendations.

Episodic Care
The draft discourages provision of narcotic prescriptions for chronic noncancer pain without objective evidence of acute injury. I applaud this principle as well as inclusion of the statement, "The treatment of patients with chronic pain is not considered an acute health service." I believe emergency physicians far too readily prescribe controlled substances.

Photo Identification
The suggestion that providers should write prescriptions for controlled substances "to require photo identification in order to fill" should apply to all controlled substance prescriptions, not just those for pain. But the best way to effect such a change should start with pharmacies, not physicians.

Reportable Acts
The committee suggests that physicians may have "an obligation" to report illegal acts by patients to law enforcement. The committee should also however admonish providers to do this only consistent with applicable statutes and ethics guidelines relating to confidentiality.

Opiate deaths result from too much drug not from too little documentation. These new rules will likely discourage many doctors from prescribing for pain, and will make it easier to discipline doctors who ignore them.

Overall these guidelines will likely fall short. There is little real substance here but much to make the prescribers who care want to avoid treating this population with narcotics. Perhaps most unfortunate is the fact that we have in buprenorphine a much safer drug which the committee does not even mention, perhaps only because the FDA has approved no oral formulation for treating pain. (Treat Physical Pain Safely with Buprenorphine) The committee, rather than demanding more documentation, should encourage prescribing of safer drugs like buprenorphine.

Taking Insurance

Surely one of the most ubiquitous euphemisms in medicine today.

Another professional (William Shryer at Diablo Behavioral Healthcare) subscribing to a listserv I read inspired me to write this with his comment on a frequent type of post: "Need psychiatrist in Omaha who takes Aetna [or some other brand of payer]." He advances this quaint idea that, rather than basing a referral on who "takes" which insurance, one should base referral on the qualifications of the provider and the clinical needs of the patient.

I imagine myself ordering two hamburgers, fries and a soda, and asking, "Do you take insurance?" like I might ask whether they accept checks or credit cards.

I imagine myself answering, when a prospective patient in our first telephone contact poses the same question, "I take money."

Insurance is definitely not money.

Taking insurance is a gamble. When the insurance company pays the provider, it is entitled under federal law, and some state laws, to say, "Gosh we didn't mean to send you that money after all. Please send it back now." And you have to send it back. I call it funny money. That applies even if the provider has not signed a contract with the payer. It's even stickier if the provider has agreed to the terms of the contract. Like the professional I mentioned above I contract with no payers, including Medicare. So I have not read one of those many paged contracts in some time. My objection arises from the fact that most of them appear to lead to the provider working, not for the patient, but for the payer, what I see as a conflict of interest.

But here's the catch: most patients cannot afford to pay our fees out-of-pocket, and many of those who can feel entitled to get something back for all those dollars they spend on premiums. I have to sympathize.

And which provider is most qualified? The provider who "takes insurance" from whomever offers it may have a very busy practice indeed. This may translate into lots of experience. Are quality and quantity necessarily at opposite ends of the spectrum? Would you rather have your appendix removed by a surgeon who does the procedure once a year or one who does it four times a week? Experience is not the only consideration though. The provider with the less busy practice may take more time and provide a more individualized approach. She may also have more time to return phone calls or schedule early appointments. Insurers usually verify credentials, attempting to guarantee at least a minimal level of competence, but providers who do not contract with insurers may stay busy enough to avoid contracting by virtue of referrals from other providers and patients who respect them.

That referral should take qualification and the clinical needs of the patient into consideration, and reimbursement may be necessary, but more patients might benefit from reading the provider's contract with the payer rather than pretending the provider answers only to the patient. Providers who complain about insurers but sign those contracts have no business complaining. They are enabling them.

Guns and Psychiatry

What comes to mind when you think of guns and psychiatry? Probably the Army psychiatrist at Fort Hood, or maybe the Virginia Tech student with psychiatric problems who went on a shooting rampage. Next you may think of the obligatory removal of access to firearms when you send home a patient at risk for self harm. Then there are the myths about violence and mentally illness.

But millions of Americans own firearms, so it should not surprise you that other considerations abound. How do you, the psychiatric provider, feel about the fact that a patient or family member might bring a concealed weapon into your office? Do you have a policy? signs on the waiting room wall? How many psychiatric providers themselves might keep firearms in the office? Would you ask a patient to leave if you discovered she had a revolver in her purse?

What about your patient with PTSD who has himself been a victim of violence and may want a weapon for protection? Would you argue against such a practice on principal? Maybe he's physically disabled as well, making him even more vulnerable.

Have you, the mental health practitioner, ever conducted a background check on a patient to determine whether there might be a history of criminal conviction? Possession of a permit to carry a concealed firearm can provide you with strong evidence that the individual has never been convicted of domestic violence or a felony in many states?

How important are leisure activities to a patient struggling with anxiety or depression? If your patient's favorite pastime relates to gun-smithing, collecting or hunting, do you want her to abandon an activity that contributes to self-esteem and possibly social connection during a time of crisis?

Most of us in the helping professions, especially medicine, are all too aware of the devastation wrought by violent death or serious injury, but do you want a patient who likes, owns, or even carries guns to feel judged by the very person to whom he has come for help?

Even if, like me, you do not believe in "transference," know where you stand with your feelings about people and firearms, and take care not to let them interfere with your work.

The Myth of the 30 Day Notice

When the doctor patient relationship goes sour medical ethics clearly allows the physician to discharge the patient, but in theory at least the physician must ordinarily make some attempt to help the patient find another doc, and continue to provide care until the patient can establish care elsewhere for a reasonable time, traditionally 30 days.

But what happens during those 30 days?

Although physicians discharge patients for many reasons, such as failure to pay, dishonesty, noncompliance, personality conflicts and others, in my practice at least patients seem to discharge themselves. They miss an appointment and don't return calls to reschedule. With phones and voice mail as they are we often encounter "mailbox full" messages, and of course sometimes we eventually do make contact and discover the patient just lost her phone. But when the patient has really dumped me I want evidence of providing adequate warning of discharge as much for liability reasons, to protect myself, as anything else. While the letters I send do often result in a phone call and continuation of care, for the patient who has left for good the letter becomes tangible evidence that I am no longer responsible for care. If I something bad happens to the patient, but I am clearly not the patient's doc at the time, there is little chance of a successful liability suit.

My standard discharge letter starts out by saying I don't know whether the patient wants to continue treatment, and to please let me know. I inform the patient that I will only continue to act as her physician for 30 days after which I will discharge her. I may also suggest some resources for finding a replacement physician. Often the letters come back undeliverable.

Many physicians seem to accept, but I hereafter challenge, the myth that we must provide a 30 day supply of whatever medication the patient takes. While that may be appropriate in some cases, simply providing a prescription does not equate with medical care, and may lead to increased, rather than decreased, risk. Suppose for example that the patient's condition changes during the 30 days. The responsible physician would want to examine the patient, possibly face to face, to evaluate and explore treatment options. In some cases the patient would be happy to oblige, but suppose the patient refuses. I believe in that situation the physician should consider refusing to provide a refill until the patient has kept an appointment. Not infrequently a patient lost to follow-up will request a refill through a pharmacy. Typically I have by that time given up after many attempts to make contact with the patient. I refuse to fill the prescription and ask the pharmacist to tell the patient to contact me.

But suppose the patient responds to your demand for a face to face visit in order to obtain a prescription or other treatment. Can I demand payment before scheduling the visit or actually seeing the patient? From the perspective of avoiding a lawsuit, the better choice might be to take the loss. But this can be hard to accept, especially when you know the patient will spend much more than your fee on the drugs you prescribe, or on their month supply of cigarettes.

How Many Psychiatrists Does It Take?

In his article in the most recent issue of Psychiatric Times Daniel Carlat, M.D. estimates that we need 45,000 more psychiatrists in the United States. In the article Pharmacists Take Larger Role on Health Team we read that pharmacists could be part of the solution to that problem as they assume roles that were once the sole province of physicians. What is missing from Carlat's article (but may appear in his references) is an estimate of how many patients a single psychiatrist can treat. Carlat advocates at the same time for psychiatrists to do more psychotherapy, but we can't have our cake and eat it too. A psychiatrist who attempts to do traditional psychotherapy and 45-50 minute sessions while also treating patients with medication or other biological interventions will not be able to manage nearly as many cases as a psychiatrist who delegates psychotherapy duties to non-prescribing professionals.

Carlat's solution to the problem of too few psychiatrists, training psychologists in the role of psycho pharmacotherapist, will perpetuate the inefficiency of psychotherapists attempting to manage biological treatments at the same time, though there will likely be more of them. In his article Carlat's justification for training psychologists to do medication management rather than recruiting more advanced practice nurses and physician assistants is his unsubstantiated notion that psychologists will be better able to handle what he calls "tough cases." If by tough cases he means the ones that do not improve with first line treatments, it is unlikely that more psychological training will help. If he means patients whose personalities interfere with their treatment, we need to keep in mind that personalities can interfere with all kinds of medical treatment. Perhaps we should train psychologists to treat diabetes and do knee replacements and colonoscopies, too.

While Carlat and others push for combining psychotherapy with medication management another trend would seem to push in the opposite direction. As more and more prescribers give up psychotherapy some would seem to take on the role of primary care provider (We don't seem to have enough of them either.) for their psychiatric patients. This role arguably demands physical examination of patients which the vast majority of psychiatrists gave up as soon as they finished residency. Of course physical findings have little if any bearing on any psychotherapy, but psychodynamic and psychoanalytically oriented psychotherapists seem to have particular difficulty with the so-called "transference" implications of so much touching and seeing on the psychological treatment.

I believe we have plenty of non-prescribing psychotherapists now and that those professionals are at least as capable as their physician counterparts. I believe physicians remain the most capable of prescribing. I also believe that much of the impetus for psychiatrists to continue providing psychotherapy comes from the psychodynamic school and that for many psychiatric patients such an approach is either completely unnecessary or maybe inferior to cognitive behavior therapy or other psychotherapies. However, I believe that improved psychotherapy skills will make for better psychiatrists. We need to develop greater efficiency in incorporating psychotherapeutic interventions into psychiatric contacts. This will require us to relinquish the traditional 45-50 minute session (Today much of such sessions is already occupied by administrative activities anyway.) in favor of a model that incorporates directed psychotherapeutic interventions into a 5-20 minute medication management visit. Furthermore, all physicians would probably benefit from learning some of these interventions.

Which direction will psychiatry take? Will it return to psychotherapy as a core service or become even more medical with performance of physical exams? Or will psychologists, nurses and pharmacists take care of the psychiatric patient of the future?

Maybe we won't need psychiatrists. If we don't make psychiatry more attractive by eliminating burdens from regulation, low fees and payer contracts we won't have psychiatrists.

Plog My Medical Records

I'm shopping for a new contact management solution. Used to be I would say software. But now it's in the cloud. At least I hope so because my main computer keeps crashing, and the software I use now is old, and the new version is too expensive and won't work on this machine.

The service (ASP for application service provider?) I'm looking at now uses a blog format for working on projects. I thought, "How could I use that?" What about for medical records? (If someone is already doing this, please tell me.)

Suppose you could access the same records your doctor keeps and make changes or add comments. It goes without saying that this would require an audit trail so you could keep track of who entered what. For medico-legal purposes the doc would always have to be able to retrieve and display her records, distinct from any proposed changes or comments made by you the patient. The doc would also have to read and respond to every comment or proposed change. Something like a new phone number might be easy. Rewriting part of the history might not be.

The good part would be the resulting collaboration between doctor and patient to get everything right. Comments added to progress notes (Let's see, progress + log = PLOG.) would take the place of email for updating the doc on changes in symptoms, side effects of drugs. The doc would review and approve each one the way bloggers get to accept or reject comments on posts.

The bad news would be the extra time for the doc. Patients who leave long voice mail messages would probably leave frequent and detailed comments. Patients would also have to understand that urgent or emergent matters would require different methods of contact, like telephone or even 911.

Suppose the doc prescribes venlafaxine and the patient experiences nausea. The patient would send this fact as a comment on the plog post from the last visit. Instead of waiting for the next visit the doc could suggest a change in dosing or when to take the drug relative to meals in another comment delivered to or accessed by the patient. Both doc and patient would be alerted to any change, maybe included incoming lab results.

The plog could also solve treatment team communication problems. For example, in psychiatric treatment, which might involve a non-physician psychotherapist, all three parties might share access.

We just need to see how the HIPAAcrits feel about it.

Pharmacists Gone Wild

(Facts altered to disguise cases.)

• A patient relates that her pharmacist told her if the increased dose of her medication failed to produce improvement in her symptoms after 21 days at the higher dose, she should revert back to the original dose.
• A pharmacist faxes me to ask the diagnosis of a patient, even though the patient pays cash for the prescription, and there is not insurance company involvement.
• A pharmacist tells a patient that a drug I frequently prescribe can be very sedating, when in fact most patients complain that it does not sedate them enough.

Everyone seems to want to play doctor these days, but how much do we want pharmacists to get into that role? There is something to be said for having each of every patient's diagnoses accessible from the pharmacy data bank. For example, it might prevent an asthmatic patient from using a potentially fatal beta blocker. But can we trust them with psychiatric or substance use disorder diagnoses? My patients already complain about pharmacists talking about such diagnoses where other customers can hear.

The first item above appears to clearly involve exceeding the boundaries of a pharmacist's competence and authority. This probably has happened as long as their have been pharmacists, but does the current climate encourage non-physicians to take liberties, possibly to the detriment of patients?

Is Grief Ever a Mental Disorder?

Listen to Kenneth Kendler and others weigh in on NPR's morning edition: 

Is Emotional Pain Necessary?

I see several false assumptions in this debate: 
1) Meeting the criteria for Major Depressive Disorder means you have the illness: Wrong. The criteria are necessary, not sufficient. Just means you may have an illness. 
2) If you have the illness, you must have treatment: Wrong. The patient gets to choose whether to be treated and how.
3) Treatment means medication: Wrong. There is also psychotherapy. And what about grief counseling. A Grief counselor is not likely to kick you out of "treatment" based on the 2 week rule. Neither is a psychotherapist. But the criteria may impact whether insurance pays for them. 
4) Treatment will remove the pain of grief. Wrong. Neither medication nor psychotherapy will prevent the aggrieved from feeling bad about a loss. One could argue that improvement after treatment suggests there is or was an illness. We don't have happy pills yet.
Bereavement and grief by definition involve reaction to an adverse life event. Depressive illness in contrast often occurs in the absence of any connected adverse event, and usually seems to insulate and distance the individual from external circumstances. Treatment of depression may lead to increased sensitivity to loss.

Doctors Who Lie!

First I read about it at shrink rap: Is It Malpractice To Lie?

Then they accused Dr. Carlat of admitting to it on the air: Carlat on NPR's "Fresh Air"

Reminds me of a retired surgeon who was still practicing when surgeons started using laser tools for various procedures. He said patients started asking him whether he would use laser tools for their procedure. He said he would look them in the eye and say, "Of course."

Whether he intended to use laser or not.

Google Ga Ga

In my earlier post EHR's and APA I outlined more than you would ever want to know about my tech resume. What follows is a brief overview of my recent moves into the cloud with free Google offerings. I do not expect that you will want to copy my implementations, but I hope this will help you generate your own ideas for managing and presenting information for your practice, and maybe your personal life. (I have found that combining personal and practice makes for much increased efficiency.)

Blogger

I am not sure why I chose this particular platform, my first real foray into things Google, but I like that when I comment on other Blogger blogs I do not have to enter my name, email address, etc.

Gmail

I started forwarding almost all my email to Gmail to take advantage of the spam filter, but after a long period with no messages I feared that Google might have identified my domain as spam and started filtering everything. Soon I expect to move the whole domain to a new server at which point I will probably move the email account with my domain to Google. Meanwhile I found a compromise: I set Gmail to bring over all the messages at random intervals. The downside: I have to delete spam from two accounts.

Google Voice

By invitation only as of now. It took a couple months, but I set up this account just before I purchased an HTC Evo with Android. I selected a new phone number (yes, for free) and connected the account to my office and mobile phones. Ironically I see to use the Evo less than before. I record my voice mail out going message at Voice from the browser. Voice transcribes messages to text. Although the errors are numerous I can glean the main points of most messages without listening to them. I could forward them via email or archive them. I can easily listen to a selected message from phone or computer without listening to all older messages. To make a call now while at the computer I copy and paste the number, tell Voice which phone I want to use and click connect. The phone rings. I pick it up and hear the ring tone until the person (or robot) I am calling picks up. Regardless of which phone I use, the recipient sees only the caller ID of my new Voice number. Since I do not block this number my patients do not have to turn off blocking of unidentified calls for me to return their call from my mobile or home numbers. I have not used the feature which makes all my designated phones ring when a caller dials my Voice number (which is a local number by my choice).

Android

I chose the Evo for many reasons, but particularly because of the integration of Android with the other Google offerings, something iPhone cannot offer. Almost everything I see from my browser now appears on my phone as well. I use GoldMine to manage all my personal, business, and professional contacts. Although outdated I expect it will continue to do the job until I find a comparable application in the cloud. Google still does not do all I need, such as keep a history of prescriptions ordered for patients, appointments and phone calls. But with Companionlink I can sync a select group of my GM contacts (phone numbers, addresses, etc.) to the Evo. Android allows me to direct all calls from selected contacts, mostly patients, to voice mail. Voice alerts me by text message that a caller has left a new voice mail message, and the phone notifies me with a distinctive ring tone.

I have not yet been able to configure the Evo to only take calls from numbers in my contacts. I tried an Android app called Gblocker, but it seemed that every few days my phone would go into silent mode with no action on my part. I deactivated Gblocker almost a week ago, and the problem has not recurred. Since then I downloaded an upgrade to Gblocker. I will likely try it again soon.

Tasks

My favorite! Integrated with gmail this to do list allows me to keep items in order and it appears in all my browsers as well as on my phone. I use it for shopping lists, too. For example, I keep on an item entitled "Home Store" a list of all the items I need to buy next time a shop at one.

Calendar

I could sync a Google calendar with GoldMine, but I am not yet comfortable having all my patients names in the cloud. But I can sync with the Evo anyway, so I have a calendar there that is as up to date as the last time I synchronized using CompanionLink. I maintain one personal calendar accessible to selected family members, some of whom have permission to make edits themselves.

Chrome

It works fine as a browser but also allows me to add widgets (?). The Voice widget displays the number of unplayed voice mails. It also allows me to easily initiate calls (or texting, which I rarely use) as described above without searching for the Voice tab. Also, phone numbers displayed on Web pages appear as links. To call the number I simply click on it, select the phone I want to use, etc. Since I started using it I have also been hearing sporadic bells ringing. Unless I am hallucinating I believe one or more of my devices may be alerting me to the arrival of a new message.

The Gmail widget turns a flip when a new message arrives and tells me how many unread messages reside in my inbox. Clicking on it takes me to the inbox. I installed another Gmail widget that should allow me to send the current URL in the browser to a selected email address. I have not used that one yet.

Docs

Not all that sexy, but I have started moving documents that I might want to access from different computers to the cloud. I wish it would allow me to incorporate the name and address from my Google contact list, which I do not really use, into a letter template. For that I still rely on GoldMine and Word.

Sites

I have recreated my practice Web site and am in the process of redirecting my domain. Again, the price is right: free. And it offers some functionality that was not available in my now obsolete MS FrontPage.

Next

One of my other reasons for selecting the Evo: It has a front facing camera that should in theory allow for videoconferencing. In fact, soon before I purchased mine I found an Android app called Fring that allowed use of a Skype account with the phone. The only time I tried it the quality was unacceptable, but I was only using 3G, instead of 4G. Since then Skype pulled the plug on Fring. I hope to try Google's own video conferencing when I get a chance.

I would like to keep patient records in the cloud, but I need to determine how private and secure they will be first. Fortunately I am not a covered entity, so I do not have to worry about HIPAA.

As for moving contacts out of GoldMine and into the cloud I understand that comparable cloud based apps exist, some of which may actually use Google apps.

With all these capabilities available for free, and with all their integration, I see little need to venture into a costly EMR.

Tarasoff Duties and Independent Examination

Gutheil and Brodsky have contributed an excellent introduction to the question of whether Tarasoff duties to warn or protect should apply to forensic examiners. (J Am Acad Psychiatry Law 38:57–60, 2010) I will add my thoughts and opinions.

Tarasoff duties and law evolved out of, and were originally intended to apply in, cases in which a patient or client obtaining treatment or other help revealed a the threat to harm a third party. More recently the AMA proclaimed (wrongly in my opinion) that forensic examinations constitute practice of medicine. Thus the question posed here arises.

The distinction between treater and examiner is not trivial. In the context of treatment the patient may view the professional as a trusted helper. By contrast the examinee in a forensic evaluation may view the examiner as the agent of an adversary bent on harming her. Any analysis of this question must keep that fact in close view. It impacts not only the examiner's analysis of the threat, but perceptions of confidentiality. The article refers to the examiner's "alliance" with the examinee, but there may be no such alliance in this setting. The examinee may be angry, hostile, fearful and distrustful, or the threat may be a manipulation in ways quite different from what might be expected in a treatment relationship. The threat might even be a way of "faking sick."

Another dimension absent from the article: The degree to which the reason for the examination relates to the threat. For example, an examinee may threaten to harm the individual(s), perhaps an employer, who referred them for evaluation, or the examinee's employer may have requested the evaluation after a less explicit threat or a display of hostility in the context of work. At the other end of the spectrum a mother undergoing parenting evaluation in the context of divorce might reveal a plan to kill a woman she believes may have stolen her new lover. 

Adding a specific warning of non-confidentiality might help avoid the whole issue. The examinee might simply refrain from revealing such a threat for fear that it will be used against her. If the examiner remains ignorant of the examinees evil intent, he will be spared this dilemma. In the case where, as described above, the third party requested the examination specifically to assess risk of violence the examiner will not get off so easily, but must actively seek evidence of such intent. In my opinion such a warning should not be needed. Arguably the examinee's attorney should warn their client prior to any such examination, but of course there may not be an attorney. Regardless, preserving the safety of the intended victim should always be the priority, easily trumping any confidentiality concerns: This is not medical care. In fact such examinations are usually about money.

Hints at a threat by the examinee may demand further questioning by the examiner. How should an independent examiner pursue such questioning? It may require departure from the matter at issue in the examination. The facts that no prior relationship between examiner and examinee exists and that no subsequent relationship will evolve further discriminates such an investigation from what might occur in the context of treatment. And embarking upon such an investigations may alter the basis of the examination, perhaps irretrievably. At a minimum the examiner will need to ascertain the identity of the intended victim with sufficient specificity to enable protective actions. But the examinee might refuse. Then what must the examiner do? If the examinee threatens to kill his cousin, for example, can the examiner assume that other authorities can and will determine this individual's identity and extend protection, and can the examiner rest assured that he has discharged all duty, or more importantly, that the individual will not come to harm? The title of the article implies accurately that such a predicament could arise in independent examinations other than psychiatric. We should keep in mind too that most non-psychiatric physicians have little training and less skill in assessment of risk of violence.


The safety of an independent examiner might be at risk more so than that of a treater. The examiner must first protect herself. The examiner must make decisions based on different kinds of knowledge. Although the examiner may have reviewed extensive records not typically accessed by a treater, the examinee might be more open and honest with someone perceived as a potentially helpful advocate rather than adversary.

There should be no duty to inform the attorney of the examiner's potential duty to warn or protect. Attorneys should be cognizant of any such duty of the examer. An attorney restricted by privilege could still advise the physician as to how to proceed.

The physician's job is to evaluate (forensic) or to diagnose and treat (clinical) not to protect others from potential violence. That is a job for law enforcement, so informing the examinee's treating professional(s) as the authors suggest might be tantamount to the blind leading the blind. And this assumes that such a treating professional exists, which may not be the case.

If you find yourself in such a predicament apply the Golden Rule. Ask yourself what you would want another examiner to do if the intended victim were yourself or a loved one. And judges, juries and lawmakers should also ask themselves whether they would want that professional to hesitate to warn or protect themselves or a loved one out of fear of professional or legal consequences arising out of such protective action. Attempting to protect an intended victim should arise, not from statutory duty or professional ethics but from "a normal sense of personal and professional responsibility."