Testing the Unconscious

Freud called dreams the "royal road to the unconscious," but the authors of the Implicit Association Test seem to claim an ability to measure "implicit cognition" (Is that a euphemism for unconscious?) by using a computer administered psychological instrument.

This approach was previously reported to uncover racial bias in the practice of medicine: http://www.ama-assn.org/amednews/2009/09/28/prsa0928.htm, but according to an article in a recent issue of Psychiatric News a variation of the test appeared to predict suicide risk more accurately than by traditional means such as psychiatric interview. I took one of the tests myself. The result was not what I would have expected. Did the test err, or do I simply not know or acknowledge my true attitudes? I suppose the authors might claim the result proves that my attitude is unconscious, but as far as I know no method of tapping the unconscious exists that might provide researchers with a way to validate the results of such a test, except perhaps by looking at my subsequent behavior.

The notion of a test of unconscious intent (Isn't that a contradiction in terms?) sends me on flights of fantasy. I imagine requiring psychiatric patients to undergo testing on a mobile device every 24 hours with results transmitted to a central clearinghouse. If the patient starts to lean toward suicide, the men in white coats home in on their GPS signal, pick them up, and hospitalize them until their attitudes right themselves, with or without treatment. Of course one would have to pass the test before purchasing a firearm, or razor blades, or matches. Or before being allowed to pilot an airplane or drive a car, or cross a street, or climb higher than the first floor of a building. Could we detect future suicide bombers?

Why limit the use of this technology to prediction of suicide, or to psychiatric patients? If such a test could detect intent to rob, rape or kill, to engage in insider trading, run a red light or shoplift, we could require everyone to take it and virtually eliminate crime. Maybe, rather than requiring formal testing, analysis of patterns of Internet use such as Web sites searched or visited could allow, for example, determination of how one might intend to vote in an election. Could such information be used to subtly influence attitude, intent or even religious belief by channeling selected stories through news sites and other media, or even what happens to you when you play World of Warcraft? And since it's all unconscious, how would you know? The possibilities for abuse approach infinity.

Somebody please make a movie!

You can take the tests yourself at: https://implicit.harvard.edu/implicit/, provided you can reign in your paranoia.

How Psychiatry Works

An admittedly oversimplified illustration of how psychiatry works:

Scenario One

You have been suffering from loss of energy and motivation for a month or so, so you visit your primary care physician. She orders a blood test and finds that your thyroid stimulating hormone (TSH) is high. She diagnoses hypothyroidism as the most likely cause of your symptoms, rules out more serious disorders with more tests, and prescribes thyroid replacement drugs. After you start taking them you get better. She recommends that you continue taking them indefinitely.

Scenario two

What doctors call the history of present illness is the same as in Scenario One, but this time when the doctor finds that all your blood tests were normal, she tells you she cannot find a physical illness that might explain your symptoms, diagnoses some kind of depression (i.e. it's all in your head) and refers you to me, the psychiatrist.

You have become a medical leftover. Specifically treatable physical illnesses do not explain your symptoms, so in many cases the only physician who will take care you is a psychiatrist. But not to worry: Psychiatrists generally like talking to people, are fascinated by mental and emotional problems, and like helping people like you solve them. In the past you might have been locked up in an asylum or referred for psychoanalysis, but today, fortunately, we have specific forms of psychotherapy that can treat mental disorders, and we have a host of drugs that for most people are relatively safe and effective, somtimes miraculously so.

Diagnosis

After collecting lots of information about your history and your symptoms I will probably have some vague idea of your diagnosis. Given all the recent controversy about DSM V you might think this is a critical step. In fact it is somewhat important. I don't want to treat someone with schizophrenia for panic disorder or someone with social phobia for bipolar disorder, but I usually make a mental jump to the most important phase which is to choose a treatment that is most likely to help you with minimal adverse effects and minimal delay. Another nice thing about many of the drugs we have today is that, for example, antidepressants, at least most of them, often work very well for anxiety as well. That makes it less critical to determine whether you suffer from, for example, dysthymic disorder, or generalized anxiety disorder. If I prescribe paroxetine and you come back two weeks later to tell me that you feel all better, who cares how we categorize your problem? (It may be important to rule out bipolar disorder since evidence suggests many drugs with antidepressant effects can exacerbate the condition.)

Over-diagnosis

Many people that get diagnosed with bipolar disorder or attention deficit disorder may have never had either. A researcher or two publish data suggesting that we have missed a few cases, and everybody jumps on the bandwagon trying to make sure they never miss the disorder. Often we overshoot the mark and apply the diagnosis inappropriately. What's wrong with that? Delay in getting the right treatment for the right problem and exposure to adverse effects of the wrong treatment. There can be other fallout from simply having the wrong label as well. For example, if a psychiatrist evaluates your child, and you tell her that Uncle Harry has bipolar disorder, this may influence how the psychiatrist diagnoses your child. So if Uncle Harry really did not have bipolar disorder, your child may get the wrong treatment.

Under-diagnosis

Missing diagnosis can cause problems too. Once more we can have delay in appropriate treatment. But when I tell a patient I don't believe they really suffer from a mental disorder, I can add that we can monitor the symptoms over time with a plan to reassess if they worsen.

Getting It Just Right

We would like to be able to do this all the time, but it just is not possible. When I hear psychiatrists talk about patients as suffering from this or that disorder as though they are absolutely certain of the diagnosis it always makes me wonder. To me, especially if the patient has not responded very well to treatment, and even sometimes when they have, I tend to think of the diagnosis as what we call a working diagnosis. This is a provisional diagnosis we assume to be correct until proven otherwise, often by treatment failure. If I get too confident or locked in to a particular diagnosis there is a risk of barking too far up the wrong tree, usually trying treatment after treatment, all doomed to failure. Better to keep an open mind.

Drugs

You may feel like a guinea pig, but really you're the director auditioning drugs instead of actors. If we get it right with the first one that's terrific, but often patients have to try several medications before finding one that works and has acceptable side effects. Everyone seems to respond differently. Be warned though: You could keep trying different psychiatric drugs and combinations for years and never find one that makes the grade. At some point you may want to figure the solution is not in the (pill) bottle. If you haven't tried it already, consider psychotherapy. For more serious problems ECT and other biological treatments can work wonders.

Once you find a drug that works you have to decide how long to continue it. Some psychiatric drugs can prevent recurrence of your illness. You wouldn't stop oral contraceptives just because you didn't get pregnant. Many patients benefit from lifelong preventive or maintenance treatment, like for the hypothyroidism in Scenario One.

Ask your psychiatrist what to expect in the way of risk of dependence on medications and risk of adverse effects and whether there are ways to manage those risks. Sometimes additional drugs help control side effects of the primary drug. Be sure to keep the psychiatrist apprised of all other medications, conditions, symptoms, and side effects. And make sure the psychiatrist knows if you are disappointed in the effectiveness of the treatment.

Psychotherapy

It works, but not necessarily for your illness. For example, there seems to be no method of psychotherapy that treats schizophrenia, bipolar disorder, or ADHD, and certainly not Alzheimer's. But psychotherapy can help you and your family cope with any of them. Some kinds of psychotherapy actually effectively treat disorders like generalized anxiety disorder and panic disorder. Your psychiatrist may or may not provide psychotherapy. If she does, make sure it's the kind of psychotherapy that best treats your condition. If she doesn't insist that the two professionals communicate about your treatment.

Ask your psychotherapist what to expect, particularly how long the treatment lasts, how it works, and whether family members can be involved. Some kinds of psychotherapy can go on so long you can't tell whether the treatment or tincture of time got you better. Be sure to make the psychotherapist aware of any disappointment in the treatment. And if you don't like your psychotherapist, tell them so. A good one won't hold it against you, and will want to address it as just another interesting problem to work toward solving together.

Disappointment and Failure

If none of the above has produced acceptable results, ask for a consultation or second opinion, or just look for a different psychiatrist or psychotherapist. Most of us want you to get better, even if someone else gets to take some credit. And if you do get better, give yourself most of the credit.

Buprenorphine: First Aid for Overdose?

A couple days ago I read about a new statute in Washington state that protects overdose victims and witnesses from prosecution if they call 911 for help. I assume addicts have died of overdose of illicit drugs either because they feared that calling 911, while possibly summoning help, might also lead to conviction for some kind of narcotic offense.

Whenever I think about illicit drug overdose I recall the scene from Pulp Fiction in which (as I remember it) John Travolta's character jams a needle about three feet long into Uma Thurmond's chest, hoping to save her from death by overdose. He has the angle and approach all wrong for what should be intracardiac injection of epinephrine (I did this myself once with a surgeon at my elbow directing me.), but if only from the pain of her sternum stopping  a large needle, she regains consciousness and survives, maybe even until the end of the film. What this got me wondering was whether even an intoxicated addict faced with an overdose situation might have sufficient cognitive capacity to administer potentially life-saving first aid to self or other with minimal -- or at least acceptable -- risk.

We have known for years that naltrexone and naloxone reverse the effects of opiate agonists like heroin and oxycodone. Show up unconscious in an emergency department, and you'll probably get an injection of naloxone (Narcan) just in case you OD'd on an opiate. But I dare say few opiate addicts keep a supply of naloxone on hand for overdose emergencies. They might, however, have another drug that can block the effects of opiate agonists and can be procured on the street: buprenorphine. And what's more, you can administer the drug by dissolving it under the tongue like nitroglycerin, which is probably safer than swallowing for an unconscious victim. No need for an injection. I even wonder whether it might be adequately absorbed rectally to save a life. Buprenorphine, if it works at all, might also offer the advantage of working longer. Naloxone works rapidly, but has been known to wear off after the patient leaves the ED. Then the drug with which they overdosed, still on board, takes over again, and death ensues.

What would be the downside? Perhaps the worst might be delay in calling for help while attempting this measure, especially if something other than an opiate overdose caused the loss of consciousness. The new WA law might help. And perhaps 911 operators could walk callers through the procedure while help is enroute. Of course if the individual was addicted to opiates and regains consciousness they will likely be in withdrawal. I would be surprised if a number of addicts out there didn't think of this and try it years ago. Should we educate all addicts about it?

What we need now is for experts on management of opiate overdose to collect some evidence and offer their opinions as to whether the idea really works and is safe and feasible, and if so to get the word out. Maybe docs who prescribe opiate analgesics for chronic pain will want to order a few buprenorphine (off label of course) for patients to keep on hand for such emergencies.

Unhinging Dr. Carlat

No, this is not a review. I have not read the book, and I don't entirely disagree with Dr. Carlat's ideas.  I did, however, read a review, which I cannot now locate, but which included a short case said to have come from the book. A brief look may demonstrate the extent to which a different perspective can influence a psychiatrist's approach and challenge the notion that psychiatrists prescribing medication should also provide psychotherapy to most patients. (Let's not blame Dr. Carlat for any of this. The reviewer may have misread Carlat, and I may have misread the reviewer. If I didn't get it right, apologies to Dr. Carlat.)

As I recall the case involved a patient prescribed zolpidem for insomnia. Because of oversedation he nearly or actually wrecked his car. The patient had not been able to muster the courage to contact the doctor about the sedation because of his reluctance to confront authority figures, such as physicians. According to the reviewer Dr. Carlat argued that had he been treating the patient with psychotherapy the patient might have overcome his reluctance, telephoned the physician, and avoided the accident.

Here's how I would approach the case: First, I never prescribe zolpidem. Even if I prescribe a drug for insomnia I prefer melatonin, gabapentin, or a very sedating antidepressant like mirtazapine or trazodone. But before prescribing I want to know the source of the insomnia, and in some cases will recommend a sleep medicine consultation. I also like to address sleep hygiene (behavior) before resorting to a drug. Why would I want to prescribe a drug like zolpidem that can lead to dependence and has been associated with patients eating a buttered cigarette or driving while asleep?

But suppose, against my best professional judgment, I do prescribe zolpidem. I would do so only after warning the patient about the risks involved. And in fact the pharmacist would probably offer the same warnings orally and in writing when dispensing the drug.

But let's say it still boils down to that problem of psychological reluctance to call the authority figure. Successfully addressing such a problem in psychotherapy could take months or years, and there's no reason to believe it would happen any faster if the psychiatrist were providing the psychotherapy rather than a non-physician. Furthermore, we should not assume that psychotherapy would address said reluctance. Many kinds of psychotherapy don't address such problems at all, at least not directly. What would make a difference, however, is how often the patient visits the physician, even for a short visit to talk about medication effects, wanted and unwanted, and even with no psychotherapy.

This case also begs the question of whether psychiatrists should provide psychotherapy so patients can muster the courage to call between appointments about a side effect. I argue that psychotherapy should address a diagnosable mental disorder (however we choose to define it).

And wait. Suppose a sleep medicine physician, or heaven forbid an orthopedic surgeon, prescribed the zolpidem. Would we want all physicians to provide psychotherapy? Orthopods don't even do physical therapy.

This case provides little or no support for the position that psychiatrists should provide psychotherapy. It does underscore the importance of careful selection of medication, avoidance of medication when possible, and adequate patient education. In some cases there may be advantages to one-stop psychiatric shopping, but in this case the frequency of contact, rather than overcoming a psychological problem with psychotherapy might have made the difference.

Medical Practice at a Distance May Be Illegal IV: ME, AK

Continued from: Medical Practice at a Distance May Be Illegal III

Maine:

When I called the Medical Board for the State of Maine I explained that a patient planning to travel during the summer might be in the state at the time of the next appointment, and I asked whether the Board might deem that I would be practicing without a license if I were to a) have a telephone conversation or b) conduct a medication management session via Internet teleconference with the patient. Both of the representatives with whom I spoke referred me to the applicable statutes which of course indicate that one must be licensed by the state in order to legally practice medicine there. However, I detected at least some suggestion that the Board might tend to adopt a lenient view of such practices. I was also told that Maine has not entered into reciprocity agreements with any other state, including New Hampshire and Canada.

Alaska:

(No Sarah Palin jokes, please.) I started with a phone call, but the representative asked me to switch to email. I indicated that a patient might work on a fishing boat harbored in Alaska during the time of the next expected monthly contact. I asked whether the Board might deem that I would be practicing without a license if I were to a) have a telephone conversation or b) conduct a medication management session via Internet teleconference with the patient.

Perhaps the most interesting aspect of the response was the suggestion that if the contact occurred while the boat was in waters beyond the 3 mile limit, Alaska would have no jurisdiction. This might solve the problem with (I count) 21 states. Of course the physician has no way of knowing exactly where the patient is, much less exactly how far from the coast of a given state, and neither the patient nor I have any idea whether the boat will have a broadband connection.

I wonder too about jurisdiction at anchor or a dock. Would the state of VA, for example, claim medical jurisdiction over a German physician attending to a French patient on an Italian cruise ship anchored in Hampton Roads? And is the 3 mile rule universal, or does it vary from state to state?

In the end the Board's representative told me, "if the patient is only here temporarily..., you’re fine." Alaska takes first place for most rational, informative, helpful and reasonable response thus far. So if you plan to boycott AZ this summer because of the immigration law, switch your itinerary to AK and need to talk to your physician, remember that he may not have to say, "Sorry, but I'm not licensed there. You'll have to find a physician who holds an AK license."

A good bet: Send Your Patients to Michigan

DEA Cracks Down On Safe and Efficient Prescribing

A couple weeks ago, after I faxed a prescription refill to a Fred Meyer pharmacy near my office, a pharmacist there telephoned me. She explained that an inspector from the Washington State Board of Pharmacy had instructed the pharmacy to stop accepting  prescriptions for controlled substances with "electronic" signatures, citing DEA regulations. 

I had heard this reference to electronic signatures before and inquired at the Board of Pharmacy where a representative assured me that since I had written the signature on my prescriptions by hand, using a stylus, the Board would not consider it to be electronic. However, when I contacted the inspector, she indicated that since I had not used chemical ink from a pen applied to paper, but instead used a stylus and digital ink on a tablet computer, my signature would now be considered electronic. Never mind that the prescription was sent via fax to the pharmacy, so the pharmacist could not see the original paper or feel for the indentation made by the pen. Presumably the fact that the signature was identical to prior signatures gave it away. (Funny. I would have thought a signature that looked different from a former signature might raise suspicion.)

So at a time when the President encourages eprescribing (where there is no signature at all), at a time when we hear that regulators may permit physicians to order even controlled substances via eprescribing, and at a time when Washington statutes will soon require physicians to use special paper forms for prescriptions (but not when the prescription is faxed), authorities are cracking down on arguably safer and more efficient methods. Now to order a prescription I must print it on paper (wasting trees), sign it with a pen (not one obtained from a pharmaceutical representative of course) with chemical ink, and only then might I scan it with a fax machine to send it electronically to the pharmacy.

But I push back. So I have instituted a policy that I will no longer fax prescriptions to the Fred Meyer pharmacy in question. Rather, after printing and signing the prescription, I will hand it to the patient. Which means the patient must be in the office. If the patient needs to renew between visits they must use a different pharmacy that still accepts "electronic" signatures.

Unfortunately it gets worse: For years I have intentionally omitted my DEA number from prescriptions to prevent patients from using it to forge prescriptions. Instead I provided it by telephone directly to the pharmacist. Now, however, I understand from pharmacists that authorities are cracking down on this practice as well, and have admonished pharmacies not to accept prescriptions for controlled substances unless the DEA number appears thereon.

We can expect to have the DEA to thank for a spike in drug-related crimes and deaths, at least until we can eliminate written or printed prescriptions altogether.

Get This Doc Out of the Pharmacy Loop

• Patient leaves request for refill with pharmacy.
• Pharmacy faxes me request for refill authorization.
• Patient goes to pharmacy expecting to pick refill which is not there.
• Patient leaves message on my voice mail: "Where's my refill!?"
• I retrieve voice mail.
• I call pharmacy: a) I did not receive refill request or b) Pharmacy did not send refill request
• Pharmacy faxes refill request.
• I fax refill or order via eprescribing service.

 I suggested a solution to tech support at the eprescribing service I have been using, allscripts.com: Give the patient limited access to and control over the refill process. Instead of calling the pharmacy the patient would access her account at the eprescribing Web site. She would click on the prescription she wanted to refill and indicate the name of the pharmacy she wanted to use. My eprescibing service alerts me to the request. I access the Web site, check the patient's name, the drug, last date filled, etc. With a click I authorize the refill, and the pharmacy receives the order. The system alerts the patient who can check the status of the whole process at any time, and may opt for email notification from the pharmacy when the prescription has been prepared for pick up. The system could even alert the patient if there is a problem, like the medication is not in stock. The patient can then select a different pharmacy.

What do you think?