Monday, December 27, 2010

Placebo Rocks

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


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

Wednesday, December 22, 2010

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.

Thursday, December 16, 2010

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

Wednesday, December 8, 2010

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.

Thursday, December 2, 2010

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.