The Santa Ana winds created significant havoc in the early part of fire season this year. Greater than 1000 homes destroyed, 2 deaths, many injuries and hundreds of thousands of evacuations. Living 8 blocks from the ocean I felt fairly secure, although we do live next to a lagoon and the authorities asked us to leave on Monday AM because of the potential for fire spread. My colleague Dr. Eric Drimmer was at greater risk as he lives more inland than I do. I pray that his home is alright as he and everyone else don't deserve to lose their homes.
A reporter asked me my thoughts about the effect of the fire and upheaval on people's mental health. I did my best to answer cogently. It is interesting that the idea of stress was first noted by a Canadian researcher named Hans Selye in 1936. It is hard to imagine that his original idea of stress affecting our physical health was originally met with skepticism. Anyway, the first effect on people is to feel anxious or tense with increased heart rate and rapid breathing. The desire to escape is significant which serves to protect us and is helped by these physiological changes. If the stress does not abate, exhaustion follows. Exhaustion is a politically correct term for depression.
What people need immediately after a life threatening stress is shelter, food and a secure place to recover with lot's of human contact. Anger, sadness and fear are common feelings and should not be denied. At the same time, acting out anger al;ways makes things worse. Walking off that feeling off is always the best approach. Any injuries or medical problems need to be addressed quickly also.
The feeling of loss of control after an out of the ordinary event is significant also. My feeling is to ask people what they would like so that the feeling of some control is returned. Making decisions is a form of control. Reassurance that they are safe and every effort will be made to help them is important. The mayor of San Diego (Larry Sanders) and Governor Arnold Schwarzenegger did an excellent job of mobilizing help and also providing for people's basic needs.
Representative Duncan Hunter was very informative in his description of being more prepared next time. The reassurance of dong more next time is important in helping others feel more safe living here. He described hitting the next fire hard initially, so that things don't get out of control. Considering the military presence and capacity in San Diego, Mr. Hunter talked about being more prepared with helicopters, fixed wing water bombers and overcoming the bureaucracy which can slow things down.
Speaking of bureaucracy, one of my patients called me in the middle of this disaster to say that her pharmacy would not refill her prescription that she has taken for at least a year, without a written doctors prescription. It is another example of how a mental health problem is always treated as less important than medical problems. Would they have been so difficult with this woman if she needed her insulin or hypertension medication? I can't tell you which pharmacy it was, as I would need to hear their side of the story. Still, it sounded officious, unhelpful and bureaucratic to me. I would assume the pharmacist would be aware that we were in an emergency situation in the county.
Duncan Hunter went on to say that Governor Schwarzenegger was an example of a hands on leader and someone who insists on getting things done quickly. I have loved Arnold since his earliest career as a weight lifter and he seems to get better with age. One person that he spoke to said she was mostly struck by how much he cared. It's too bad that more of our politicians aren't like him and Duncan Hunter.
Children should be reassured and kept close. Constant re-exposre to the trauma by watching TV is not a good idea for children and adults. Especially when they show the same pictures and tell the same story over and over. I must say that I was more impressed by the local TV than the national coverage. Keeping family and friends close, apart from providing for basic needs, is really the best we can do to help. As time goes by, the need for more mental health help is probably wise, depending on each and every case. Early trauma counseling probably does more harm than good according to studies after 9-11. Still the risk of emerging Post Traumatic Stress disorder or depression is not insignificant. Getting enough sleep, starting to rebuild and recognizing that the worst off people lost family, friends or pets is a good start. Houses can be rebuilt, people can't.
This is my view at least. In general, I was impressed by how much help was made available. As Dr. Selye remarked years ago, helping others is very good for both your physical and mental health. I try to never forget that one of the best exercises for the heart is to reach down and help someone up. Let me know what you think and take care.
Thursday, October 25, 2007
Sunday, October 21, 2007
Living in America
I moved to America to live and work in the most productive country in the world. My grandfather was a coal miner from Pennsylvania, my wife was born in northern California and it was exciting to move here from Canada. My intent was to live in an environment where the finest minds in Psychiatry existed. The University of California, San Diego has numerous thought leaders in mental health and their presence inspires me. I had not yet experienced interacting with health care insurance companies where doctors are assumed to be either stupid or fraudulent, although that is another story.
A woman named Dr. Georgiana Rodiger lives and works in Pasadena California and last week I went to visit her. She is not a famous academic at a famous university, although I had heard much about her from my partner Dr. Pam Laidlaw. The office I practice in with Dr. Laidlaw was originally Dr. Rodiger's. Before meeting Dr. Rodiger I read her book, "The Miracle Cure." In Pasadena I had the chance to observe Dr. Rodiger supervise her colleagues as they brought forward people that were struggling in psychotherapy (talking therapy) that they treated. Dr. Rodiger's comments were a combination of both kindness and insight that can only be found in experienced experts. The comments she made were direct and easy to appreciate for seasoned colleagues. After the supervision, Dr. Rodiger spoke to me about my son and a number of other issues. She mentioned casually that she has made a a study of numerous saints as Dr. Rodiger is also a religious and spiritual person.
Driving back to San Diego I could not stop thinking about the morning's experience. That night I had trouble sleeping, which is uncommon for me unless I am excited or worried. Since we met, when I think of Dr. Rodiger's wisdom and generosity, I think she may be a saint herself. In my career I have met many extraordinary individuals that work in mental health. Dr. Rodiger exceeds all of these individuals in my opinion. I spoke to Dr. Laidlaw about my impression and she agreed with me as do most of the people that Dr. Rodiger works with. America is privileged to have people like Dr. Rodiger caring for and teaching others how to help people with mental health conditions. It makes me proud to be a psychiatrist knowing I have colleagues like Dr. Rodiger.
At the same time there are disturbing things in America. It seems the higher one goes, the greater potential for the depths. In the November 2007 Vanity Fair, I read about issues that shocked me. According to one article, some military contractors appear to be committing fraud, stealing money from American taxpayers at an amazing rate. Some estimates are that billions have been over charged, making a small group of these thieves wealthy. Until the cases are heard everyone is innocent, although apparently the justice department is reluctant to go after contractors like Halliburton and it's subsidiary KBR.
While congress debates cutbacks for mental health care, it seems ironic. The thought of cutting millions that help people get better and/or even return them to becoming taxpayers themselves, while neglecting the prosecution of people charged with stealing billions seems wrong to me. If hte stolen money could be recovered it could be put toward a good cause with moneyh to spare. There would probably be enough for some of my patients to even buy a bike which tey fantasize about. Can you imagine getting around San Diego on foot, let alone a bike? Please read the article on page 212 of Vanity Fair November 2007 edition titled "The People vs. The Profiteers" by David Rose. See if you find it as disturbing as I did, considering all the other needs in America that require those stolen funds. In fairness, maybe there was no intent to defraud, it was just an honest mistake. Maybe the tooth fairy is real also.
Two weeks ago I was on the deck of the Midway, an aircraft carrier docked in San Diego. The description of landing and leaving the deck of this great ship by brave airmen left me with goosebumps. What the people of America have been able to accomplish in so many settings is inspiring. From the mental health practitioners to the brave people of their military, American's have much to be proud of. The problems will be solved and my hope is to make a contribution to this great country and the great people I have met. If someone has stolen from these people, they should be ashamed of themselves. No matter how rich they became though their greed.
A woman named Dr. Georgiana Rodiger lives and works in Pasadena California and last week I went to visit her. She is not a famous academic at a famous university, although I had heard much about her from my partner Dr. Pam Laidlaw. The office I practice in with Dr. Laidlaw was originally Dr. Rodiger's. Before meeting Dr. Rodiger I read her book, "The Miracle Cure." In Pasadena I had the chance to observe Dr. Rodiger supervise her colleagues as they brought forward people that were struggling in psychotherapy (talking therapy) that they treated. Dr. Rodiger's comments were a combination of both kindness and insight that can only be found in experienced experts. The comments she made were direct and easy to appreciate for seasoned colleagues. After the supervision, Dr. Rodiger spoke to me about my son and a number of other issues. She mentioned casually that she has made a a study of numerous saints as Dr. Rodiger is also a religious and spiritual person.
Driving back to San Diego I could not stop thinking about the morning's experience. That night I had trouble sleeping, which is uncommon for me unless I am excited or worried. Since we met, when I think of Dr. Rodiger's wisdom and generosity, I think she may be a saint herself. In my career I have met many extraordinary individuals that work in mental health. Dr. Rodiger exceeds all of these individuals in my opinion. I spoke to Dr. Laidlaw about my impression and she agreed with me as do most of the people that Dr. Rodiger works with. America is privileged to have people like Dr. Rodiger caring for and teaching others how to help people with mental health conditions. It makes me proud to be a psychiatrist knowing I have colleagues like Dr. Rodiger.
At the same time there are disturbing things in America. It seems the higher one goes, the greater potential for the depths. In the November 2007 Vanity Fair, I read about issues that shocked me. According to one article, some military contractors appear to be committing fraud, stealing money from American taxpayers at an amazing rate. Some estimates are that billions have been over charged, making a small group of these thieves wealthy. Until the cases are heard everyone is innocent, although apparently the justice department is reluctant to go after contractors like Halliburton and it's subsidiary KBR.
While congress debates cutbacks for mental health care, it seems ironic. The thought of cutting millions that help people get better and/or even return them to becoming taxpayers themselves, while neglecting the prosecution of people charged with stealing billions seems wrong to me. If hte stolen money could be recovered it could be put toward a good cause with moneyh to spare. There would probably be enough for some of my patients to even buy a bike which tey fantasize about. Can you imagine getting around San Diego on foot, let alone a bike? Please read the article on page 212 of Vanity Fair November 2007 edition titled "The People vs. The Profiteers" by David Rose. See if you find it as disturbing as I did, considering all the other needs in America that require those stolen funds. In fairness, maybe there was no intent to defraud, it was just an honest mistake. Maybe the tooth fairy is real also.
Two weeks ago I was on the deck of the Midway, an aircraft carrier docked in San Diego. The description of landing and leaving the deck of this great ship by brave airmen left me with goosebumps. What the people of America have been able to accomplish in so many settings is inspiring. From the mental health practitioners to the brave people of their military, American's have much to be proud of. The problems will be solved and my hope is to make a contribution to this great country and the great people I have met. If someone has stolen from these people, they should be ashamed of themselves. No matter how rich they became though their greed.
Tuesday, October 9, 2007
Access to care
A very serious illness called Schizophrenia is not being treated adequately because of access to care. This illness has had a number of new medications introduced over the last 15 years to treat it. Unfortunately, many of these medications are not effective enough. Some of them have side effects that are very serious like weight gain, diabetes and elevated lipid levels. Clearly the side effects are not more significant than the illness, in terms of disability. Unfortunately, because of the lawyers wanting a piece of the health care pie, the side effect issue is often augmented and used as an opportunity to make some people rich (not the people with the problem, those that represent them). Even though medications are necessary for this illness, they are usually available, even if it is at a very high price. Maybe the price wouldn't be so high if the companies making the medications could worry less about litigation.
The treatment where access is denied by many insurers and even some governments is talking therapy and rehabilitation. Did you know that if you don't have medi-care and medi-cal coverage in California, there are many rehabilitation programs you can't attend. These programs are the only way many patients can learn to cope better, care for themselves and maybe in some instances even work. The combination of our current medications with rehabilitation programs is the only way to get better. It would be called optimal treatment, what you would want for your loved one's or yourself. Medications managed by doctors that care enough to optimize treatment and reduce side effects, along with talking therapy that helps patient fear less. Many psychiatrists I have worked with fit this bill. To assist the patient with schizophrenia get to a point where their self-esteem will recover to some extent. To deny access to this kind of care that can be provided at not a great expense, is a crime.
Schizophrenia is a condition where people feel that others might want to hurt them. In an excellent outpatient program like Palomar Intensive Outpatient program, people have a chance to be their best with a devastating disease. The staff at this program are dedicated, caring, empathic and devoted to helping people with severe mental illnesses achieve their goals. I have seen families break down and cry when they discuss their loved ones suffering and how the staff at Palomar helped them. Nothing is more rewarding to a health care provider than to see someone face their illness and fears, get the assistance they require and watch the person smile again.
Karen, Teri, Mona, Victoria, Jackie, Judith and Angelica are the people in our program that save lives and then assist our patients to embrace the idea that their lives matter. That they matter. Working with the people I work with makes me feel like there couldn't be a better branch of medicine than psychiatry. To think that if you get the diagnosis of schizophrenia after the age of 18 years and not be able to get medicare so you can get the rehabilitation necessary, is arbitrary and cruel.
Maybe a congressman, senator or President needs to have a loved one go through this illness, not have rich parents, and need a program like ours that they can't get into before things change. I don't care how things need to change so that people with a difficult illness get the help they need, just that they get it. Thanks again to the staff and patients at Palomar Intensive Outpatient Program.
I should mention our administrators Sheila and Susan for helping us make it happen also. Their friendly and professional attitude makes a difference when advocating for mental health care. If you agree or think otherwise about any of these thoughts, leave a comment for all of us who care to ponder.
The treatment where access is denied by many insurers and even some governments is talking therapy and rehabilitation. Did you know that if you don't have medi-care and medi-cal coverage in California, there are many rehabilitation programs you can't attend. These programs are the only way many patients can learn to cope better, care for themselves and maybe in some instances even work. The combination of our current medications with rehabilitation programs is the only way to get better. It would be called optimal treatment, what you would want for your loved one's or yourself. Medications managed by doctors that care enough to optimize treatment and reduce side effects, along with talking therapy that helps patient fear less. Many psychiatrists I have worked with fit this bill. To assist the patient with schizophrenia get to a point where their self-esteem will recover to some extent. To deny access to this kind of care that can be provided at not a great expense, is a crime.
Schizophrenia is a condition where people feel that others might want to hurt them. In an excellent outpatient program like Palomar Intensive Outpatient program, people have a chance to be their best with a devastating disease. The staff at this program are dedicated, caring, empathic and devoted to helping people with severe mental illnesses achieve their goals. I have seen families break down and cry when they discuss their loved ones suffering and how the staff at Palomar helped them. Nothing is more rewarding to a health care provider than to see someone face their illness and fears, get the assistance they require and watch the person smile again.
Karen, Teri, Mona, Victoria, Jackie, Judith and Angelica are the people in our program that save lives and then assist our patients to embrace the idea that their lives matter. That they matter. Working with the people I work with makes me feel like there couldn't be a better branch of medicine than psychiatry. To think that if you get the diagnosis of schizophrenia after the age of 18 years and not be able to get medicare so you can get the rehabilitation necessary, is arbitrary and cruel.
Maybe a congressman, senator or President needs to have a loved one go through this illness, not have rich parents, and need a program like ours that they can't get into before things change. I don't care how things need to change so that people with a difficult illness get the help they need, just that they get it. Thanks again to the staff and patients at Palomar Intensive Outpatient Program.
I should mention our administrators Sheila and Susan for helping us make it happen also. Their friendly and professional attitude makes a difference when advocating for mental health care. If you agree or think otherwise about any of these thoughts, leave a comment for all of us who care to ponder.
Tuesday, October 2, 2007
60 Minutes
60 Minutes is perhaps the best news show ever. It is a staple of American life, or at least my life. The courage of reporting and trying to show both sides of a story seems to be the policy. Last Sunday, Katie Couric exposed a serious issue for people that visit psychiatrist's.
Apparently, a young girl (age 3 I believe) was behaving in an odd way according to her parents and they sought psychiatric help. The psychiatrist seemed like a nice person that was trying to help them. A diagnosis of Bipolar disorder was made in the child and medications were prescribed. According to the story, the parents gave more medication than the doctor recommended and the child died. Nothing for a parent could be worse than losing a child. Still, the parent or parents were charged with murder and the mom is now behind bars. The details are no doubt greater than what was in the show.
Katie interviewed the mom and a psychiatrist in Boston who has done a tremendous amount of research into Bipolar disorder in children. He is a well known doctor in child psychiatry circles and is clearly an authority. In terms of moving knowledge forward, he is doing his best. A psychiatrist in Oregon was interviewed also. His contribution to the story was his experience with children in his practice that take numerous medications for Bipolar disorder. Some of these children had their diagnosis changed and were prescribed fewer medications with good outcomes. Bipolar disorder may occur in children although it is probably infrequent. Options other than medications might be reasonable considering the lack of study using medications in children this young. I am assuming that talking or behavior therapy were not offered although I may be incorrect.
The whole story is important as another example of "who's to blame." Psychiatrists that prescribe medications not approved for children are taking a big risk with their patients. Still, as the expert from Boston argued, something needs to be done now and not always when all the data is in. I would argue that as long as patients can appreciate the risks and controversy, they can at least make informed decisions. If the doctor feels that he would proceed with the treatment in his/her own children, it is a viable option. All of the options take time to explain however, and not everyone can understand things quickly.
My position is to wait after explaining my perspective for up to a week until the parents or patient can digest the discussion and return to ask further questions. The risk of treatment must be less than the risk of the condition at least. All of this takes time, and many doctors are asked to see patients quickly to cut costs and see more patients, encouraged by the insurance companies so they can make more money or control care. Most insurers will pay for 15 minutes of a psychiatrists time and make the doctor jump through lots of hoops if he or she would like more time to talk to the patient. It is the principle reason I have gone into a practice where the shortest visit is 30 minutes and I usually recommend 1 hour. I don't call my sessions medication management either. The sessions are to discuss psychiatric management, talking therapy and other options. Not just medications. Medications are an important aspect of treatment when it is necessary, although it can't be the only approach to consider.
It was not emphasized in the show, although hurrying lends itself to making mistakes in psychiatry and other branches of medicine. This perspective may not be a factor in this tragedy, although I would be surprised if it didn't play some role. With more time to talk to the parents, consider other approaches and diagnoses, maybe this tragedy might have been averted. It is not to blame anyone, just to offer another explanation for what happened to a little girl, that is now not with us anymore. Too much emphasis on using medications and not enough time to assess patients. Like all tragedies, there are many factors that must come together for it to occur. Let me know what you think as I don't intend to blame anyone.
Apparently, a young girl (age 3 I believe) was behaving in an odd way according to her parents and they sought psychiatric help. The psychiatrist seemed like a nice person that was trying to help them. A diagnosis of Bipolar disorder was made in the child and medications were prescribed. According to the story, the parents gave more medication than the doctor recommended and the child died. Nothing for a parent could be worse than losing a child. Still, the parent or parents were charged with murder and the mom is now behind bars. The details are no doubt greater than what was in the show.
Katie interviewed the mom and a psychiatrist in Boston who has done a tremendous amount of research into Bipolar disorder in children. He is a well known doctor in child psychiatry circles and is clearly an authority. In terms of moving knowledge forward, he is doing his best. A psychiatrist in Oregon was interviewed also. His contribution to the story was his experience with children in his practice that take numerous medications for Bipolar disorder. Some of these children had their diagnosis changed and were prescribed fewer medications with good outcomes. Bipolar disorder may occur in children although it is probably infrequent. Options other than medications might be reasonable considering the lack of study using medications in children this young. I am assuming that talking or behavior therapy were not offered although I may be incorrect.
The whole story is important as another example of "who's to blame." Psychiatrists that prescribe medications not approved for children are taking a big risk with their patients. Still, as the expert from Boston argued, something needs to be done now and not always when all the data is in. I would argue that as long as patients can appreciate the risks and controversy, they can at least make informed decisions. If the doctor feels that he would proceed with the treatment in his/her own children, it is a viable option. All of the options take time to explain however, and not everyone can understand things quickly.
My position is to wait after explaining my perspective for up to a week until the parents or patient can digest the discussion and return to ask further questions. The risk of treatment must be less than the risk of the condition at least. All of this takes time, and many doctors are asked to see patients quickly to cut costs and see more patients, encouraged by the insurance companies so they can make more money or control care. Most insurers will pay for 15 minutes of a psychiatrists time and make the doctor jump through lots of hoops if he or she would like more time to talk to the patient. It is the principle reason I have gone into a practice where the shortest visit is 30 minutes and I usually recommend 1 hour. I don't call my sessions medication management either. The sessions are to discuss psychiatric management, talking therapy and other options. Not just medications. Medications are an important aspect of treatment when it is necessary, although it can't be the only approach to consider.
It was not emphasized in the show, although hurrying lends itself to making mistakes in psychiatry and other branches of medicine. This perspective may not be a factor in this tragedy, although I would be surprised if it didn't play some role. With more time to talk to the parents, consider other approaches and diagnoses, maybe this tragedy might have been averted. It is not to blame anyone, just to offer another explanation for what happened to a little girl, that is now not with us anymore. Too much emphasis on using medications and not enough time to assess patients. Like all tragedies, there are many factors that must come together for it to occur. Let me know what you think as I don't intend to blame anyone.
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