Shrink Rap News

Kaitlin Bell Barnett’s first book, Dosed: The Medication Generation Grows Up is a series of case studies of young people who have been taking psychotropic medications since childhood or adolescence. It’s also a look at how being on medication has affected them – not just in terms of how it treated their illnesses or modified their symptoms – but also in terms of how it altered their perceptions of themselves, their personal growth, their relationships with others, and their ability to feel confident about their standing in the world.  

I’d first heard about the book from the author’s Kickstarter campaign to raise funds, and before the book was published, I’d e-mailed the author and knew she had spent dozens of hours with each of her interview subjects, and she assured me that this wouldn’t be an anti-psychiatry tirade, but rather an honest look at how this “first generation” of medicated young adults saw themselves.

I knew just a little about the author from her website and a posted video: She is young, attractive, articulate, and motivated enough to be writing a book on a complex subject. She holds degrees from Dartmouth and Columbia, and she’s been on antidepressants for a decade. 

My first thought – and this is admittedly a bit shallow because I know nothing of her suffering or what dark places she may have been – was that the author didn’t seem any worse for the wear because of her own experiences with psychotropics.  

I expected the book to be more narrowly focused on the emotional lives of the young people whose stories are told, and oddly enough, I was hoping the manuscript would yield some definitive answers!  A bit naive a wish for an experienced psychiatrist, but I can hope for such things, right?

Ms. Barnett tells the stories of five young people who have been treated with medications for the long haul, and she intersperses her own experiences into the narrative.  None of the patients suffered from severe psychotic disorders, and she recreates their stories from their own perspectives, as well as from information she has gotten from family members. The narratives, however, are not the meat of the book – the author uses them as springboards to lead into discussions of all the issues that come up around the use of medications in children.

She does an impressive job of going into depth on every issue one might consider when prescribing medications to children – including metabolic concerns, black box warnings, what factors improve compliance, and how the foster care system uses these treatments, to name just a few.  

And while I mentioned that the emotional lives of the patients aren’t the entire focus of the book, she does a good job of exploring how being on medicine influences how these patients attribute the events in their lives – where their responsibility for their feelings and behaviors may interplay with facets of illness and medication. She presents their stories with balance, some occasional healthy skepticism, and she skips the sensationalist tone that journalists usually take when talking about children and psychiatric medications.  

Usually, when I read a psychiatry book that is written by someone other than a psychiatrist, no matter how good the book is, at some point, I have the sense that there are aspects of illness or treatment that the author just doesn’t fully understand; there may be something that is portrayed with simplicity or the use of  borrowed terms. This book was the exception: Kaitlin Bell Barnett “gets it” and she fully understands the issues she discusses about child and adolescent psychiatry. Had there been an “M.D.” after her name, I would have read this book believing she was a child psychiatrist.  Her level of sophistication and her comfort with psychiatric jargon was such that I wondered if the lay reader – a teenager or a parent considering medication for their child – would fully understand.  For the nuanced reader, however, and certainly for everyone prescribing to children, this book is a tremendous contribution.  

I had two criticisms of the book that I want to expand on from my own experience. The author talks in detail about how taking medications influences children’s views of themselves and their experience of the world, and how people are often secretive and alone in this endeavor. There were moments when I felt like she was talking about the issues related to medication in a vacuum, but the children she portrays are not playing on a level field with children who don’t have psychiatric problems. They start out with tangible suffering, described quite poignantly, and the question of how medications influence the young person’s worldview is a difficult one.  

 

The first question, which is alluded to but is not the topic of the book, is how does having a mental illness and all that entails, color the child’s life, relationships, self-attitude, and future?  I don’t believe the two questions – how does medicine change you, versus how does mental illness change you –c an ever fully be separated, and in all fairness, the author didn’t actually try to separate them, she simply emphasized the medication aspect and all the unknowns that go along with that.

My second issue with the book is a bigger gripe, one I’m not giving a pass to.  There are many references to how medications are prescribed – quickly and sometimes thoughtlessly – and the role of psychotherapy – mostly cognitive-behavioral therapy – in the treatment of mental disorders. The author talks about the “15-minute medication check” and how psychiatry doesn’t allow the time for doctors to get to know their patients in the full context of their lives, much less allow time for the patients to discuss how they feel about their medications.  Ah, psychiatry is reduced to a symptom checklist followed by medication adjustments.

And while this may be how psychiatry is practiced by some doctors or in some settings, it’s not how everyone practices, and there are certainly child psychiatrists who see patients for psychotherapy, or who see patients for 50-minute sessions to monitor medications, even if formal psychotherapy is not being done. The author does not mention, except as an afterthought at the very end of the book, the option of seeing a psychiatrist for more than a rushed visit.    

I’ll let the young people’s histories speak for themselves; they did not all turn out as I would have expected and the reader will enjoy following their stories.

The book is thoughtfully written, a wonderful presentation of the full range of the issues everyone should be thinking about when prescribing psychotropics to children and teens, and Kaitlin Bell Barnett does a commendable job of communicating her masterful understanding of a complex topic.

—Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you’d like to see Kaitlin Bell Barnett talk about her book, her video is posted on Shrink Rap here (taken from the Kickstarter site).

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Kaitlin Bell Barnett’s first book, Dosed: The Medication Generation Grows Up is a series of case studies of young people who have been taking psychotropic medications since childhood or adolescence. It’s also a look at how being on medication has affected them – not just in terms of how it treated their illnesses or modified their symptoms – but also in terms of how it altered their perceptions of themselves, their personal growth, their relationships with others, and their ability to feel confident about their standing in the world.  

I’d first heard about the book from the author’s Kickstarter campaign to raise funds, and before the book was published, I’d e-mailed the author and knew she had spent dozens of hours with each of her interview subjects, and she assured me that this wouldn’t be an anti-psychiatry tirade, but rather an honest look at how this “first generation” of medicated young adults saw themselves.

I knew just a little about the author from her website and a posted video: She is young, attractive, articulate, and motivated enough to be writing a book on a complex subject. She holds degrees from Dartmouth and Columbia, and she’s been on antidepressants for a decade. 

My first thought – and this is admittedly a bit shallow because I know nothing of her suffering or what dark places she may have been – was that the author didn’t seem any worse for the wear because of her own experiences with psychotropics.  

I expected the book to be more narrowly focused on the emotional lives of the young people whose stories are told, and oddly enough, I was hoping the manuscript would yield some definitive answers!  A bit naive a wish for an experienced psychiatrist, but I can hope for such things, right?

Ms. Barnett tells the stories of five young people who have been treated with medications for the long haul, and she intersperses her own experiences into the narrative.  None of the patients suffered from severe psychotic disorders, and she recreates their stories from their own perspectives, as well as from information she has gotten from family members. The narratives, however, are not the meat of the book – the author uses them as springboards to lead into discussions of all the issues that come up around the use of medications in children.

She does an impressive job of going into depth on every issue one might consider when prescribing medications to children – including metabolic concerns, black box warnings, what factors improve compliance, and how the foster care system uses these treatments, to name just a few.  

And while I mentioned that the emotional lives of the patients aren’t the entire focus of the book, she does a good job of exploring how being on medicine influences how these patients attribute the events in their lives – where their responsibility for their feelings and behaviors may interplay with facets of illness and medication. She presents their stories with balance, some occasional healthy skepticism, and she skips the sensationalist tone that journalists usually take when talking about children and psychiatric medications.  

Usually, when I read a psychiatry book that is written by someone other than a psychiatrist, no matter how good the book is, at some point, I have the sense that there are aspects of illness or treatment that the author just doesn’t fully understand; there may be something that is portrayed with simplicity or the use of  borrowed terms. This book was the exception: Kaitlin Bell Barnett “gets it” and she fully understands the issues she discusses about child and adolescent psychiatry. Had there been an “M.D.” after her name, I would have read this book believing she was a child psychiatrist.  Her level of sophistication and her comfort with psychiatric jargon was such that I wondered if the lay reader – a teenager or a parent considering medication for their child – would fully understand.  For the nuanced reader, however, and certainly for everyone prescribing to children, this book is a tremendous contribution.  

I had two criticisms of the book that I want to expand on from my own experience. The author talks in detail about how taking medications influences children’s views of themselves and their experience of the world, and how people are often secretive and alone in this endeavor. There were moments when I felt like she was talking about the issues related to medication in a vacuum, but the children she portrays are not playing on a level field with children who don’t have psychiatric problems. They start out with tangible suffering, described quite poignantly, and the question of how medications influence the young person’s worldview is a difficult one.  

 

The first question, which is alluded to but is not the topic of the book, is how does having a mental illness and all that entails, color the child’s life, relationships, self-attitude, and future?  I don’t believe the two questions – how does medicine change you, versus how does mental illness change you –c an ever fully be separated, and in all fairness, the author didn’t actually try to separate them, she simply emphasized the medication aspect and all the unknowns that go along with that.

My second issue with the book is a bigger gripe, one I’m not giving a pass to.  There are many references to how medications are prescribed – quickly and sometimes thoughtlessly – and the role of psychotherapy – mostly cognitive-behavioral therapy – in the treatment of mental disorders. The author talks about the “15-minute medication check” and how psychiatry doesn’t allow the time for doctors to get to know their patients in the full context of their lives, much less allow time for the patients to discuss how they feel about their medications.  Ah, psychiatry is reduced to a symptom checklist followed by medication adjustments.

And while this may be how psychiatry is practiced by some doctors or in some settings, it’s not how everyone practices, and there are certainly child psychiatrists who see patients for psychotherapy, or who see patients for 50-minute sessions to monitor medications, even if formal psychotherapy is not being done. The author does not mention, except as an afterthought at the very end of the book, the option of seeing a psychiatrist for more than a rushed visit.    

I’ll let the young people’s histories speak for themselves; they did not all turn out as I would have expected and the reader will enjoy following their stories.

The book is thoughtfully written, a wonderful presentation of the full range of the issues everyone should be thinking about when prescribing psychotropics to children and teens, and Kaitlin Bell Barnett does a commendable job of communicating her masterful understanding of a complex topic.

—Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you’d like to see Kaitlin Bell Barnett talk about her book, her video is posted on Shrink Rap here (taken from the Kickstarter site).

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Kaitlin Bell Barnett’s first book, Dosed: The Medication Generation Grows Up is a series of case studies of young people who have been taking psychotropic medications since childhood or adolescence. It’s also a look at how being on medication has affected them – not just in terms of how it treated their illnesses or modified their symptoms – but also in terms of how it altered their perceptions of themselves, their personal growth, their relationships with others, and their ability to feel confident about their standing in the world.  

I’d first heard about the book from the author’s Kickstarter campaign to raise funds, and before the book was published, I’d e-mailed the author and knew she had spent dozens of hours with each of her interview subjects, and she assured me that this wouldn’t be an anti-psychiatry tirade, but rather an honest look at how this “first generation” of medicated young adults saw themselves.

I knew just a little about the author from her website and a posted video: She is young, attractive, articulate, and motivated enough to be writing a book on a complex subject. She holds degrees from Dartmouth and Columbia, and she’s been on antidepressants for a decade. 

My first thought – and this is admittedly a bit shallow because I know nothing of her suffering or what dark places she may have been – was that the author didn’t seem any worse for the wear because of her own experiences with psychotropics.  

I expected the book to be more narrowly focused on the emotional lives of the young people whose stories are told, and oddly enough, I was hoping the manuscript would yield some definitive answers!  A bit naive a wish for an experienced psychiatrist, but I can hope for such things, right?

Ms. Barnett tells the stories of five young people who have been treated with medications for the long haul, and she intersperses her own experiences into the narrative.  None of the patients suffered from severe psychotic disorders, and she recreates their stories from their own perspectives, as well as from information she has gotten from family members. The narratives, however, are not the meat of the book – the author uses them as springboards to lead into discussions of all the issues that come up around the use of medications in children.

She does an impressive job of going into depth on every issue one might consider when prescribing medications to children – including metabolic concerns, black box warnings, what factors improve compliance, and how the foster care system uses these treatments, to name just a few.  

And while I mentioned that the emotional lives of the patients aren’t the entire focus of the book, she does a good job of exploring how being on medicine influences how these patients attribute the events in their lives – where their responsibility for their feelings and behaviors may interplay with facets of illness and medication. She presents their stories with balance, some occasional healthy skepticism, and she skips the sensationalist tone that journalists usually take when talking about children and psychiatric medications.  

Usually, when I read a psychiatry book that is written by someone other than a psychiatrist, no matter how good the book is, at some point, I have the sense that there are aspects of illness or treatment that the author just doesn’t fully understand; there may be something that is portrayed with simplicity or the use of  borrowed terms. This book was the exception: Kaitlin Bell Barnett “gets it” and she fully understands the issues she discusses about child and adolescent psychiatry. Had there been an “M.D.” after her name, I would have read this book believing she was a child psychiatrist.  Her level of sophistication and her comfort with psychiatric jargon was such that I wondered if the lay reader – a teenager or a parent considering medication for their child – would fully understand.  For the nuanced reader, however, and certainly for everyone prescribing to children, this book is a tremendous contribution.  

I had two criticisms of the book that I want to expand on from my own experience. The author talks in detail about how taking medications influences children’s views of themselves and their experience of the world, and how people are often secretive and alone in this endeavor. There were moments when I felt like she was talking about the issues related to medication in a vacuum, but the children she portrays are not playing on a level field with children who don’t have psychiatric problems. They start out with tangible suffering, described quite poignantly, and the question of how medications influence the young person’s worldview is a difficult one.  

 

The first question, which is alluded to but is not the topic of the book, is how does having a mental illness and all that entails, color the child’s life, relationships, self-attitude, and future?  I don’t believe the two questions – how does medicine change you, versus how does mental illness change you –c an ever fully be separated, and in all fairness, the author didn’t actually try to separate them, she simply emphasized the medication aspect and all the unknowns that go along with that.

My second issue with the book is a bigger gripe, one I’m not giving a pass to.  There are many references to how medications are prescribed – quickly and sometimes thoughtlessly – and the role of psychotherapy – mostly cognitive-behavioral therapy – in the treatment of mental disorders. The author talks about the “15-minute medication check” and how psychiatry doesn’t allow the time for doctors to get to know their patients in the full context of their lives, much less allow time for the patients to discuss how they feel about their medications.  Ah, psychiatry is reduced to a symptom checklist followed by medication adjustments.

And while this may be how psychiatry is practiced by some doctors or in some settings, it’s not how everyone practices, and there are certainly child psychiatrists who see patients for psychotherapy, or who see patients for 50-minute sessions to monitor medications, even if formal psychotherapy is not being done. The author does not mention, except as an afterthought at the very end of the book, the option of seeing a psychiatrist for more than a rushed visit.    

I’ll let the young people’s histories speak for themselves; they did not all turn out as I would have expected and the reader will enjoy following their stories.

The book is thoughtfully written, a wonderful presentation of the full range of the issues everyone should be thinking about when prescribing psychotropics to children and teens, and Kaitlin Bell Barnett does a commendable job of communicating her masterful understanding of a complex topic.

—Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you’d like to see Kaitlin Bell Barnett talk about her book, her video is posted on Shrink Rap here (taken from the Kickstarter site).

DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

The 165th Annual Meeting of the American Psychiatric Association begins on May 5 and goes through May 9 in downtown Philadelphia. The theme for this year’s meeting, chosen by President John Oldham MD, is Integrated Care, which is inherent in some of the talks we will be giving, especially on health information technology.

Courtesy S.R. Daviss, M.D.

The Shrink Rap crew will all be there this year and plan to write about interesting talks and observations thoughout the week. You will be able to find these posts either here, on Shrink Rap and HIT Shrink, and also by following us on Facebook and Twitter (@clinkshrink, @shrinkrapdinah, @shrinkraproy).

Here are the talks we are giving this year.

Workshop 11: EHRs: What to look for when selecting an EHR for your practice

Saturday, May 5 11-12:30p. Convention Center, Level 1, Rm 109A

Co-Chairs: Steven R. Daviss, M.D., Robert M. Plovnick, M.D., M.S.
Presenters: Edward Pontius, M.D., Lori Simon, M.D., Zebulon Taintor, M.D., Roger Duda, M.D.

At the conclusion of the session the participant should be able to: 1) Explain the purpose of certification of EHRs, 2) Describe three methods of assessing EHR usability, 3) Enumerate five different types of functionality to look for when selecting an EHR for a psychiatric practice, 4) List the steps involved in EHR implementation, and 5) Describe the different ways that Health Information Exchanges deal with sensitive health information.

Seminar 7: Writing, Blogging, and Podcasting About Psychiatry for the Public: A Guide for the Perplexed

Sunday, May 6 8-12n. Marriott Downtown, Level 5, Registration II.

Directors: Steven R. Daviss, M.D. Annette Hanson, M.D.   Faculty(s): Dinah Miller, M.D.

At the conclusion of the session the participant should be able to: 1) Understand the major steps involved in getting a book published; 2) Identify what a blog is and understand the pros and cons of writing about psychiatry on the Internet; 3) Know about a variety of ways to communicate to the public about the field of psychiatry in a variety of new media formats, including podcasts, Twitter, Facebook, and Google+.

Note: the APA added this type of extended seminar this year to allow time for more in-depth coverage and more attendee interaction. In previous years, this would have been a paid course, but is now free.

Symposium 60: Electronic Health Records & Privacy Issues

Monday, May 7 2-5p. Convention Ctr, Level 1, Rm 117

Deven McGraw: Privacy as Health IT Enabler: Are we There Yet?

Glen Martin: Health Information Exchanges or the Healthy Exchange of Information:

Can It Be Done While Protecting our Patients’ Privacy Interests?

Robert Kolodner: Open-Source Software as Shared Infrastructure: A Novel Strategy to Enhance Data Interoperability While Improving Information Privacy in EHRs and HIEs

Steven Daviss: Balancing Privacy With Convenience and Utility in Health Networks: Merging of HIEs, PHRs, and Social Media

Zebulon Taintor: Trends and Consequences in Breaches of Protected Health Information

Deborah Peel: Discussant

Workshop 114: Psychiatrists and the New Media: Gaining Control of Our Specialty's Public Image

Tuesday, May 8, 1:30-3p. Convention Ctr, Level 1, 102B

Presenter(s): Annette Hanson, M.D., Hsiung C. Robert, M.D., Steven Balt, M.D., M.S., Dinah Miller, M.D.

Psychiatrists have long been challenged to get a fair shake in mainstream “old media”, such as film, TV, and print. Stereotypes and caricatures of psychiatrists have predominated in these media, with sensationalist portrayals gaining the most attention. As a result, those who have never had contact with a psychiatrist have opinions of us formed largely out of these skewed impressions. “New media” carry the promise of psychiatrists having greater control over the opinions formed of us. Social media is more personal and more empowering, requiring only an internet connection to broadcast one’s ideas to the global village. With this new power comes more opportunities for successfully portraying what the practice of psychiatry is all about, yet also more hazards for us to get it wrong.

There is also a book signing at the Johns Hopkins University Press booth #426 on the Exhibit floor at 12:15 on Sunday. I also expect there will be free copies of Clinical Psychiatry News at the Elsevier booth #407.

Please stop in at one or more of our presentations and say Hi while enjoying Philadelphia and the meeting. (Dinah may even still have ducks to give out.)
—Steven Roy Daviss, MD, DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, on the Health Standards Committee at URAC, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

The 165th Annual Meeting of the American Psychiatric Association begins on May 5 and goes through May 9 in downtown Philadelphia. The theme for this year’s meeting, chosen by President John Oldham MD, is Integrated Care, which is inherent in some of the talks we will be giving, especially on health information technology.

Courtesy S.R. Daviss, M.D.

The Shrink Rap crew will all be there this year and plan to write about interesting talks and observations thoughout the week. You will be able to find these posts either here, on Shrink Rap and HIT Shrink, and also by following us on Facebook and Twitter (@clinkshrink, @shrinkrapdinah, @shrinkraproy).

Here are the talks we are giving this year.

Workshop 11: EHRs: What to look for when selecting an EHR for your practice

Saturday, May 5 11-12:30p. Convention Center, Level 1, Rm 109A

Co-Chairs: Steven R. Daviss, M.D., Robert M. Plovnick, M.D., M.S.
Presenters: Edward Pontius, M.D., Lori Simon, M.D., Zebulon Taintor, M.D., Roger Duda, M.D.

At the conclusion of the session the participant should be able to: 1) Explain the purpose of certification of EHRs, 2) Describe three methods of assessing EHR usability, 3) Enumerate five different types of functionality to look for when selecting an EHR for a psychiatric practice, 4) List the steps involved in EHR implementation, and 5) Describe the different ways that Health Information Exchanges deal with sensitive health information.

Seminar 7: Writing, Blogging, and Podcasting About Psychiatry for the Public: A Guide for the Perplexed

Sunday, May 6 8-12n. Marriott Downtown, Level 5, Registration II.

Directors: Steven R. Daviss, M.D. Annette Hanson, M.D.   Faculty(s): Dinah Miller, M.D.

At the conclusion of the session the participant should be able to: 1) Understand the major steps involved in getting a book published; 2) Identify what a blog is and understand the pros and cons of writing about psychiatry on the Internet; 3) Know about a variety of ways to communicate to the public about the field of psychiatry in a variety of new media formats, including podcasts, Twitter, Facebook, and Google+.

Note: the APA added this type of extended seminar this year to allow time for more in-depth coverage and more attendee interaction. In previous years, this would have been a paid course, but is now free.

Symposium 60: Electronic Health Records & Privacy Issues

Monday, May 7 2-5p. Convention Ctr, Level 1, Rm 117

Deven McGraw: Privacy as Health IT Enabler: Are we There Yet?

Glen Martin: Health Information Exchanges or the Healthy Exchange of Information:

Can It Be Done While Protecting our Patients’ Privacy Interests?

Robert Kolodner: Open-Source Software as Shared Infrastructure: A Novel Strategy to Enhance Data Interoperability While Improving Information Privacy in EHRs and HIEs

Steven Daviss: Balancing Privacy With Convenience and Utility in Health Networks: Merging of HIEs, PHRs, and Social Media

Zebulon Taintor: Trends and Consequences in Breaches of Protected Health Information

Deborah Peel: Discussant

Workshop 114: Psychiatrists and the New Media: Gaining Control of Our Specialty's Public Image

Tuesday, May 8, 1:30-3p. Convention Ctr, Level 1, 102B

Presenter(s): Annette Hanson, M.D., Hsiung C. Robert, M.D., Steven Balt, M.D., M.S., Dinah Miller, M.D.

Psychiatrists have long been challenged to get a fair shake in mainstream “old media”, such as film, TV, and print. Stereotypes and caricatures of psychiatrists have predominated in these media, with sensationalist portrayals gaining the most attention. As a result, those who have never had contact with a psychiatrist have opinions of us formed largely out of these skewed impressions. “New media” carry the promise of psychiatrists having greater control over the opinions formed of us. Social media is more personal and more empowering, requiring only an internet connection to broadcast one’s ideas to the global village. With this new power comes more opportunities for successfully portraying what the practice of psychiatry is all about, yet also more hazards for us to get it wrong.

There is also a book signing at the Johns Hopkins University Press booth #426 on the Exhibit floor at 12:15 on Sunday. I also expect there will be free copies of Clinical Psychiatry News at the Elsevier booth #407.

Please stop in at one or more of our presentations and say Hi while enjoying Philadelphia and the meeting. (Dinah may even still have ducks to give out.)
—Steven Roy Daviss, MD, DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, on the Health Standards Committee at URAC, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

The 165th Annual Meeting of the American Psychiatric Association begins on May 5 and goes through May 9 in downtown Philadelphia. The theme for this year’s meeting, chosen by President John Oldham MD, is Integrated Care, which is inherent in some of the talks we will be giving, especially on health information technology.

Courtesy S.R. Daviss, M.D.

The Shrink Rap crew will all be there this year and plan to write about interesting talks and observations thoughout the week. You will be able to find these posts either here, on Shrink Rap and HIT Shrink, and also by following us on Facebook and Twitter (@clinkshrink, @shrinkrapdinah, @shrinkraproy).

Here are the talks we are giving this year.

Workshop 11: EHRs: What to look for when selecting an EHR for your practice

Saturday, May 5 11-12:30p. Convention Center, Level 1, Rm 109A

Co-Chairs: Steven R. Daviss, M.D., Robert M. Plovnick, M.D., M.S.
Presenters: Edward Pontius, M.D., Lori Simon, M.D., Zebulon Taintor, M.D., Roger Duda, M.D.

At the conclusion of the session the participant should be able to: 1) Explain the purpose of certification of EHRs, 2) Describe three methods of assessing EHR usability, 3) Enumerate five different types of functionality to look for when selecting an EHR for a psychiatric practice, 4) List the steps involved in EHR implementation, and 5) Describe the different ways that Health Information Exchanges deal with sensitive health information.

Seminar 7: Writing, Blogging, and Podcasting About Psychiatry for the Public: A Guide for the Perplexed

Sunday, May 6 8-12n. Marriott Downtown, Level 5, Registration II.

Directors: Steven R. Daviss, M.D. Annette Hanson, M.D.   Faculty(s): Dinah Miller, M.D.

At the conclusion of the session the participant should be able to: 1) Understand the major steps involved in getting a book published; 2) Identify what a blog is and understand the pros and cons of writing about psychiatry on the Internet; 3) Know about a variety of ways to communicate to the public about the field of psychiatry in a variety of new media formats, including podcasts, Twitter, Facebook, and Google+.

Note: the APA added this type of extended seminar this year to allow time for more in-depth coverage and more attendee interaction. In previous years, this would have been a paid course, but is now free.

Symposium 60: Electronic Health Records & Privacy Issues

Monday, May 7 2-5p. Convention Ctr, Level 1, Rm 117

Deven McGraw: Privacy as Health IT Enabler: Are we There Yet?

Glen Martin: Health Information Exchanges or the Healthy Exchange of Information:

Can It Be Done While Protecting our Patients’ Privacy Interests?

Robert Kolodner: Open-Source Software as Shared Infrastructure: A Novel Strategy to Enhance Data Interoperability While Improving Information Privacy in EHRs and HIEs

Steven Daviss: Balancing Privacy With Convenience and Utility in Health Networks: Merging of HIEs, PHRs, and Social Media

Zebulon Taintor: Trends and Consequences in Breaches of Protected Health Information

Deborah Peel: Discussant

Workshop 114: Psychiatrists and the New Media: Gaining Control of Our Specialty's Public Image

Tuesday, May 8, 1:30-3p. Convention Ctr, Level 1, 102B

Presenter(s): Annette Hanson, M.D., Hsiung C. Robert, M.D., Steven Balt, M.D., M.S., Dinah Miller, M.D.

Psychiatrists have long been challenged to get a fair shake in mainstream “old media”, such as film, TV, and print. Stereotypes and caricatures of psychiatrists have predominated in these media, with sensationalist portrayals gaining the most attention. As a result, those who have never had contact with a psychiatrist have opinions of us formed largely out of these skewed impressions. “New media” carry the promise of psychiatrists having greater control over the opinions formed of us. Social media is more personal and more empowering, requiring only an internet connection to broadcast one’s ideas to the global village. With this new power comes more opportunities for successfully portraying what the practice of psychiatry is all about, yet also more hazards for us to get it wrong.

There is also a book signing at the Johns Hopkins University Press booth #426 on the Exhibit floor at 12:15 on Sunday. I also expect there will be free copies of Clinical Psychiatry News at the Elsevier booth #407.

Please stop in at one or more of our presentations and say Hi while enjoying Philadelphia and the meeting. (Dinah may even still have ducks to give out.)
—Steven Roy Daviss, MD, DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, on the Health Standards Committee at URAC, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

The relationship between art and mental illness has frequently been explored by mental health professionals, most notably in Dr. Kay Redfield Jamison’s book, “Touched With Fire: Manic-Depressive Illness and the Artistic Temperament.”

Within the world of art, creations by people with mental illness have formed the basis of the visionary art movement. Visionary artists are self-taught or untrained painters or sculptors whose work is the external representation of an internal vision or image. Visionary art often portrays religious, philosophical, or mystical themes.

Photo used with permission

Recently, the Whitney Museum of American Art biennial exhibit featured the work of an early American impressionist, a visionary artist by the name of Forrest Bess.

Born in 1911, Forrest Bess initially attended college in architecture but eventually dropped out to independently study Jungian psychology, philosophy, anthropology, and mythology. He lived an isolated life in a shack on an island off the coast of Texas, where he worked as a fisherman.

He told people that he experienced visions that he described in detailed notes that he kept. His paintings incorporated male and female images, and he was enthralled with the use of symbols. Over time, he developed an extensive personal symbolism based upon the belief that immortality and the relief of all suffering could be achieved by the union of male and female. He wrote many letters about this theory to anyone who would listen, including Jung himself.

Eventually, he was able to sell several paintings and he used the money to travel to New York. There, he met gallery owner Betty Parsons, who displayed several of his works and brought them to national attention. Bess wanted her to also present his symbolic theories along with the work, but she refused.

Bess continued to write letters about his hermaphrodite theory to anthropologists and psychiatrists. Eventually, under the influence of alcohol, he made an incision in his own scrotum out of the belief that he could turn himself into his hermaphroditic ideal. He wrote to the renown sex researcher Dr. John Money about his experiment. Money later published an article about Bess’s mutilation in a case series about genital self-surgery.

In the 1970s, Bess was committed by his brother to San Antonio Hospital, the same facility where his grandmother had died. He was diagnosed with schizophrenia there. He died of skin cancer in a nursing home in 1977.

I’ve seen exhibits of other visionary artists before, to include art made by institutionalized psychiatric patients. What struck me about this exhibit was that the curator made the effort to present Bess’s art in the context that Bess intended: alongside letters and documents about his delusion. The fact of his hospitalization and illness is mentioned, but not as an explanation of the art or as a social commentary.

In other visionary art exhibits, the treatment of psychiatry is not so benign. The artist is often portrayed as being “misunderstood” as mentally ill, and treatment is portrayed as an attempt to restrain the artistic temperament or to enforce conformity. There is usually a commentary about the negative effects of psychiatric medication or the politics of medical power.

The uniqueness of the Whitney display of Bess’s work was its lack of anti-psychiatry commentary and the statement it made that people with mental illness, even when untreated, can create greatness.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The relationship between art and mental illness has frequently been explored by mental health professionals, most notably in Dr. Kay Redfield Jamison’s book, “Touched With Fire: Manic-Depressive Illness and the Artistic Temperament.”

Within the world of art, creations by people with mental illness have formed the basis of the visionary art movement. Visionary artists are self-taught or untrained painters or sculptors whose work is the external representation of an internal vision or image. Visionary art often portrays religious, philosophical, or mystical themes.

Photo used with permission

Recently, the Whitney Museum of American Art biennial exhibit featured the work of an early American impressionist, a visionary artist by the name of Forrest Bess.

Born in 1911, Forrest Bess initially attended college in architecture but eventually dropped out to independently study Jungian psychology, philosophy, anthropology, and mythology. He lived an isolated life in a shack on an island off the coast of Texas, where he worked as a fisherman.

He told people that he experienced visions that he described in detailed notes that he kept. His paintings incorporated male and female images, and he was enthralled with the use of symbols. Over time, he developed an extensive personal symbolism based upon the belief that immortality and the relief of all suffering could be achieved by the union of male and female. He wrote many letters about this theory to anyone who would listen, including Jung himself.

Eventually, he was able to sell several paintings and he used the money to travel to New York. There, he met gallery owner Betty Parsons, who displayed several of his works and brought them to national attention. Bess wanted her to also present his symbolic theories along with the work, but she refused.

Bess continued to write letters about his hermaphrodite theory to anthropologists and psychiatrists. Eventually, under the influence of alcohol, he made an incision in his own scrotum out of the belief that he could turn himself into his hermaphroditic ideal. He wrote to the renown sex researcher Dr. John Money about his experiment. Money later published an article about Bess’s mutilation in a case series about genital self-surgery.

In the 1970s, Bess was committed by his brother to San Antonio Hospital, the same facility where his grandmother had died. He was diagnosed with schizophrenia there. He died of skin cancer in a nursing home in 1977.

I’ve seen exhibits of other visionary artists before, to include art made by institutionalized psychiatric patients. What struck me about this exhibit was that the curator made the effort to present Bess’s art in the context that Bess intended: alongside letters and documents about his delusion. The fact of his hospitalization and illness is mentioned, but not as an explanation of the art or as a social commentary.

In other visionary art exhibits, the treatment of psychiatry is not so benign. The artist is often portrayed as being “misunderstood” as mentally ill, and treatment is portrayed as an attempt to restrain the artistic temperament or to enforce conformity. There is usually a commentary about the negative effects of psychiatric medication or the politics of medical power.

The uniqueness of the Whitney display of Bess’s work was its lack of anti-psychiatry commentary and the statement it made that people with mental illness, even when untreated, can create greatness.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The relationship between art and mental illness has frequently been explored by mental health professionals, most notably in Dr. Kay Redfield Jamison’s book, “Touched With Fire: Manic-Depressive Illness and the Artistic Temperament.”

Within the world of art, creations by people with mental illness have formed the basis of the visionary art movement. Visionary artists are self-taught or untrained painters or sculptors whose work is the external representation of an internal vision or image. Visionary art often portrays religious, philosophical, or mystical themes.

Photo used with permission

Recently, the Whitney Museum of American Art biennial exhibit featured the work of an early American impressionist, a visionary artist by the name of Forrest Bess.

Born in 1911, Forrest Bess initially attended college in architecture but eventually dropped out to independently study Jungian psychology, philosophy, anthropology, and mythology. He lived an isolated life in a shack on an island off the coast of Texas, where he worked as a fisherman.

He told people that he experienced visions that he described in detailed notes that he kept. His paintings incorporated male and female images, and he was enthralled with the use of symbols. Over time, he developed an extensive personal symbolism based upon the belief that immortality and the relief of all suffering could be achieved by the union of male and female. He wrote many letters about this theory to anyone who would listen, including Jung himself.

Eventually, he was able to sell several paintings and he used the money to travel to New York. There, he met gallery owner Betty Parsons, who displayed several of his works and brought them to national attention. Bess wanted her to also present his symbolic theories along with the work, but she refused.

Bess continued to write letters about his hermaphrodite theory to anthropologists and psychiatrists. Eventually, under the influence of alcohol, he made an incision in his own scrotum out of the belief that he could turn himself into his hermaphroditic ideal. He wrote to the renown sex researcher Dr. John Money about his experiment. Money later published an article about Bess’s mutilation in a case series about genital self-surgery.

In the 1970s, Bess was committed by his brother to San Antonio Hospital, the same facility where his grandmother had died. He was diagnosed with schizophrenia there. He died of skin cancer in a nursing home in 1977.

I’ve seen exhibits of other visionary artists before, to include art made by institutionalized psychiatric patients. What struck me about this exhibit was that the curator made the effort to present Bess’s art in the context that Bess intended: alongside letters and documents about his delusion. The fact of his hospitalization and illness is mentioned, but not as an explanation of the art or as a social commentary.

In other visionary art exhibits, the treatment of psychiatry is not so benign. The artist is often portrayed as being “misunderstood” as mentally ill, and treatment is portrayed as an attempt to restrain the artistic temperament or to enforce conformity. There is usually a commentary about the negative effects of psychiatric medication or the politics of medical power.

The uniqueness of the Whitney display of Bess’s work was its lack of anti-psychiatry commentary and the statement it made that people with mental illness, even when untreated, can create greatness.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Please forgive me for the provocative title. Nothing about researching or writing this article was comfortable, and I imagine parts of this will be difficult for some people to read. We've been writing blog posts at Shrink Rap for seven years now, and often the comments from readers reflect their dissatisfaction with the psychiatric care they’ve received.

Recently, a reader wrote in to discuss how violated she felt about being made to undress as part of the admission procedure to a psychiatric unit. She was required to undress in front of a staff member, and called this a “strip search,” and I borrowed her term for my article title.This patient had been a victim of sexual abuse, and felt the body search was humiliating and retraumatizing.
      
I hadn’t realized that patients were searched in this way – I’ve worked exclusively in outpatient settings since residency, and no patient has ever mentioned an issue with a body search while they were on an inpatient unit. But I was not surprised, and I assumed this must be routine procedure on all psychiatric units. It is the obligation of the inpatient service to do what is necessary to keep the patients and staff safe, and we all suffer minor indignities in the name of health, safety, or even the communal shower at the gym. Initially, I assumed that some form of a “strip search” was one of those moments to be endured.
    
What did surprise me was when other readers responded with such a wide variety of experiences about the policies at different psychiatric hospitals. Some had multiple admissions and were told to undress at one facility, but not at another. Some described more sensitive searches where they were instructed to change into a gown privately and to hand their clothes to a nurse.  Others felt they were being purposely humiliated as part of a power play by the staff, and described being made to stand naked, stretch their arms, or have their clothing removed forcibly against their will.
     
Earlier this month, the Supreme Court affirmed the right of the police to conduct strip searches on people who are arrested for even the most minor of offenses.  Florence vs. Board of Chosen Freeholders was filed by a man who was erroneously arrested while driving with his family, for not paying a traffic fine. In fact, he had paid the fine years before. During the course of his six-day incarceration, he was strip searched twice, and the media reported jarring details.  I posted about this on Shrink Rap, and readers again began writing in with the indignities they suffered in psychiatric hospitals.

I started to wonder how common this is. If some hospitals do not feel it is necessary to have patients undress in front of staff to maintain safety, why do others? In Massachusetts, a patient filed a suit against a hospital after she was forcibly undressed by five male guards during a voluntary visit to the ER. In Sampson vs. Beth Israel Deaconess, the hospital settled the suit and changed its policies on blanket “strip search” requirements for all psychiatric patients.  

In Vermont, Anne Donahue wrote in the Fall 2009 edition of Counterpoint, (a newsletter for psychiatric survivors, consumers, and their families) in “Strip Searches: Going Too Far?”:

The new policy was only in effect for a few weeks. Mandatory full body searches for every person being admitted to the psychiatric unit at Rutland Regional Medical Center were discontinued. Under the new safety search policy, a patient removes all clothing behind a curtain so that the clothing can be searched. Only a specific risk of harm in an individual circumstance might lead to a full body search.

Still wondering, I posted a quick survey on Shrink Rap asking about body searches.  The responses I got were a snapshot, not a scientific study as there was no validation, no controls, and I left it to the reader to define “strip search.”  I asked readers to take the survey if they’d been hospitalized in the last 3 years.  For what it’s worth the majority of respondents – just over half – had not been strip searched.  Of those who had been, most, but not all, found the experience to be “very distressing.”   
 
One patient wrote:

I was strip searched 2 years ago. It was in a private university, top five hospital in New York City, New York state. The admission was voluntary, for depression. I was told that I was being searched because it was the policy because they needed to mark all scars and open wounds present on my body in case more appeared later – to prevent litigation. I protested I had no history of violence against myself or others and no diagnosis of personality disorder. I was told the policy was across the board. I protested that the other branch of this same hospital, where I had been a month earlier, did not strip search me. They matter of factly said that I was lying because it was a hospital wide policy.
I was directed to take off all my clothing except underwear and bra, and turn around holding out all my limbs one at a time. There were two women (I am female) present. The door was closed. I was then asked to remove my bra, replace it, and then lower my underwear front and back, then replace it. I was then told to replace my clothing while they continued searching my belongings. One nurse seemed apologetic. The other was angry that I was questioning the procedure.

I was biting back tears of shame, humiliation and flat out terror, despite never having been abused in any way. It was a gross violation of my privacy and personhood.

 

Another wrote:

The female nurse told me to take off my clothes and I started shaking and sobbing into my hands covering my face. The nurse kept saying, "oh, it’s no big deal, it's not that bad,” when it clearly was very bad for me. I shook and sobbed and took off my clothes. She said she needed me to take off my underwear, too, and I shook and sobbed and said, "no no no no no." She unlatched my bra and took it as far off as possible for a person whose hands are on her face. She pulled my underwear down to my knees. She gave me a gown, which I put on hastily, then I pulled my undergarments back in place. She cheerfully said, “see it wasn’t that bad!” and left me with a couple blankets and took my clothes and other things. I wrapped myself up in the blankets as tightly as I could, curled up as small as I could, and had a panic attack for the next hour.

I wondered about the policy at our local hospitals in the Baltimore area, and I considered contacting the chairman of a number of  psychiatry departments. And then I felt my stomach turn. Could I really ask if patients are strip searched?  I finally decided to ask what the policies are regarding searching new admissions.  Nothing about these conversations was easy.
 
I received a variety of responses along the entire spectrum of options.  Dr. Steven Daviss, chairman of psychiatry at Baltimore Washington Medical Center told me, “We do request patients change into gowns. Most have no problem with it, they go into the bathroom, and change. If they refuse, the metal detector wand is used.”

Dr. Robert Roca, medical director at Sheppard Pratt noted, “The nursing assessment includes a head-to-toe skin examination. As a rule nothing more invasive is done.”  Their assessment includes documentation of scars or lesions, and he noted that many of their patients have been victims of abuse and subsequently have histories of self-mutilation, so they feel it important to search all patients carefully.  

Judith Rohde, director of the psychiatry nursing department at Johns Hopkins Hospital, told me they have access to a metal detector wand in the ER and upon admission to the units, “We ask patients to remove their shoes and socks, and invert their pockets.”  Obviously, in hospitals where all patients are not asked to undress, or to do so privately, by policy, the hospital may conduct more intrusive searches if specific patients are felt to pose a risk.

Psychiatry is practiced within the context of a culture, and here we have no clear standards, and no research that shows that one hospital is safer than another, or has better outcomes, because every psychiatric patient has been forced to undress in front of staff.  Until we are certain that visual inspection increases safety on psychiatry units, such policies should be ended, and replaced by practices that are more respectful of patient privacy and dignity.

As psychiatrists, we strive to mitigate psychic distress and suffering, and these searches exacerbate distress in some patients. Callous dismissal of the patients’ discomfort embarrasses our profession and fuels the vocal anti-psychiatric movements. And most of all, any requirement to strip search all psychiatric patients leaves us as egregious perpetrators of stigma against those with mental illnesses,  since other medical patients are not subject to this indignity. As one patient wrote:

Anyone who has worked in a hospital knows that violence is not limited to psychiatric patients, it’s sometimes family members or ex-lovers or just patients who are mean. Regarding the issue of contraband, all units in a hospital have patients with substance abuse issues and with that, the high likelihood of drugs/alcohol being smuggled in. Hospitals don’t take the extreme approach and strip search patients upon admission to the GI or Neurology units just because some patients who are admitted have substance abuse issues or because security was called for assistance with some other unruly patient or family member a week ago. …Sadly, the practice seems only to apply to patients being admitted to some psych units in certain hospitals. I’m relieved not all hospitals do this to psych patients, or I wouldn’t be seeing the psychiatrist I see now. I would be too afraid of him.

There may be patients who do not have a problem with being strip searched.  This does not justify the practice.... It’s hard enough to be a psychiatric patient as is.  

Is it time for your facility to rethink patient search policies?

—Dinah Miller, M.D.

 

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you would like to see the Shrink Rap readers comments on “Tell Me About Your Psych Unit Search Stories,” please go here.  You are welcome to join in the discussion on Shrink Rap.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Please forgive me for the provocative title. Nothing about researching or writing this article was comfortable, and I imagine parts of this will be difficult for some people to read. We've been writing blog posts at Shrink Rap for seven years now, and often the comments from readers reflect their dissatisfaction with the psychiatric care they’ve received.

Recently, a reader wrote in to discuss how violated she felt about being made to undress as part of the admission procedure to a psychiatric unit. She was required to undress in front of a staff member, and called this a “strip search,” and I borrowed her term for my article title.This patient had been a victim of sexual abuse, and felt the body search was humiliating and retraumatizing.
      
I hadn’t realized that patients were searched in this way – I’ve worked exclusively in outpatient settings since residency, and no patient has ever mentioned an issue with a body search while they were on an inpatient unit. But I was not surprised, and I assumed this must be routine procedure on all psychiatric units. It is the obligation of the inpatient service to do what is necessary to keep the patients and staff safe, and we all suffer minor indignities in the name of health, safety, or even the communal shower at the gym. Initially, I assumed that some form of a “strip search” was one of those moments to be endured.
    
What did surprise me was when other readers responded with such a wide variety of experiences about the policies at different psychiatric hospitals. Some had multiple admissions and were told to undress at one facility, but not at another. Some described more sensitive searches where they were instructed to change into a gown privately and to hand their clothes to a nurse.  Others felt they were being purposely humiliated as part of a power play by the staff, and described being made to stand naked, stretch their arms, or have their clothing removed forcibly against their will.
     
Earlier this month, the Supreme Court affirmed the right of the police to conduct strip searches on people who are arrested for even the most minor of offenses.  Florence vs. Board of Chosen Freeholders was filed by a man who was erroneously arrested while driving with his family, for not paying a traffic fine. In fact, he had paid the fine years before. During the course of his six-day incarceration, he was strip searched twice, and the media reported jarring details.  I posted about this on Shrink Rap, and readers again began writing in with the indignities they suffered in psychiatric hospitals.

I started to wonder how common this is. If some hospitals do not feel it is necessary to have patients undress in front of staff to maintain safety, why do others? In Massachusetts, a patient filed a suit against a hospital after she was forcibly undressed by five male guards during a voluntary visit to the ER. In Sampson vs. Beth Israel Deaconess, the hospital settled the suit and changed its policies on blanket “strip search” requirements for all psychiatric patients.  

In Vermont, Anne Donahue wrote in the Fall 2009 edition of Counterpoint, (a newsletter for psychiatric survivors, consumers, and their families) in “Strip Searches: Going Too Far?”:

The new policy was only in effect for a few weeks. Mandatory full body searches for every person being admitted to the psychiatric unit at Rutland Regional Medical Center were discontinued. Under the new safety search policy, a patient removes all clothing behind a curtain so that the clothing can be searched. Only a specific risk of harm in an individual circumstance might lead to a full body search.

Still wondering, I posted a quick survey on Shrink Rap asking about body searches.  The responses I got were a snapshot, not a scientific study as there was no validation, no controls, and I left it to the reader to define “strip search.”  I asked readers to take the survey if they’d been hospitalized in the last 3 years.  For what it’s worth the majority of respondents – just over half – had not been strip searched.  Of those who had been, most, but not all, found the experience to be “very distressing.”   
 
One patient wrote:

I was strip searched 2 years ago. It was in a private university, top five hospital in New York City, New York state. The admission was voluntary, for depression. I was told that I was being searched because it was the policy because they needed to mark all scars and open wounds present on my body in case more appeared later – to prevent litigation. I protested I had no history of violence against myself or others and no diagnosis of personality disorder. I was told the policy was across the board. I protested that the other branch of this same hospital, where I had been a month earlier, did not strip search me. They matter of factly said that I was lying because it was a hospital wide policy.
I was directed to take off all my clothing except underwear and bra, and turn around holding out all my limbs one at a time. There were two women (I am female) present. The door was closed. I was then asked to remove my bra, replace it, and then lower my underwear front and back, then replace it. I was then told to replace my clothing while they continued searching my belongings. One nurse seemed apologetic. The other was angry that I was questioning the procedure.

I was biting back tears of shame, humiliation and flat out terror, despite never having been abused in any way. It was a gross violation of my privacy and personhood.

 

Another wrote:

The female nurse told me to take off my clothes and I started shaking and sobbing into my hands covering my face. The nurse kept saying, "oh, it’s no big deal, it's not that bad,” when it clearly was very bad for me. I shook and sobbed and took off my clothes. She said she needed me to take off my underwear, too, and I shook and sobbed and said, "no no no no no." She unlatched my bra and took it as far off as possible for a person whose hands are on her face. She pulled my underwear down to my knees. She gave me a gown, which I put on hastily, then I pulled my undergarments back in place. She cheerfully said, “see it wasn’t that bad!” and left me with a couple blankets and took my clothes and other things. I wrapped myself up in the blankets as tightly as I could, curled up as small as I could, and had a panic attack for the next hour.

I wondered about the policy at our local hospitals in the Baltimore area, and I considered contacting the chairman of a number of  psychiatry departments. And then I felt my stomach turn. Could I really ask if patients are strip searched?  I finally decided to ask what the policies are regarding searching new admissions.  Nothing about these conversations was easy.
 
I received a variety of responses along the entire spectrum of options.  Dr. Steven Daviss, chairman of psychiatry at Baltimore Washington Medical Center told me, “We do request patients change into gowns. Most have no problem with it, they go into the bathroom, and change. If they refuse, the metal detector wand is used.”

Dr. Robert Roca, medical director at Sheppard Pratt noted, “The nursing assessment includes a head-to-toe skin examination. As a rule nothing more invasive is done.”  Their assessment includes documentation of scars or lesions, and he noted that many of their patients have been victims of abuse and subsequently have histories of self-mutilation, so they feel it important to search all patients carefully.  

Judith Rohde, director of the psychiatry nursing department at Johns Hopkins Hospital, told me they have access to a metal detector wand in the ER and upon admission to the units, “We ask patients to remove their shoes and socks, and invert their pockets.”  Obviously, in hospitals where all patients are not asked to undress, or to do so privately, by policy, the hospital may conduct more intrusive searches if specific patients are felt to pose a risk.

Psychiatry is practiced within the context of a culture, and here we have no clear standards, and no research that shows that one hospital is safer than another, or has better outcomes, because every psychiatric patient has been forced to undress in front of staff.  Until we are certain that visual inspection increases safety on psychiatry units, such policies should be ended, and replaced by practices that are more respectful of patient privacy and dignity.

As psychiatrists, we strive to mitigate psychic distress and suffering, and these searches exacerbate distress in some patients. Callous dismissal of the patients’ discomfort embarrasses our profession and fuels the vocal anti-psychiatric movements. And most of all, any requirement to strip search all psychiatric patients leaves us as egregious perpetrators of stigma against those with mental illnesses,  since other medical patients are not subject to this indignity. As one patient wrote:

Anyone who has worked in a hospital knows that violence is not limited to psychiatric patients, it’s sometimes family members or ex-lovers or just patients who are mean. Regarding the issue of contraband, all units in a hospital have patients with substance abuse issues and with that, the high likelihood of drugs/alcohol being smuggled in. Hospitals don’t take the extreme approach and strip search patients upon admission to the GI or Neurology units just because some patients who are admitted have substance abuse issues or because security was called for assistance with some other unruly patient or family member a week ago. …Sadly, the practice seems only to apply to patients being admitted to some psych units in certain hospitals. I’m relieved not all hospitals do this to psych patients, or I wouldn’t be seeing the psychiatrist I see now. I would be too afraid of him.

There may be patients who do not have a problem with being strip searched.  This does not justify the practice.... It’s hard enough to be a psychiatric patient as is.  

Is it time for your facility to rethink patient search policies?

—Dinah Miller, M.D.

 

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you would like to see the Shrink Rap readers comments on “Tell Me About Your Psych Unit Search Stories,” please go here.  You are welcome to join in the discussion on Shrink Rap.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Please forgive me for the provocative title. Nothing about researching or writing this article was comfortable, and I imagine parts of this will be difficult for some people to read. We've been writing blog posts at Shrink Rap for seven years now, and often the comments from readers reflect their dissatisfaction with the psychiatric care they’ve received.

Recently, a reader wrote in to discuss how violated she felt about being made to undress as part of the admission procedure to a psychiatric unit. She was required to undress in front of a staff member, and called this a “strip search,” and I borrowed her term for my article title.This patient had been a victim of sexual abuse, and felt the body search was humiliating and retraumatizing.
      
I hadn’t realized that patients were searched in this way – I’ve worked exclusively in outpatient settings since residency, and no patient has ever mentioned an issue with a body search while they were on an inpatient unit. But I was not surprised, and I assumed this must be routine procedure on all psychiatric units. It is the obligation of the inpatient service to do what is necessary to keep the patients and staff safe, and we all suffer minor indignities in the name of health, safety, or even the communal shower at the gym. Initially, I assumed that some form of a “strip search” was one of those moments to be endured.
    
What did surprise me was when other readers responded with such a wide variety of experiences about the policies at different psychiatric hospitals. Some had multiple admissions and were told to undress at one facility, but not at another. Some described more sensitive searches where they were instructed to change into a gown privately and to hand their clothes to a nurse.  Others felt they were being purposely humiliated as part of a power play by the staff, and described being made to stand naked, stretch their arms, or have their clothing removed forcibly against their will.
     
Earlier this month, the Supreme Court affirmed the right of the police to conduct strip searches on people who are arrested for even the most minor of offenses.  Florence vs. Board of Chosen Freeholders was filed by a man who was erroneously arrested while driving with his family, for not paying a traffic fine. In fact, he had paid the fine years before. During the course of his six-day incarceration, he was strip searched twice, and the media reported jarring details.  I posted about this on Shrink Rap, and readers again began writing in with the indignities they suffered in psychiatric hospitals.

I started to wonder how common this is. If some hospitals do not feel it is necessary to have patients undress in front of staff to maintain safety, why do others? In Massachusetts, a patient filed a suit against a hospital after she was forcibly undressed by five male guards during a voluntary visit to the ER. In Sampson vs. Beth Israel Deaconess, the hospital settled the suit and changed its policies on blanket “strip search” requirements for all psychiatric patients.  

In Vermont, Anne Donahue wrote in the Fall 2009 edition of Counterpoint, (a newsletter for psychiatric survivors, consumers, and their families) in “Strip Searches: Going Too Far?”:

The new policy was only in effect for a few weeks. Mandatory full body searches for every person being admitted to the psychiatric unit at Rutland Regional Medical Center were discontinued. Under the new safety search policy, a patient removes all clothing behind a curtain so that the clothing can be searched. Only a specific risk of harm in an individual circumstance might lead to a full body search.

Still wondering, I posted a quick survey on Shrink Rap asking about body searches.  The responses I got were a snapshot, not a scientific study as there was no validation, no controls, and I left it to the reader to define “strip search.”  I asked readers to take the survey if they’d been hospitalized in the last 3 years.  For what it’s worth the majority of respondents – just over half – had not been strip searched.  Of those who had been, most, but not all, found the experience to be “very distressing.”   
 
One patient wrote:

I was strip searched 2 years ago. It was in a private university, top five hospital in New York City, New York state. The admission was voluntary, for depression. I was told that I was being searched because it was the policy because they needed to mark all scars and open wounds present on my body in case more appeared later – to prevent litigation. I protested I had no history of violence against myself or others and no diagnosis of personality disorder. I was told the policy was across the board. I protested that the other branch of this same hospital, where I had been a month earlier, did not strip search me. They matter of factly said that I was lying because it was a hospital wide policy.
I was directed to take off all my clothing except underwear and bra, and turn around holding out all my limbs one at a time. There were two women (I am female) present. The door was closed. I was then asked to remove my bra, replace it, and then lower my underwear front and back, then replace it. I was then told to replace my clothing while they continued searching my belongings. One nurse seemed apologetic. The other was angry that I was questioning the procedure.

I was biting back tears of shame, humiliation and flat out terror, despite never having been abused in any way. It was a gross violation of my privacy and personhood.

 

Another wrote:

The female nurse told me to take off my clothes and I started shaking and sobbing into my hands covering my face. The nurse kept saying, "oh, it’s no big deal, it's not that bad,” when it clearly was very bad for me. I shook and sobbed and took off my clothes. She said she needed me to take off my underwear, too, and I shook and sobbed and said, "no no no no no." She unlatched my bra and took it as far off as possible for a person whose hands are on her face. She pulled my underwear down to my knees. She gave me a gown, which I put on hastily, then I pulled my undergarments back in place. She cheerfully said, “see it wasn’t that bad!” and left me with a couple blankets and took my clothes and other things. I wrapped myself up in the blankets as tightly as I could, curled up as small as I could, and had a panic attack for the next hour.

I wondered about the policy at our local hospitals in the Baltimore area, and I considered contacting the chairman of a number of  psychiatry departments. And then I felt my stomach turn. Could I really ask if patients are strip searched?  I finally decided to ask what the policies are regarding searching new admissions.  Nothing about these conversations was easy.
 
I received a variety of responses along the entire spectrum of options.  Dr. Steven Daviss, chairman of psychiatry at Baltimore Washington Medical Center told me, “We do request patients change into gowns. Most have no problem with it, they go into the bathroom, and change. If they refuse, the metal detector wand is used.”

Dr. Robert Roca, medical director at Sheppard Pratt noted, “The nursing assessment includes a head-to-toe skin examination. As a rule nothing more invasive is done.”  Their assessment includes documentation of scars or lesions, and he noted that many of their patients have been victims of abuse and subsequently have histories of self-mutilation, so they feel it important to search all patients carefully.  

Judith Rohde, director of the psychiatry nursing department at Johns Hopkins Hospital, told me they have access to a metal detector wand in the ER and upon admission to the units, “We ask patients to remove their shoes and socks, and invert their pockets.”  Obviously, in hospitals where all patients are not asked to undress, or to do so privately, by policy, the hospital may conduct more intrusive searches if specific patients are felt to pose a risk.

Psychiatry is practiced within the context of a culture, and here we have no clear standards, and no research that shows that one hospital is safer than another, or has better outcomes, because every psychiatric patient has been forced to undress in front of staff.  Until we are certain that visual inspection increases safety on psychiatry units, such policies should be ended, and replaced by practices that are more respectful of patient privacy and dignity.

As psychiatrists, we strive to mitigate psychic distress and suffering, and these searches exacerbate distress in some patients. Callous dismissal of the patients’ discomfort embarrasses our profession and fuels the vocal anti-psychiatric movements. And most of all, any requirement to strip search all psychiatric patients leaves us as egregious perpetrators of stigma against those with mental illnesses,  since other medical patients are not subject to this indignity. As one patient wrote:

Anyone who has worked in a hospital knows that violence is not limited to psychiatric patients, it’s sometimes family members or ex-lovers or just patients who are mean. Regarding the issue of contraband, all units in a hospital have patients with substance abuse issues and with that, the high likelihood of drugs/alcohol being smuggled in. Hospitals don’t take the extreme approach and strip search patients upon admission to the GI or Neurology units just because some patients who are admitted have substance abuse issues or because security was called for assistance with some other unruly patient or family member a week ago. …Sadly, the practice seems only to apply to patients being admitted to some psych units in certain hospitals. I’m relieved not all hospitals do this to psych patients, or I wouldn’t be seeing the psychiatrist I see now. I would be too afraid of him.

There may be patients who do not have a problem with being strip searched.  This does not justify the practice.... It’s hard enough to be a psychiatric patient as is.  

Is it time for your facility to rethink patient search policies?

—Dinah Miller, M.D.

 

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

If you would like to see the Shrink Rap readers comments on “Tell Me About Your Psych Unit Search Stories,” please go here.  You are welcome to join in the discussion on Shrink Rap.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Tuberculosis used to be much more widespread, often going undiagnosed and untreated. The Public Health community decided to make TB screening a part of routine screening, leaving a tremendous impact on detection and treatment. Now, imagine the same thing for depression.

We know depression is underdiagnosed and undertreated. SAMHSA’s most recent publication on the state of Mental Health (“Mental Health, United States, 2010”) found that the percentage of adults with an episode of major depression over the previous 12 months was between 5.2% to 9.5%, varying from state to state (page 68). The percentage of those individuals actually receiving any treatment statistically increased from 2009 to 2010, going from 64.4% to 68.2% (see data table). This is much higher than I would have thought, but there are still many who go undiagnosed and untreated.

The Center for Medicare and Medicaid Services (CMS) recently published its notice of proposed rule-making (NPRM) for Stage 2 of Meaningful Use. If you don’t know what I’m talking about, you might want to read this article by Drs. Neil Skolnik and Chris Notte first, which discussed what it’s all about (increasing the adoption of certified electronic health records, or EHRs, which are used meaningfully) and introduces the Stage 1 criteria.

I won’t go into all the changes that are made in Stage 2, but I will talk about an aspect that may prove to have a very large impact on the identification and treatment of people with depression. The Stage 2 NPRM tweaks the definition of a “meaningful EHR user” as follows:

We propose to include clinical quality measure reporting as part of the definition of “meaningful EHR user” instead of as a separate meaningful use objective under 42 CFR 495.6.

To be considered compliant with Stage 2 meaningful use, this change requires that eligible providers, or EPs, must collect and report on a core set of “clinical quality measures,” as well as a menu set of clinical quality measures, which I won’t go into here. (Note: this is actually more complicated, as an alternative schema was offered, as well. If you really want to know more, read the NPRM or e-mail me.)
The core CQMs are mandatory and there are 11 of them. These include the following areas:

• receiving consultant reports

• functional status assessments for patients with complex chronic conditions

• controlled hypertension

• medication reconciliation

• use of high risk meds in the elderly

• therapeutic drug monitoring

• antithrombotic use in ischemic vascular disease

• obesity screening and counseling in kids

• tobacco use screening in adults

• cholesterol screening in adults

• depression screening for ages 12 and up

Notice that last one. "Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool and follow up plan documented."

Let me repeat this. To qualify for financial incentives (and to avoid financial penalties starting in 2015), all your patients age 12 and up must be screened for “clinical depression” annually. This applies to all specialties, so even the ophthalmologists will need to screen their patients. The other side of the coin is that psychiatrists will need to document blood pressures and cholesterol, even if the data are obtained by the PCP. (If you have something to say about these proposed changes, speak up by providing your public comment by May 7.)

This means that many of the people who are not getting identified and treated are likely to be provided care for their depression. Of course, those who don’t ever make it to a provider won’t get screened. But those who do will need to be treated. This means more PCPs managing depression, and more referrals to psychiatrists, psychologists, nurse practitioners and therapists, counselors, and social workers. More antidepressant prescriptions. More psychotherapy.

It will also likely mean more patients getting harmed by treatment. A proportion of these people screening positive for depression will have a bipolar disorder, but screening for bipolar disorder may not be required for people screening positive for depression. There is a CQM in the menu set that includes bipolar screening, but it seems likely that the final set of menu CQMs will not include this option. We will need to ensure that PCPs know how to screen for bipolar disorder, and that they are able to recognize mania or hypomania induced by an antidepressant.

There are surely other consequences of this near-universal depression screening. What do you think of these changes? Comment here or over on HITshrink. I'll address other issues about Stage 2 MU in later columns.

—Steven Roy Daviss, M.D., DFAPA

 

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

Tuberculosis used to be much more widespread, often going undiagnosed and untreated. The Public Health community decided to make TB screening a part of routine screening, leaving a tremendous impact on detection and treatment. Now, imagine the same thing for depression.

We know depression is underdiagnosed and undertreated. SAMHSA’s most recent publication on the state of Mental Health (“Mental Health, United States, 2010”) found that the percentage of adults with an episode of major depression over the previous 12 months was between 5.2% to 9.5%, varying from state to state (page 68). The percentage of those individuals actually receiving any treatment statistically increased from 2009 to 2010, going from 64.4% to 68.2% (see data table). This is much higher than I would have thought, but there are still many who go undiagnosed and untreated.

The Center for Medicare and Medicaid Services (CMS) recently published its notice of proposed rule-making (NPRM) for Stage 2 of Meaningful Use. If you don’t know what I’m talking about, you might want to read this article by Drs. Neil Skolnik and Chris Notte first, which discussed what it’s all about (increasing the adoption of certified electronic health records, or EHRs, which are used meaningfully) and introduces the Stage 1 criteria.

I won’t go into all the changes that are made in Stage 2, but I will talk about an aspect that may prove to have a very large impact on the identification and treatment of people with depression. The Stage 2 NPRM tweaks the definition of a “meaningful EHR user” as follows:

We propose to include clinical quality measure reporting as part of the definition of “meaningful EHR user” instead of as a separate meaningful use objective under 42 CFR 495.6.

To be considered compliant with Stage 2 meaningful use, this change requires that eligible providers, or EPs, must collect and report on a core set of “clinical quality measures,” as well as a menu set of clinical quality measures, which I won’t go into here. (Note: this is actually more complicated, as an alternative schema was offered, as well. If you really want to know more, read the NPRM or e-mail me.)
The core CQMs are mandatory and there are 11 of them. These include the following areas:

• receiving consultant reports

• functional status assessments for patients with complex chronic conditions

• controlled hypertension

• medication reconciliation

• use of high risk meds in the elderly

• therapeutic drug monitoring

• antithrombotic use in ischemic vascular disease

• obesity screening and counseling in kids

• tobacco use screening in adults

• cholesterol screening in adults

• depression screening for ages 12 and up

Notice that last one. "Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool and follow up plan documented."

Let me repeat this. To qualify for financial incentives (and to avoid financial penalties starting in 2015), all your patients age 12 and up must be screened for “clinical depression” annually. This applies to all specialties, so even the ophthalmologists will need to screen their patients. The other side of the coin is that psychiatrists will need to document blood pressures and cholesterol, even if the data are obtained by the PCP. (If you have something to say about these proposed changes, speak up by providing your public comment by May 7.)

This means that many of the people who are not getting identified and treated are likely to be provided care for their depression. Of course, those who don’t ever make it to a provider won’t get screened. But those who do will need to be treated. This means more PCPs managing depression, and more referrals to psychiatrists, psychologists, nurse practitioners and therapists, counselors, and social workers. More antidepressant prescriptions. More psychotherapy.

It will also likely mean more patients getting harmed by treatment. A proportion of these people screening positive for depression will have a bipolar disorder, but screening for bipolar disorder may not be required for people screening positive for depression. There is a CQM in the menu set that includes bipolar screening, but it seems likely that the final set of menu CQMs will not include this option. We will need to ensure that PCPs know how to screen for bipolar disorder, and that they are able to recognize mania or hypomania induced by an antidepressant.

There are surely other consequences of this near-universal depression screening. What do you think of these changes? Comment here or over on HITshrink. I'll address other issues about Stage 2 MU in later columns.

—Steven Roy Daviss, M.D., DFAPA

 

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

Tuberculosis used to be much more widespread, often going undiagnosed and untreated. The Public Health community decided to make TB screening a part of routine screening, leaving a tremendous impact on detection and treatment. Now, imagine the same thing for depression.

We know depression is underdiagnosed and undertreated. SAMHSA’s most recent publication on the state of Mental Health (“Mental Health, United States, 2010”) found that the percentage of adults with an episode of major depression over the previous 12 months was between 5.2% to 9.5%, varying from state to state (page 68). The percentage of those individuals actually receiving any treatment statistically increased from 2009 to 2010, going from 64.4% to 68.2% (see data table). This is much higher than I would have thought, but there are still many who go undiagnosed and untreated.

The Center for Medicare and Medicaid Services (CMS) recently published its notice of proposed rule-making (NPRM) for Stage 2 of Meaningful Use. If you don’t know what I’m talking about, you might want to read this article by Drs. Neil Skolnik and Chris Notte first, which discussed what it’s all about (increasing the adoption of certified electronic health records, or EHRs, which are used meaningfully) and introduces the Stage 1 criteria.

I won’t go into all the changes that are made in Stage 2, but I will talk about an aspect that may prove to have a very large impact on the identification and treatment of people with depression. The Stage 2 NPRM tweaks the definition of a “meaningful EHR user” as follows:

We propose to include clinical quality measure reporting as part of the definition of “meaningful EHR user” instead of as a separate meaningful use objective under 42 CFR 495.6.

To be considered compliant with Stage 2 meaningful use, this change requires that eligible providers, or EPs, must collect and report on a core set of “clinical quality measures,” as well as a menu set of clinical quality measures, which I won’t go into here. (Note: this is actually more complicated, as an alternative schema was offered, as well. If you really want to know more, read the NPRM or e-mail me.)
The core CQMs are mandatory and there are 11 of them. These include the following areas:

• receiving consultant reports

• functional status assessments for patients with complex chronic conditions

• controlled hypertension

• medication reconciliation

• use of high risk meds in the elderly

• therapeutic drug monitoring

• antithrombotic use in ischemic vascular disease

• obesity screening and counseling in kids

• tobacco use screening in adults

• cholesterol screening in adults

• depression screening for ages 12 and up

Notice that last one. "Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool and follow up plan documented."

Let me repeat this. To qualify for financial incentives (and to avoid financial penalties starting in 2015), all your patients age 12 and up must be screened for “clinical depression” annually. This applies to all specialties, so even the ophthalmologists will need to screen their patients. The other side of the coin is that psychiatrists will need to document blood pressures and cholesterol, even if the data are obtained by the PCP. (If you have something to say about these proposed changes, speak up by providing your public comment by May 7.)

This means that many of the people who are not getting identified and treated are likely to be provided care for their depression. Of course, those who don’t ever make it to a provider won’t get screened. But those who do will need to be treated. This means more PCPs managing depression, and more referrals to psychiatrists, psychologists, nurse practitioners and therapists, counselors, and social workers. More antidepressant prescriptions. More psychotherapy.

It will also likely mean more patients getting harmed by treatment. A proportion of these people screening positive for depression will have a bipolar disorder, but screening for bipolar disorder may not be required for people screening positive for depression. There is a CQM in the menu set that includes bipolar screening, but it seems likely that the final set of menu CQMs will not include this option. We will need to ensure that PCPs know how to screen for bipolar disorder, and that they are able to recognize mania or hypomania induced by an antidepressant.

There are surely other consequences of this near-universal depression screening. What do you think of these changes? Comment here or over on HITshrink. I'll address other issues about Stage 2 MU in later columns.

—Steven Roy Daviss, M.D., DFAPA

 

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

The power of color has long been recognized in marketing. Companies have even trademarked colors and color combinations in the market.

Home Depot is orange. Lowe's is blue. The same thinking has also been
applied to advocacy causes. Yellow ribbons signify veterans. Pink ribbons breast cancer.

What’s the color for mental health?

That is the question Shannon Jacuzzi asked not long after her sister committed suicide 5 years ago. It became clear to her that the mental health advocacy community lacked a color to make its cause immediately recognizable. “There is silver for disorders of the brain. But mental health to me is inclusive of all humans because we all have a brain; we all need to take care of it.”

She thought a bright and cheerful color would be most appropriate. So,

Jacuzzi embarked on a mission to equate the color lime with mental health. She and her partners have been increasingly in the limelight,
kicking off a movement of lime green awareness ribbons, bags, rubber bracelets, and other reminders that mental health is important and needs to be talked about.

“Some of us struggle harder to maintain good mental health – the other side of the coin being mental illness.  But they are both important. I believe if we discuss mental health in both contexts, we can reduce
stigma to mental illness and treatment avoidance. We should incorporate mental health screening from childhood/adolescence and preventive care.

“If we all talk about it from earliest age, it becomes ‘normal’ instead of shameful. Color has done so much to bring talk and attention to important causes.  Limelighting mental health out of the darkness is part of the reason lime is an effective color for mental health.”

Indeed, the limelighting seems to be working. Google shows more than 2 million hits on entering “limelight mental health.” On Facebook, pages for Limelight Mental Health and GO LIME Awareness for Mental Health has more than 1,500 likes.

As we head into May, which is Mental Health Awareness Month, think lime. And grab a ribbon at http://bit.ly/lime4mentalhealth to place on your website or Facebook page to spread the power of lime.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is found on Twitter @HITshrink, at drdavissATgmail.com, and on the Shrink Rap blog.

The power of color has long been recognized in marketing. Companies have even trademarked colors and color combinations in the market.

Home Depot is orange. Lowe's is blue. The same thinking has also been
applied to advocacy causes. Yellow ribbons signify veterans. Pink ribbons breast cancer.

What’s the color for mental health?

That is the question Shannon Jacuzzi asked not long after her sister committed suicide 5 years ago. It became clear to her that the mental health advocacy community lacked a color to make its cause immediately recognizable. “There is silver for disorders of the brain. But mental health to me is inclusive of all humans because we all have a brain; we all need to take care of it.”

She thought a bright and cheerful color would be most appropriate. So,

Jacuzzi embarked on a mission to equate the color lime with mental health. She and her partners have been increasingly in the limelight,
kicking off a movement of lime green awareness ribbons, bags, rubber bracelets, and other reminders that mental health is important and needs to be talked about.

“Some of us struggle harder to maintain good mental health – the other side of the coin being mental illness.  But they are both important. I believe if we discuss mental health in both contexts, we can reduce
stigma to mental illness and treatment avoidance. We should incorporate mental health screening from childhood/adolescence and preventive care.

“If we all talk about it from earliest age, it becomes ‘normal’ instead of shameful. Color has done so much to bring talk and attention to important causes.  Limelighting mental health out of the darkness is part of the reason lime is an effective color for mental health.”

Indeed, the limelighting seems to be working. Google shows more than 2 million hits on entering “limelight mental health.” On Facebook, pages for Limelight Mental Health and GO LIME Awareness for Mental Health has more than 1,500 likes.

As we head into May, which is Mental Health Awareness Month, think lime. And grab a ribbon at http://bit.ly/lime4mentalhealth to place on your website or Facebook page to spread the power of lime.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is found on Twitter @HITshrink, at drdavissATgmail.com, and on the Shrink Rap blog.

The power of color has long been recognized in marketing. Companies have even trademarked colors and color combinations in the market.

Home Depot is orange. Lowe's is blue. The same thinking has also been
applied to advocacy causes. Yellow ribbons signify veterans. Pink ribbons breast cancer.

What’s the color for mental health?

That is the question Shannon Jacuzzi asked not long after her sister committed suicide 5 years ago. It became clear to her that the mental health advocacy community lacked a color to make its cause immediately recognizable. “There is silver for disorders of the brain. But mental health to me is inclusive of all humans because we all have a brain; we all need to take care of it.”

She thought a bright and cheerful color would be most appropriate. So,

Jacuzzi embarked on a mission to equate the color lime with mental health. She and her partners have been increasingly in the limelight,
kicking off a movement of lime green awareness ribbons, bags, rubber bracelets, and other reminders that mental health is important and needs to be talked about.

“Some of us struggle harder to maintain good mental health – the other side of the coin being mental illness.  But they are both important. I believe if we discuss mental health in both contexts, we can reduce
stigma to mental illness and treatment avoidance. We should incorporate mental health screening from childhood/adolescence and preventive care.

“If we all talk about it from earliest age, it becomes ‘normal’ instead of shameful. Color has done so much to bring talk and attention to important causes.  Limelighting mental health out of the darkness is part of the reason lime is an effective color for mental health.”

Indeed, the limelighting seems to be working. Google shows more than 2 million hits on entering “limelight mental health.” On Facebook, pages for Limelight Mental Health and GO LIME Awareness for Mental Health has more than 1,500 likes.

As we head into May, which is Mental Health Awareness Month, think lime. And grab a ribbon at http://bit.ly/lime4mentalhealth to place on your website or Facebook page to spread the power of lime.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is found on Twitter @HITshrink, at drdavissATgmail.com, and on the Shrink Rap blog.

March was a busy month for very public psychotic episodes.

First there was the flight attendant with bipolar disorder who disrupted a flight by shouting about a bomb on the plane. Then, the director of a popular documentary was taken to a hospital after running nude down the street. Finally, we hear about a JetBlue pilot who became agitated on a plane, ranted about Israel and Iraq, and demanded that the plane land. He reportedly was subdued by passengers, including a former NYPD officer and a correctional officer.

Besides the general concern about airline safety, as a clinician I can’t help wonder how these people can return to a normal life after such a public and dramatic breakdown.

I know the problems faced by my prisoners when they try to reintegrate into society: problems finding employment and housing, and the challenge of rebuilding disrupted relationships. If there are barriers due to being an ex-offender, imagine the challenges faced by someone who has had a psychotic episode broadcast to the world.

When a first episode happens to a young adult in his pre-professional years, adjustment is a bit easier. They may need to adjust goals or lower expectations. The patient may need to take time off from college or change schools, but eventually there is always the chance to quietly begin again somewhere else.

This option disappears when your breakdown makes national news. This is particularly true when the patient is a lawyer, a pilot, a doctor, a law enforcement, or other professional who holds a duty to public safety. These professionals have a requirement to report mental disability to a licensure board, and failure to do this is a crime in some states. Personal privacy is trumped by public security needs, and fitness for duty is closely scrutinized. A public breakdown could mean losing one’s career.

What are the options?

If the individual recovers completely and is otherwise qualified for the demands of the job, he would be protected by the Americans With Disabilities Act. If he needed some accommodation, he would be required to tell his employer about his disability and request it, but he could still work if he didn’t represent a danger to others.

Handling a relationship with a co-worker is a bit trickier. Do you go back to work and not mention what happened? Do you mention it in passing and reassure everyone that really, even though you almost brought down a plane, there’s nothing to worry about? Or do you become a public spokesperson and advocate for the mentally ill, like Carrie Fisher, who has created an entire show around her bipolar disorder?

There is no single right approach to this problem. Most people come to accept that an illness is part of who they are, but it does not become a public persona or part of one’s identity. But neither can it be entirely ignored or left unaddressed.

As Mark Vonnegut said in one of his memoirs, “Once you’ve been talked to by voices, it’s not possible to go back to a world where talking voices is not possible.”

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

March was a busy month for very public psychotic episodes.

First there was the flight attendant with bipolar disorder who disrupted a flight by shouting about a bomb on the plane. Then, the director of a popular documentary was taken to a hospital after running nude down the street. Finally, we hear about a JetBlue pilot who became agitated on a plane, ranted about Israel and Iraq, and demanded that the plane land. He reportedly was subdued by passengers, including a former NYPD officer and a correctional officer.

Besides the general concern about airline safety, as a clinician I can’t help wonder how these people can return to a normal life after such a public and dramatic breakdown.

I know the problems faced by my prisoners when they try to reintegrate into society: problems finding employment and housing, and the challenge of rebuilding disrupted relationships. If there are barriers due to being an ex-offender, imagine the challenges faced by someone who has had a psychotic episode broadcast to the world.

When a first episode happens to a young adult in his pre-professional years, adjustment is a bit easier. They may need to adjust goals or lower expectations. The patient may need to take time off from college or change schools, but eventually there is always the chance to quietly begin again somewhere else.

This option disappears when your breakdown makes national news. This is particularly true when the patient is a lawyer, a pilot, a doctor, a law enforcement, or other professional who holds a duty to public safety. These professionals have a requirement to report mental disability to a licensure board, and failure to do this is a crime in some states. Personal privacy is trumped by public security needs, and fitness for duty is closely scrutinized. A public breakdown could mean losing one’s career.

What are the options?

If the individual recovers completely and is otherwise qualified for the demands of the job, he would be protected by the Americans With Disabilities Act. If he needed some accommodation, he would be required to tell his employer about his disability and request it, but he could still work if he didn’t represent a danger to others.

Handling a relationship with a co-worker is a bit trickier. Do you go back to work and not mention what happened? Do you mention it in passing and reassure everyone that really, even though you almost brought down a plane, there’s nothing to worry about? Or do you become a public spokesperson and advocate for the mentally ill, like Carrie Fisher, who has created an entire show around her bipolar disorder?

There is no single right approach to this problem. Most people come to accept that an illness is part of who they are, but it does not become a public persona or part of one’s identity. But neither can it be entirely ignored or left unaddressed.

As Mark Vonnegut said in one of his memoirs, “Once you’ve been talked to by voices, it’s not possible to go back to a world where talking voices is not possible.”

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

March was a busy month for very public psychotic episodes.

First there was the flight attendant with bipolar disorder who disrupted a flight by shouting about a bomb on the plane. Then, the director of a popular documentary was taken to a hospital after running nude down the street. Finally, we hear about a JetBlue pilot who became agitated on a plane, ranted about Israel and Iraq, and demanded that the plane land. He reportedly was subdued by passengers, including a former NYPD officer and a correctional officer.

Besides the general concern about airline safety, as a clinician I can’t help wonder how these people can return to a normal life after such a public and dramatic breakdown.

I know the problems faced by my prisoners when they try to reintegrate into society: problems finding employment and housing, and the challenge of rebuilding disrupted relationships. If there are barriers due to being an ex-offender, imagine the challenges faced by someone who has had a psychotic episode broadcast to the world.

When a first episode happens to a young adult in his pre-professional years, adjustment is a bit easier. They may need to adjust goals or lower expectations. The patient may need to take time off from college or change schools, but eventually there is always the chance to quietly begin again somewhere else.

This option disappears when your breakdown makes national news. This is particularly true when the patient is a lawyer, a pilot, a doctor, a law enforcement, or other professional who holds a duty to public safety. These professionals have a requirement to report mental disability to a licensure board, and failure to do this is a crime in some states. Personal privacy is trumped by public security needs, and fitness for duty is closely scrutinized. A public breakdown could mean losing one’s career.

What are the options?

If the individual recovers completely and is otherwise qualified for the demands of the job, he would be protected by the Americans With Disabilities Act. If he needed some accommodation, he would be required to tell his employer about his disability and request it, but he could still work if he didn’t represent a danger to others.

Handling a relationship with a co-worker is a bit trickier. Do you go back to work and not mention what happened? Do you mention it in passing and reassure everyone that really, even though you almost brought down a plane, there’s nothing to worry about? Or do you become a public spokesperson and advocate for the mentally ill, like Carrie Fisher, who has created an entire show around her bipolar disorder?

There is no single right approach to this problem. Most people come to accept that an illness is part of who they are, but it does not become a public persona or part of one’s identity. But neither can it be entirely ignored or left unaddressed.

As Mark Vonnegut said in one of his memoirs, “Once you’ve been talked to by voices, it’s not possible to go back to a world where talking voices is not possible.”

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Two weeks ago on this CPN website, Dr. Annette Hanson and I wrote about our objections to proposed legislation in the Maryland General Assembly to legalize medical marijuana. The same article appeared as an op-ed piece in the Baltimore Sun, in both its print publication (3/9/12) and online (3/7/12).

The response to the articles was notable, and with the exception of a few supportive e-mails, the majority of commenters – and e-mailers, and a single phone caller – were strongly opposed to our viewpoints. I want to use this column to talk about my thoughts on the comments in the Sun.  

Let me start by saying that if I believed that legislation was about making marijuana accessible to those with cancer, AIDS, or debilitating pain, I would not be writing an article in opposition to the legislation.  If I thought the legislation would have no adverse impact on the treatment of psychiatric patients, I would also not be commenting.  And finally, if the legislation proposed either the legalization or decriminalization of marijuana, I would view that as a legal issue.  

I am a general adult psychiatrist, and substance use and abuse are common among psychiatric patients. Many patients report a history (past or present) of recreational marijuana use that has not had any negative impact on their lives. It does seem, however, that a percentage of the population does not do well with marijuana. For them, marijuana leads to addiction, a lack of motivation, an increase in psychiatric symptoms, and tremendous unmet potential.  In clinical practice, I will point out the ways in which these patients' lives are not going well – ways that are typical of what I see with people who smoke too much weed – and suggest they try an experiment on themselves: Give up marijuana for a few months and see if life gets better. Very few people take me up on this suggestion – at least not at first – and I’ve heard a lot of rhetoric about NORML and how the government lies to people about the evils of marijuana. 

My patients insist that pot helps them sleep, or feel less anxious, and they argue that it has nothing to do with their persistent symptoms or their inability to progress in their lives – problems that led them to seek treatment with me.  

Among those who are not psychiatric patients, cannabis may induce a sense of complacency that leaves the smokers satisfied with their lives and with what “medical marijuana” has done for them, when they should be striving for so much more. So I believe that marijuana interrupts the lives of some of the people who use it and blinds them to the reality of their problems, and legalizing medical marijuana would provide an easy means to both obtain and divert cannabis. It may also cause these problems in well-meaning people who seek treatment but would not otherwise consider regular use of an illicit substance, just as the legal use of benzodiazepines, narcotics, and barbituates has done more harm than good for some patients. 

The current mechanism of recommending medical marijuana and providing a one-year use card bypasses the usual risk-benefit discussions and worries about adverse outcomes that we’ve learned about with other medications the hard way.

The truth remains that in some states, medical marijuana is used primarily to treat psychiatric symptoms such as anxiety, depression, and insomnia, and prescribers of medical marijuana make substantial incomes seeing patients for cursory evaluations that do not resemble the usual standards of medical care.

Thompson and Koenen write in “Physicians as Gatekeepers in the Use of Medical Marijuana,” in The Journal of the American Academy of Psychiatry and the Law (2011;39:460-4):
 
“During the course of a typical day of psychiatric evaluations for Social Security Disability, it is not uncommon for every examinee to have a medical marijuana card or so called green card; and the data support this observation. Studies have revealed that a large percentage of individuals seeking marijuana do so for the treatment of anxiety, depression, and other psychiatric conditions. In many cases, individuals seeking medical marijuana have a history of alcohol and drug abuse since adolescence and continue to use illicit substances.
 
Physician tolerance of the use of medical marijuana among patients with substance abuse problems is a serious concern. Teenagers frequently obtain medical marijuana for purposes of treating psychiatric problems commonly associated with adolescence. The fact that teenagers can smoke marijuana (because it is medicine) complicates substance abuse treatment in this vulnerable population.…The co-author has evaluated patients who presented to the clinic too intoxicated on medical marijuana to engage in meaningful treatment.”
 
I’ve broken down the 45 comments from the Sun article into the following categories:
 

 

• Legalization will benefit those with illnesses. Some wrote in with their own anecdotes of how marijuana helped the following: OCD, seizures, Crohn’s disease, migraines, chronic pain such that the user could stop taking narcotics, bone disease, and “saved my marriage, my heart, and my soul.” One commenter asserted that in Oregon, marijuana cures cancer.

• FDA approval is a catch-22 because cannabis is a Schedule I drug, and this stymies research. In a country where 17 states have legalized medical marijuana, I agree that the FDA should revisit this issue.

• FDA-approved medications have resulted in many deaths, and FDA-approved medications have been withdrawn for safety reasons.  Readers specifically noted Ambien, Xanax, Oxycontin, Vioxx, Avandia, Fen-Phen, and silicone breast implants. They contend that marijuana is safer than these substances.

• Other legal substances are unsafe, specifically alcohol, tobacco, and the above-mentioned prescription drugs. This is similar to the point made above, and I agree, but I am not sure it’s relevant to the discussion of medical marijuana.

• Marijuana is safe and effective, and any facts that are presented to the contrary are wrong.  There is really no answer to this because this point of view, by definition, is closed to discussion.

• Marijuana doesn’t kill.  If you stay out of a car, don’t lace it with it toxins, and don’t mix it with other drugs, this is probably true.

• There are inconsistencies in medical practice, and people can get Viagra by calling an 800 number.  

• Marijuana is an herbal product that has been used as medicine for thousands of years and should not treated as a pharmaceutical.  Again, this is different issue from those addressed in medical marijuana legislation.

• Doctors are pawns of the pharmaceutical industry and can’t profit if medical marijuana is legalized.  One writer suggested that psychiatrists would be put out of business because marijuana would replace Prozac, and several commenters stated as a fact that my co-author and I are pharmaceutical “shills” who are more interested in dinners and harbor cruises. Neither Dr. Hanson nor I have any financial relationships with pharmaceutical companies, and it’s been years since I’ve gotten so much as a pen, much less a chicken salad sandwich, from a drug rep. I’m not terribly worried that medical marijuana will put me out of business, but I am concerned that it will make my job harder.

• There were some insults that added nothing to the conversation. "Psychiatrists are the worst kind of quacks because they believe their own nonsense.  Their 'successes' are people who are drugged into the equivalent of a chemical lobotomy.”

 
Personally, I do believe that marijuana should be re-scheduled and that it should be available for use for specific indications where other treatments have been inadequate. But it should be prescribed cautiously, purchased from a pharmacy, with a prescription noting dosage and frequency, and marketed without the propaganda that it lacks adverse effects or the possibility of addiction. 

I do not believe that non-psychiatrists should prescribe medical marijuana for psychiatric symptoms, (especially if the patient is also seeing a psychiatrist) and I certainly don’t believe that legislators should propose psychiatric indications for cannabis in opposition to current treatment standards. I believe that if marijuana is used as “medicine,” it should be used because conventional medications, including Marinol, the oral form of  synthetic THC, either haven’t worked or have caused unacceptable side effects.  
 

The current mechanism of prescribing medical marijuana is not about cancer, AIDS, MS, or chronic pain patients.  Unlike other “medications,” marijuana (medical or otherwise) causes smokers to get high, and legalization requires that we address how this will play out for the work place and our overall productivity as a society. 

If the conversation is about increasing access to marijuana for all Americans, one might contend that our current War on Drugs has been a dismal failure, and discussions  regarding decriminalization or legalization might best be left to the lawmakers, the constituents, the crime fighters, and the addiction specialists. That’s a conversation that can be had without my input.
 
If you’d like to read the original article with the comments in the Baltimore Sun, click here.
 
If you’d like to read an article by a Steve Balt, a California psychiatrist who discusses the issues involved in treating patients who are getting medical marijuana from another prescriber, click  here.
 
And, finally, if you’d like to read an article from Time magazine called "The United States of Amerijuana," click here.
 
Please note, the ideas expressed here are mine alone and do reflect the views of the co-author of the original article, Dr. Hanson.  

 

 —Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.
 
You can also comment on our original Shrink Rap blog by clicking here.  
 
DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Two weeks ago on this CPN website, Dr. Annette Hanson and I wrote about our objections to proposed legislation in the Maryland General Assembly to legalize medical marijuana. The same article appeared as an op-ed piece in the Baltimore Sun, in both its print publication (3/9/12) and online (3/7/12).

The response to the articles was notable, and with the exception of a few supportive e-mails, the majority of commenters – and e-mailers, and a single phone caller – were strongly opposed to our viewpoints. I want to use this column to talk about my thoughts on the comments in the Sun.  

Let me start by saying that if I believed that legislation was about making marijuana accessible to those with cancer, AIDS, or debilitating pain, I would not be writing an article in opposition to the legislation.  If I thought the legislation would have no adverse impact on the treatment of psychiatric patients, I would also not be commenting.  And finally, if the legislation proposed either the legalization or decriminalization of marijuana, I would view that as a legal issue.  

I am a general adult psychiatrist, and substance use and abuse are common among psychiatric patients. Many patients report a history (past or present) of recreational marijuana use that has not had any negative impact on their lives. It does seem, however, that a percentage of the population does not do well with marijuana. For them, marijuana leads to addiction, a lack of motivation, an increase in psychiatric symptoms, and tremendous unmet potential.  In clinical practice, I will point out the ways in which these patients' lives are not going well – ways that are typical of what I see with people who smoke too much weed – and suggest they try an experiment on themselves: Give up marijuana for a few months and see if life gets better. Very few people take me up on this suggestion – at least not at first – and I’ve heard a lot of rhetoric about NORML and how the government lies to people about the evils of marijuana. 

My patients insist that pot helps them sleep, or feel less anxious, and they argue that it has nothing to do with their persistent symptoms or their inability to progress in their lives – problems that led them to seek treatment with me.  

Among those who are not psychiatric patients, cannabis may induce a sense of complacency that leaves the smokers satisfied with their lives and with what “medical marijuana” has done for them, when they should be striving for so much more. So I believe that marijuana interrupts the lives of some of the people who use it and blinds them to the reality of their problems, and legalizing medical marijuana would provide an easy means to both obtain and divert cannabis. It may also cause these problems in well-meaning people who seek treatment but would not otherwise consider regular use of an illicit substance, just as the legal use of benzodiazepines, narcotics, and barbituates has done more harm than good for some patients. 

The current mechanism of recommending medical marijuana and providing a one-year use card bypasses the usual risk-benefit discussions and worries about adverse outcomes that we’ve learned about with other medications the hard way.

The truth remains that in some states, medical marijuana is used primarily to treat psychiatric symptoms such as anxiety, depression, and insomnia, and prescribers of medical marijuana make substantial incomes seeing patients for cursory evaluations that do not resemble the usual standards of medical care.

Thompson and Koenen write in “Physicians as Gatekeepers in the Use of Medical Marijuana,” in The Journal of the American Academy of Psychiatry and the Law (2011;39:460-4):
 
“During the course of a typical day of psychiatric evaluations for Social Security Disability, it is not uncommon for every examinee to have a medical marijuana card or so called green card; and the data support this observation. Studies have revealed that a large percentage of individuals seeking marijuana do so for the treatment of anxiety, depression, and other psychiatric conditions. In many cases, individuals seeking medical marijuana have a history of alcohol and drug abuse since adolescence and continue to use illicit substances.
 
Physician tolerance of the use of medical marijuana among patients with substance abuse problems is a serious concern. Teenagers frequently obtain medical marijuana for purposes of treating psychiatric problems commonly associated with adolescence. The fact that teenagers can smoke marijuana (because it is medicine) complicates substance abuse treatment in this vulnerable population.…The co-author has evaluated patients who presented to the clinic too intoxicated on medical marijuana to engage in meaningful treatment.”
 
I’ve broken down the 45 comments from the Sun article into the following categories:
 

 

• Legalization will benefit those with illnesses. Some wrote in with their own anecdotes of how marijuana helped the following: OCD, seizures, Crohn’s disease, migraines, chronic pain such that the user could stop taking narcotics, bone disease, and “saved my marriage, my heart, and my soul.” One commenter asserted that in Oregon, marijuana cures cancer.

• FDA approval is a catch-22 because cannabis is a Schedule I drug, and this stymies research. In a country where 17 states have legalized medical marijuana, I agree that the FDA should revisit this issue.

• FDA-approved medications have resulted in many deaths, and FDA-approved medications have been withdrawn for safety reasons.  Readers specifically noted Ambien, Xanax, Oxycontin, Vioxx, Avandia, Fen-Phen, and silicone breast implants. They contend that marijuana is safer than these substances.

• Other legal substances are unsafe, specifically alcohol, tobacco, and the above-mentioned prescription drugs. This is similar to the point made above, and I agree, but I am not sure it’s relevant to the discussion of medical marijuana.

• Marijuana is safe and effective, and any facts that are presented to the contrary are wrong.  There is really no answer to this because this point of view, by definition, is closed to discussion.

• Marijuana doesn’t kill.  If you stay out of a car, don’t lace it with it toxins, and don’t mix it with other drugs, this is probably true.

• There are inconsistencies in medical practice, and people can get Viagra by calling an 800 number.  

• Marijuana is an herbal product that has been used as medicine for thousands of years and should not treated as a pharmaceutical.  Again, this is different issue from those addressed in medical marijuana legislation.

• Doctors are pawns of the pharmaceutical industry and can’t profit if medical marijuana is legalized.  One writer suggested that psychiatrists would be put out of business because marijuana would replace Prozac, and several commenters stated as a fact that my co-author and I are pharmaceutical “shills” who are more interested in dinners and harbor cruises. Neither Dr. Hanson nor I have any financial relationships with pharmaceutical companies, and it’s been years since I’ve gotten so much as a pen, much less a chicken salad sandwich, from a drug rep. I’m not terribly worried that medical marijuana will put me out of business, but I am concerned that it will make my job harder.

• There were some insults that added nothing to the conversation. "Psychiatrists are the worst kind of quacks because they believe their own nonsense.  Their 'successes' are people who are drugged into the equivalent of a chemical lobotomy.”

 
Personally, I do believe that marijuana should be re-scheduled and that it should be available for use for specific indications where other treatments have been inadequate. But it should be prescribed cautiously, purchased from a pharmacy, with a prescription noting dosage and frequency, and marketed without the propaganda that it lacks adverse effects or the possibility of addiction. 

I do not believe that non-psychiatrists should prescribe medical marijuana for psychiatric symptoms, (especially if the patient is also seeing a psychiatrist) and I certainly don’t believe that legislators should propose psychiatric indications for cannabis in opposition to current treatment standards. I believe that if marijuana is used as “medicine,” it should be used because conventional medications, including Marinol, the oral form of  synthetic THC, either haven’t worked or have caused unacceptable side effects.  
 

The current mechanism of prescribing medical marijuana is not about cancer, AIDS, MS, or chronic pain patients.  Unlike other “medications,” marijuana (medical or otherwise) causes smokers to get high, and legalization requires that we address how this will play out for the work place and our overall productivity as a society. 

If the conversation is about increasing access to marijuana for all Americans, one might contend that our current War on Drugs has been a dismal failure, and discussions  regarding decriminalization or legalization might best be left to the lawmakers, the constituents, the crime fighters, and the addiction specialists. That’s a conversation that can be had without my input.
 
If you’d like to read the original article with the comments in the Baltimore Sun, click here.
 
If you’d like to read an article by a Steve Balt, a California psychiatrist who discusses the issues involved in treating patients who are getting medical marijuana from another prescriber, click  here.
 
And, finally, if you’d like to read an article from Time magazine called "The United States of Amerijuana," click here.
 
Please note, the ideas expressed here are mine alone and do reflect the views of the co-author of the original article, Dr. Hanson.  

 

 —Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.
 
You can also comment on our original Shrink Rap blog by clicking here.  
 
DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Two weeks ago on this CPN website, Dr. Annette Hanson and I wrote about our objections to proposed legislation in the Maryland General Assembly to legalize medical marijuana. The same article appeared as an op-ed piece in the Baltimore Sun, in both its print publication (3/9/12) and online (3/7/12).

The response to the articles was notable, and with the exception of a few supportive e-mails, the majority of commenters – and e-mailers, and a single phone caller – were strongly opposed to our viewpoints. I want to use this column to talk about my thoughts on the comments in the Sun.  

Let me start by saying that if I believed that legislation was about making marijuana accessible to those with cancer, AIDS, or debilitating pain, I would not be writing an article in opposition to the legislation.  If I thought the legislation would have no adverse impact on the treatment of psychiatric patients, I would also not be commenting.  And finally, if the legislation proposed either the legalization or decriminalization of marijuana, I would view that as a legal issue.  

I am a general adult psychiatrist, and substance use and abuse are common among psychiatric patients. Many patients report a history (past or present) of recreational marijuana use that has not had any negative impact on their lives. It does seem, however, that a percentage of the population does not do well with marijuana. For them, marijuana leads to addiction, a lack of motivation, an increase in psychiatric symptoms, and tremendous unmet potential.  In clinical practice, I will point out the ways in which these patients' lives are not going well – ways that are typical of what I see with people who smoke too much weed – and suggest they try an experiment on themselves: Give up marijuana for a few months and see if life gets better. Very few people take me up on this suggestion – at least not at first – and I’ve heard a lot of rhetoric about NORML and how the government lies to people about the evils of marijuana. 

My patients insist that pot helps them sleep, or feel less anxious, and they argue that it has nothing to do with their persistent symptoms or their inability to progress in their lives – problems that led them to seek treatment with me.  

Among those who are not psychiatric patients, cannabis may induce a sense of complacency that leaves the smokers satisfied with their lives and with what “medical marijuana” has done for them, when they should be striving for so much more. So I believe that marijuana interrupts the lives of some of the people who use it and blinds them to the reality of their problems, and legalizing medical marijuana would provide an easy means to both obtain and divert cannabis. It may also cause these problems in well-meaning people who seek treatment but would not otherwise consider regular use of an illicit substance, just as the legal use of benzodiazepines, narcotics, and barbituates has done more harm than good for some patients. 

The current mechanism of recommending medical marijuana and providing a one-year use card bypasses the usual risk-benefit discussions and worries about adverse outcomes that we’ve learned about with other medications the hard way.

The truth remains that in some states, medical marijuana is used primarily to treat psychiatric symptoms such as anxiety, depression, and insomnia, and prescribers of medical marijuana make substantial incomes seeing patients for cursory evaluations that do not resemble the usual standards of medical care.

Thompson and Koenen write in “Physicians as Gatekeepers in the Use of Medical Marijuana,” in The Journal of the American Academy of Psychiatry and the Law (2011;39:460-4):
 
“During the course of a typical day of psychiatric evaluations for Social Security Disability, it is not uncommon for every examinee to have a medical marijuana card or so called green card; and the data support this observation. Studies have revealed that a large percentage of individuals seeking marijuana do so for the treatment of anxiety, depression, and other psychiatric conditions. In many cases, individuals seeking medical marijuana have a history of alcohol and drug abuse since adolescence and continue to use illicit substances.
 
Physician tolerance of the use of medical marijuana among patients with substance abuse problems is a serious concern. Teenagers frequently obtain medical marijuana for purposes of treating psychiatric problems commonly associated with adolescence. The fact that teenagers can smoke marijuana (because it is medicine) complicates substance abuse treatment in this vulnerable population.…The co-author has evaluated patients who presented to the clinic too intoxicated on medical marijuana to engage in meaningful treatment.”
 
I’ve broken down the 45 comments from the Sun article into the following categories:
 

 

• Legalization will benefit those with illnesses. Some wrote in with their own anecdotes of how marijuana helped the following: OCD, seizures, Crohn’s disease, migraines, chronic pain such that the user could stop taking narcotics, bone disease, and “saved my marriage, my heart, and my soul.” One commenter asserted that in Oregon, marijuana cures cancer.

• FDA approval is a catch-22 because cannabis is a Schedule I drug, and this stymies research. In a country where 17 states have legalized medical marijuana, I agree that the FDA should revisit this issue.

• FDA-approved medications have resulted in many deaths, and FDA-approved medications have been withdrawn for safety reasons.  Readers specifically noted Ambien, Xanax, Oxycontin, Vioxx, Avandia, Fen-Phen, and silicone breast implants. They contend that marijuana is safer than these substances.

• Other legal substances are unsafe, specifically alcohol, tobacco, and the above-mentioned prescription drugs. This is similar to the point made above, and I agree, but I am not sure it’s relevant to the discussion of medical marijuana.

• Marijuana is safe and effective, and any facts that are presented to the contrary are wrong.  There is really no answer to this because this point of view, by definition, is closed to discussion.

• Marijuana doesn’t kill.  If you stay out of a car, don’t lace it with it toxins, and don’t mix it with other drugs, this is probably true.

• There are inconsistencies in medical practice, and people can get Viagra by calling an 800 number.  

• Marijuana is an herbal product that has been used as medicine for thousands of years and should not treated as a pharmaceutical.  Again, this is different issue from those addressed in medical marijuana legislation.

• Doctors are pawns of the pharmaceutical industry and can’t profit if medical marijuana is legalized.  One writer suggested that psychiatrists would be put out of business because marijuana would replace Prozac, and several commenters stated as a fact that my co-author and I are pharmaceutical “shills” who are more interested in dinners and harbor cruises. Neither Dr. Hanson nor I have any financial relationships with pharmaceutical companies, and it’s been years since I’ve gotten so much as a pen, much less a chicken salad sandwich, from a drug rep. I’m not terribly worried that medical marijuana will put me out of business, but I am concerned that it will make my job harder.

• There were some insults that added nothing to the conversation. "Psychiatrists are the worst kind of quacks because they believe their own nonsense.  Their 'successes' are people who are drugged into the equivalent of a chemical lobotomy.”

 
Personally, I do believe that marijuana should be re-scheduled and that it should be available for use for specific indications where other treatments have been inadequate. But it should be prescribed cautiously, purchased from a pharmacy, with a prescription noting dosage and frequency, and marketed without the propaganda that it lacks adverse effects or the possibility of addiction. 

I do not believe that non-psychiatrists should prescribe medical marijuana for psychiatric symptoms, (especially if the patient is also seeing a psychiatrist) and I certainly don’t believe that legislators should propose psychiatric indications for cannabis in opposition to current treatment standards. I believe that if marijuana is used as “medicine,” it should be used because conventional medications, including Marinol, the oral form of  synthetic THC, either haven’t worked or have caused unacceptable side effects.  
 

The current mechanism of prescribing medical marijuana is not about cancer, AIDS, MS, or chronic pain patients.  Unlike other “medications,” marijuana (medical or otherwise) causes smokers to get high, and legalization requires that we address how this will play out for the work place and our overall productivity as a society. 

If the conversation is about increasing access to marijuana for all Americans, one might contend that our current War on Drugs has been a dismal failure, and discussions  regarding decriminalization or legalization might best be left to the lawmakers, the constituents, the crime fighters, and the addiction specialists. That’s a conversation that can be had without my input.
 
If you’d like to read the original article with the comments in the Baltimore Sun, click here.
 
If you’d like to read an article by a Steve Balt, a California psychiatrist who discusses the issues involved in treating patients who are getting medical marijuana from another prescriber, click  here.
 
And, finally, if you’d like to read an article from Time magazine called "The United States of Amerijuana," click here.
 
Please note, the ideas expressed here are mine alone and do reflect the views of the co-author of the original article, Dr. Hanson.  

 

 —Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.
 
You can also comment on our original Shrink Rap blog by clicking here.  
 
DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Forgive me for stating the obvious, but incarceration is rough on families.

Intact families are important for prisoners because good external relationships are associated with better adjustment after release and lower recidivism rates. Unfortunately, some prisoners don’t always have the best family dynamics to begin with, if they have family at all.

The family might have more than one incarcerated member who all rely on the same overwhelmed mother. The prisoner might be the disciplinarian of the family, and in his absence the children might run wild over the more passive partner. The abandoned girlfriend might be at home struggling to pay the rent while managing her own addictions.

Regardless of the specific scenario, the correctional facility can become the focal point of the external family’s displaced frustration and anger. Angry family phone calls often get routed to the institutional psychology department. The relative – usually a mother – wants to know why her loved one hasn’t been transferred to another facility or placed in a program or hasn’t had a parole hearing.

These are issues that do not involve the psychology department. Yet the mental health practitioner must allow some time to listen and explain the incarceration process, offering guidance about whom to contact for each issue.

Now, add to these problems the concern about a prisoner who also has a mental illness. What role, if any, does outside family play in the care of a mentally ill prisoner?

Some aspects are similar to free society care: I cannot give out information about the patient without his consent, and prisoners also have a right to be free of involuntary treatment if they are not dangerous. However, family contact in the correctional setting can be even more valuable than in free society care. Family members can be engaged as an ally and partner in the care of mentally ill prisoners. When a family member calls, I immediately thank her for calling and explain ways that she can help me care for her relative. It’s important for her to know that she can provide a great deal of care, even from a distance.

I recommend that she write a letter outlining the patient’s symptoms – particularly ones the patient would be reluctant to reveal or those he might not be aware of – as well as any pertinent early warning signs of relapse. This letter also should document which medicines seem to help, which he definitely had bad reactions to, and ways to relate to the patient so he will be more likely to take his medicines and keep his appointments.

I encourage the relative to contact prison administration to find out what kinds of programs and resources are available at the facility the patient is sent to, and then follow up with that facility’s social work department to coordinate release and aftercare planning. It’s important to keep expectations clear, invite participation, and solicit feedback.

Finally, I ask the family member to stay in touch with the patient and to call the psychology department if she notices anything of concern. During the course of this conversation, it might become clear that the relative is exhausted and overwhelmed, or secretly relieved to be turning over the responsibility of care to someone else. In this case, I tactfully suggest that it would be best for her to care for herself during the incarceration rather than invest energy in a situation beyond her control. This relieves some degree of guilt she might be experiencing, and allows her time to recover from fatigue and frustration.

Incarceration does not mean permanent disruption of family relationships. When managed properly, the time can be used to enhance patient self-reliance and teach proper distance between overly engaged or enmeshed relatives. I know I’ve struck the right level of engagement when I get a family phone call after the patient has been released, asking for referrals or a medication renewal. I enjoy these calls, which to me are a sign that the family has moved from anger and frustration, to hope and rededication. It also means I might never hear from them again, for all the right reasons.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Forgive me for stating the obvious, but incarceration is rough on families.

Intact families are important for prisoners because good external relationships are associated with better adjustment after release and lower recidivism rates. Unfortunately, some prisoners don’t always have the best family dynamics to begin with, if they have family at all.

The family might have more than one incarcerated member who all rely on the same overwhelmed mother. The prisoner might be the disciplinarian of the family, and in his absence the children might run wild over the more passive partner. The abandoned girlfriend might be at home struggling to pay the rent while managing her own addictions.

Regardless of the specific scenario, the correctional facility can become the focal point of the external family’s displaced frustration and anger. Angry family phone calls often get routed to the institutional psychology department. The relative – usually a mother – wants to know why her loved one hasn’t been transferred to another facility or placed in a program or hasn’t had a parole hearing.

These are issues that do not involve the psychology department. Yet the mental health practitioner must allow some time to listen and explain the incarceration process, offering guidance about whom to contact for each issue.

Now, add to these problems the concern about a prisoner who also has a mental illness. What role, if any, does outside family play in the care of a mentally ill prisoner?

Some aspects are similar to free society care: I cannot give out information about the patient without his consent, and prisoners also have a right to be free of involuntary treatment if they are not dangerous. However, family contact in the correctional setting can be even more valuable than in free society care. Family members can be engaged as an ally and partner in the care of mentally ill prisoners. When a family member calls, I immediately thank her for calling and explain ways that she can help me care for her relative. It’s important for her to know that she can provide a great deal of care, even from a distance.

I recommend that she write a letter outlining the patient’s symptoms – particularly ones the patient would be reluctant to reveal or those he might not be aware of – as well as any pertinent early warning signs of relapse. This letter also should document which medicines seem to help, which he definitely had bad reactions to, and ways to relate to the patient so he will be more likely to take his medicines and keep his appointments.

I encourage the relative to contact prison administration to find out what kinds of programs and resources are available at the facility the patient is sent to, and then follow up with that facility’s social work department to coordinate release and aftercare planning. It’s important to keep expectations clear, invite participation, and solicit feedback.

Finally, I ask the family member to stay in touch with the patient and to call the psychology department if she notices anything of concern. During the course of this conversation, it might become clear that the relative is exhausted and overwhelmed, or secretly relieved to be turning over the responsibility of care to someone else. In this case, I tactfully suggest that it would be best for her to care for herself during the incarceration rather than invest energy in a situation beyond her control. This relieves some degree of guilt she might be experiencing, and allows her time to recover from fatigue and frustration.

Incarceration does not mean permanent disruption of family relationships. When managed properly, the time can be used to enhance patient self-reliance and teach proper distance between overly engaged or enmeshed relatives. I know I’ve struck the right level of engagement when I get a family phone call after the patient has been released, asking for referrals or a medication renewal. I enjoy these calls, which to me are a sign that the family has moved from anger and frustration, to hope and rededication. It also means I might never hear from them again, for all the right reasons.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Forgive me for stating the obvious, but incarceration is rough on families.

Intact families are important for prisoners because good external relationships are associated with better adjustment after release and lower recidivism rates. Unfortunately, some prisoners don’t always have the best family dynamics to begin with, if they have family at all.

The family might have more than one incarcerated member who all rely on the same overwhelmed mother. The prisoner might be the disciplinarian of the family, and in his absence the children might run wild over the more passive partner. The abandoned girlfriend might be at home struggling to pay the rent while managing her own addictions.

Regardless of the specific scenario, the correctional facility can become the focal point of the external family’s displaced frustration and anger. Angry family phone calls often get routed to the institutional psychology department. The relative – usually a mother – wants to know why her loved one hasn’t been transferred to another facility or placed in a program or hasn’t had a parole hearing.

These are issues that do not involve the psychology department. Yet the mental health practitioner must allow some time to listen and explain the incarceration process, offering guidance about whom to contact for each issue.

Now, add to these problems the concern about a prisoner who also has a mental illness. What role, if any, does outside family play in the care of a mentally ill prisoner?

Some aspects are similar to free society care: I cannot give out information about the patient without his consent, and prisoners also have a right to be free of involuntary treatment if they are not dangerous. However, family contact in the correctional setting can be even more valuable than in free society care. Family members can be engaged as an ally and partner in the care of mentally ill prisoners. When a family member calls, I immediately thank her for calling and explain ways that she can help me care for her relative. It’s important for her to know that she can provide a great deal of care, even from a distance.

I recommend that she write a letter outlining the patient’s symptoms – particularly ones the patient would be reluctant to reveal or those he might not be aware of – as well as any pertinent early warning signs of relapse. This letter also should document which medicines seem to help, which he definitely had bad reactions to, and ways to relate to the patient so he will be more likely to take his medicines and keep his appointments.

I encourage the relative to contact prison administration to find out what kinds of programs and resources are available at the facility the patient is sent to, and then follow up with that facility’s social work department to coordinate release and aftercare planning. It’s important to keep expectations clear, invite participation, and solicit feedback.

Finally, I ask the family member to stay in touch with the patient and to call the psychology department if she notices anything of concern. During the course of this conversation, it might become clear that the relative is exhausted and overwhelmed, or secretly relieved to be turning over the responsibility of care to someone else. In this case, I tactfully suggest that it would be best for her to care for herself during the incarceration rather than invest energy in a situation beyond her control. This relieves some degree of guilt she might be experiencing, and allows her time to recover from fatigue and frustration.

Incarceration does not mean permanent disruption of family relationships. When managed properly, the time can be used to enhance patient self-reliance and teach proper distance between overly engaged or enmeshed relatives. I know I’ve struck the right level of engagement when I get a family phone call after the patient has been released, asking for referrals or a medication renewal. I enjoy these calls, which to me are a sign that the family has moved from anger and frustration, to hope and rededication. It also means I might never hear from them again, for all the right reasons.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Despite the fact that marijuana remains a controlled substance that is illegal in the United States under federal law, 16 states and the District of Columbia have legalized “medical marijuana.”

Del. Cheryl D. Glenn’s House Bill 15 (H.B. 15), the “Maryland Medical Marijuana Act,” was introduced and first read on Jan. 11, 2012, the first day of this year’s General Assembly session. Two more bills calling for the legalization of medical marijuana have been introduced since. We would like to make the case that medical marijuana as currently “prescribed” makes a farce of medicine.

While inhaled marijuana may have some medical uses, to legislate medical treatments evades the standard protocols that the Food and Drug Administration have put in place for the regulation of all other medications. Why would this “medication” alone be exempt from the usual monitoring and safety regulations, especially given that we know that significant risks are involved with the use of inhaled cannabis?

In all states where medical marijuana is legal, access is granted with a card, authorized by a physician, and the card expires in 1 year. There is no stipulation as to dose or frequency of administration, or for standard follow-up appointments to determine whether the marijuana is helpful or is causing side effects. For those people for whom marijuana induces a negative reaction in the form of an addiction, lowered motivation, paranoia, or even schizophrenia, no mechanism is in place for the physician to monitor or halt use of the drug if the patient wishes to continue using it against medical advice. This seems like a strange way to prescribe the use of a controlled substance.

Medical marijuana is distributed by specialized dispensaries – not pharmacies. In some states, these dispensaries are marketed as boutiques with a variety of “flavors” and preparations, and the message is that smoking marijuana is part of “wellness.” There is no quality control to regulate the potency of the active ingredient or to standardize and safeguard the product being delivered.

While it seems heartless to oppose the legalization of marijuana for those who are suffering from cancer, end-stage AIDS, or debilitating pain, medical marijuana is often used for a much wider variety of conditions that fall under the realm of “chronic disorders.”

In Colorado, it is estimated that only 2% of registered medical marijuana users suffer from cancer or AIDS. Medicinal marijuana is often prescribed for psychiatric conditions such as insomnia, anxiety, and mood disorders – and often by prescribers who have no specialized training in psychiatric disorders. There is no research to support this practice, and it is not the current standard to recommend marijuana for psychiatric conditions. In fact, cannabis is known to exacerbate and accelerate some psychiatric symptoms.

Still, H.B. 15 specifically stipulates five psychiatric conditions that medical marijuana would be indicated for: anxiety, depression, bipolar disorder, posttraumatic stress disorder, and agitation in Alzheimer’s disease. As psychiatrists, we are speechless.

Of the two other medical marijuana bills being considered by our state legislature, one – House Bill 1024 – would allow for medical marijuana to be distributed by academic centers with oversight by a Marijuana Commission, and would require that data and outcomes be collected and published. The other, House Bill 1158, also would require the formation of a Marijuana Oversight Commission. In addition, H.B. 1158 would require training and certification of physicians who prescribe marijuana, but would allow for prescription outside of academic centers and would not require data collection.

The wide variety of ways in which our legislators believe it is appropriate to use marijuana for medical conditions leave one to wonder whether doctors, rather than lawmakers, shouldn’t be making decisions about medical treatments.

Access to medical marijuana has led to litigation in facilities where controlled substances are restricted or tightly regulated, and correctional facilities have defended lawsuits by inmates seeking to continue smoking medical marijuana while incarcerated.

We believe that marijuana for medical conditions should undergo the same study, scrutiny, and prescription monitoring as every other prescribed medication and that the current means of “prescribing” violates all of the usual practices of medicine.  What other medication do we authorize for a year, with no stipulation as to frequency, dose, or certainty that there has been a positive response without side effects?

It has been suggested that medicalization is the first step toward legalization. If legalization is, in fact, the goal, perhaps that can be done without physicians as intermediaries. While legalizing marijuana may not make sense from the standpoint of public health and safety, there are certainly many examples of ways we allow members of our society to put themselves at risk without legislating a role for physicians.

 

How has medical marijuana been received in your state?  We’d love to hear how the legalization of marijuana has influenced psychiatry in your state.

—Dinah Miller, M.D. and Anne Hanson, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

You can also comment on our Shrink Rap blog at http://psychiatrist-blog.blogspot.com/2012/02/should-state-legislators-determine.html.

DR. MILLER and DR. HANSON are two of the authors of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Despite the fact that marijuana remains a controlled substance that is illegal in the United States under federal law, 16 states and the District of Columbia have legalized “medical marijuana.”

Del. Cheryl D. Glenn’s House Bill 15 (H.B. 15), the “Maryland Medical Marijuana Act,” was introduced and first read on Jan. 11, 2012, the first day of this year’s General Assembly session. Two more bills calling for the legalization of medical marijuana have been introduced since. We would like to make the case that medical marijuana as currently “prescribed” makes a farce of medicine.

While inhaled marijuana may have some medical uses, to legislate medical treatments evades the standard protocols that the Food and Drug Administration have put in place for the regulation of all other medications. Why would this “medication” alone be exempt from the usual monitoring and safety regulations, especially given that we know that significant risks are involved with the use of inhaled cannabis?

In all states where medical marijuana is legal, access is granted with a card, authorized by a physician, and the card expires in 1 year. There is no stipulation as to dose or frequency of administration, or for standard follow-up appointments to determine whether the marijuana is helpful or is causing side effects. For those people for whom marijuana induces a negative reaction in the form of an addiction, lowered motivation, paranoia, or even schizophrenia, no mechanism is in place for the physician to monitor or halt use of the drug if the patient wishes to continue using it against medical advice. This seems like a strange way to prescribe the use of a controlled substance.

Medical marijuana is distributed by specialized dispensaries – not pharmacies. In some states, these dispensaries are marketed as boutiques with a variety of “flavors” and preparations, and the message is that smoking marijuana is part of “wellness.” There is no quality control to regulate the potency of the active ingredient or to standardize and safeguard the product being delivered.

While it seems heartless to oppose the legalization of marijuana for those who are suffering from cancer, end-stage AIDS, or debilitating pain, medical marijuana is often used for a much wider variety of conditions that fall under the realm of “chronic disorders.”

In Colorado, it is estimated that only 2% of registered medical marijuana users suffer from cancer or AIDS. Medicinal marijuana is often prescribed for psychiatric conditions such as insomnia, anxiety, and mood disorders – and often by prescribers who have no specialized training in psychiatric disorders. There is no research to support this practice, and it is not the current standard to recommend marijuana for psychiatric conditions. In fact, cannabis is known to exacerbate and accelerate some psychiatric symptoms.

Still, H.B. 15 specifically stipulates five psychiatric conditions that medical marijuana would be indicated for: anxiety, depression, bipolar disorder, posttraumatic stress disorder, and agitation in Alzheimer’s disease. As psychiatrists, we are speechless.

Of the two other medical marijuana bills being considered by our state legislature, one – House Bill 1024 – would allow for medical marijuana to be distributed by academic centers with oversight by a Marijuana Commission, and would require that data and outcomes be collected and published. The other, House Bill 1158, also would require the formation of a Marijuana Oversight Commission. In addition, H.B. 1158 would require training and certification of physicians who prescribe marijuana, but would allow for prescription outside of academic centers and would not require data collection.

The wide variety of ways in which our legislators believe it is appropriate to use marijuana for medical conditions leave one to wonder whether doctors, rather than lawmakers, shouldn’t be making decisions about medical treatments.

Access to medical marijuana has led to litigation in facilities where controlled substances are restricted or tightly regulated, and correctional facilities have defended lawsuits by inmates seeking to continue smoking medical marijuana while incarcerated.

We believe that marijuana for medical conditions should undergo the same study, scrutiny, and prescription monitoring as every other prescribed medication and that the current means of “prescribing” violates all of the usual practices of medicine.  What other medication do we authorize for a year, with no stipulation as to frequency, dose, or certainty that there has been a positive response without side effects?

It has been suggested that medicalization is the first step toward legalization. If legalization is, in fact, the goal, perhaps that can be done without physicians as intermediaries. While legalizing marijuana may not make sense from the standpoint of public health and safety, there are certainly many examples of ways we allow members of our society to put themselves at risk without legislating a role for physicians.

 

How has medical marijuana been received in your state?  We’d love to hear how the legalization of marijuana has influenced psychiatry in your state.

—Dinah Miller, M.D. and Anne Hanson, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

You can also comment on our Shrink Rap blog at http://psychiatrist-blog.blogspot.com/2012/02/should-state-legislators-determine.html.

DR. MILLER and DR. HANSON are two of the authors of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Despite the fact that marijuana remains a controlled substance that is illegal in the United States under federal law, 16 states and the District of Columbia have legalized “medical marijuana.”

Del. Cheryl D. Glenn’s House Bill 15 (H.B. 15), the “Maryland Medical Marijuana Act,” was introduced and first read on Jan. 11, 2012, the first day of this year’s General Assembly session. Two more bills calling for the legalization of medical marijuana have been introduced since. We would like to make the case that medical marijuana as currently “prescribed” makes a farce of medicine.

While inhaled marijuana may have some medical uses, to legislate medical treatments evades the standard protocols that the Food and Drug Administration have put in place for the regulation of all other medications. Why would this “medication” alone be exempt from the usual monitoring and safety regulations, especially given that we know that significant risks are involved with the use of inhaled cannabis?

In all states where medical marijuana is legal, access is granted with a card, authorized by a physician, and the card expires in 1 year. There is no stipulation as to dose or frequency of administration, or for standard follow-up appointments to determine whether the marijuana is helpful or is causing side effects. For those people for whom marijuana induces a negative reaction in the form of an addiction, lowered motivation, paranoia, or even schizophrenia, no mechanism is in place for the physician to monitor or halt use of the drug if the patient wishes to continue using it against medical advice. This seems like a strange way to prescribe the use of a controlled substance.

Medical marijuana is distributed by specialized dispensaries – not pharmacies. In some states, these dispensaries are marketed as boutiques with a variety of “flavors” and preparations, and the message is that smoking marijuana is part of “wellness.” There is no quality control to regulate the potency of the active ingredient or to standardize and safeguard the product being delivered.

While it seems heartless to oppose the legalization of marijuana for those who are suffering from cancer, end-stage AIDS, or debilitating pain, medical marijuana is often used for a much wider variety of conditions that fall under the realm of “chronic disorders.”

In Colorado, it is estimated that only 2% of registered medical marijuana users suffer from cancer or AIDS. Medicinal marijuana is often prescribed for psychiatric conditions such as insomnia, anxiety, and mood disorders – and often by prescribers who have no specialized training in psychiatric disorders. There is no research to support this practice, and it is not the current standard to recommend marijuana for psychiatric conditions. In fact, cannabis is known to exacerbate and accelerate some psychiatric symptoms.

Still, H.B. 15 specifically stipulates five psychiatric conditions that medical marijuana would be indicated for: anxiety, depression, bipolar disorder, posttraumatic stress disorder, and agitation in Alzheimer’s disease. As psychiatrists, we are speechless.

Of the two other medical marijuana bills being considered by our state legislature, one – House Bill 1024 – would allow for medical marijuana to be distributed by academic centers with oversight by a Marijuana Commission, and would require that data and outcomes be collected and published. The other, House Bill 1158, also would require the formation of a Marijuana Oversight Commission. In addition, H.B. 1158 would require training and certification of physicians who prescribe marijuana, but would allow for prescription outside of academic centers and would not require data collection.

The wide variety of ways in which our legislators believe it is appropriate to use marijuana for medical conditions leave one to wonder whether doctors, rather than lawmakers, shouldn’t be making decisions about medical treatments.

Access to medical marijuana has led to litigation in facilities where controlled substances are restricted or tightly regulated, and correctional facilities have defended lawsuits by inmates seeking to continue smoking medical marijuana while incarcerated.

We believe that marijuana for medical conditions should undergo the same study, scrutiny, and prescription monitoring as every other prescribed medication and that the current means of “prescribing” violates all of the usual practices of medicine.  What other medication do we authorize for a year, with no stipulation as to frequency, dose, or certainty that there has been a positive response without side effects?

It has been suggested that medicalization is the first step toward legalization. If legalization is, in fact, the goal, perhaps that can be done without physicians as intermediaries. While legalizing marijuana may not make sense from the standpoint of public health and safety, there are certainly many examples of ways we allow members of our society to put themselves at risk without legislating a role for physicians.

 

How has medical marijuana been received in your state?  We’d love to hear how the legalization of marijuana has influenced psychiatry in your state.

—Dinah Miller, M.D. and Anne Hanson, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.

You can also comment on our Shrink Rap blog at http://psychiatrist-blog.blogspot.com/2012/02/should-state-legislators-determine.html.

DR. MILLER and DR. HANSON are two of the authors of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.