Shrink Rap News

Given the EHR angst that many of us have been feeling about whether to go electronic and how to make the decision, it is timely that data.gov recently published raw data on which electronic health records physicians are using to receive their health IT stimulus money.

The Office of the National Coordinator for Health Information Technology (ONC) released the spreadsheet of all the eligible providers (Medicare and Medicaid) who attested to Stage 1 Meaningful Use (MU) of certified electronic health records (EHRs). I downloaded the results and did some pivot table magic to see which EHRs are being used by physicians identifying their specialty as “Psychiatry.”

There were 285 of these people who said they were compliant with Stage 1 MU. Interestingly, there were others who identified themselves in other ways. Three were “Community Mental Health Centers,” even though HITECH specifically excluded them (but a doc there can attest, so I guess it’s OK); they used Meditech and HCA. Five identified as “Psychiatric” (Cerner, Design Clinicals, Siemens, and Wellsoft). And 16 as “Psychiatric Unit” (Epic, Cerner, NextGen, McKesson, GE, HCA, Meditech, Midas+, Siemens). Below are the data on the 285 identified as “psychiatry.”

After discounting the large system products (eg, Epic, Cerner), you can get an idea about the EHR products being used in outpatient private practices. Some of these are primarily for electronic prescribing. I haven’t looked to see which of these have iPad apps (Epic has Canto), but if you know about or have experience with any of these or other products, please comment below or on my blog at hitshrink.blogspot.com.

The APA will soon have a tool for members to compare EHRs and comment on their experiences. I will let you know when that is available.

This table lists the vendors in descending order of popularity among those psychiatrists attesting for Stage 1 Meaningful Use through the end of 2011. Links are provided for convenience only. (Disclosure: I have no financial interests in nor have I received money from any EHR vendor.)

(The following had only one user each: ADP AdvancedMD, athenahealth/athenaClinicals, DrChrono, GE/Centricity, HealthFusion/MediTouch, Henry Schein/MicroMD, Ingenix/CareTracker, IOS/Medios, iSALUS/OfficeEMR, Medical Informatics Engineering/WebChart, and SuiteMed/IMS.)

<[QM]>—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.

Given the EHR angst that many of us have been feeling about whether to go electronic and how to make the decision, it is timely that data.gov recently published raw data on which electronic health records physicians are using to receive their health IT stimulus money.

The Office of the National Coordinator for Health Information Technology (ONC) released the spreadsheet of all the eligible providers (Medicare and Medicaid) who attested to Stage 1 Meaningful Use (MU) of certified electronic health records (EHRs). I downloaded the results and did some pivot table magic to see which EHRs are being used by physicians identifying their specialty as “Psychiatry.”

There were 285 of these people who said they were compliant with Stage 1 MU. Interestingly, there were others who identified themselves in other ways. Three were “Community Mental Health Centers,” even though HITECH specifically excluded them (but a doc there can attest, so I guess it’s OK); they used Meditech and HCA. Five identified as “Psychiatric” (Cerner, Design Clinicals, Siemens, and Wellsoft). And 16 as “Psychiatric Unit” (Epic, Cerner, NextGen, McKesson, GE, HCA, Meditech, Midas+, Siemens). Below are the data on the 285 identified as “psychiatry.”

After discounting the large system products (eg, Epic, Cerner), you can get an idea about the EHR products being used in outpatient private practices. Some of these are primarily for electronic prescribing. I haven’t looked to see which of these have iPad apps (Epic has Canto), but if you know about or have experience with any of these or other products, please comment below or on my blog at hitshrink.blogspot.com.

The APA will soon have a tool for members to compare EHRs and comment on their experiences. I will let you know when that is available.

This table lists the vendors in descending order of popularity among those psychiatrists attesting for Stage 1 Meaningful Use through the end of 2011. Links are provided for convenience only. (Disclosure: I have no financial interests in nor have I received money from any EHR vendor.)

(The following had only one user each: ADP AdvancedMD, athenahealth/athenaClinicals, DrChrono, GE/Centricity, HealthFusion/MediTouch, Henry Schein/MicroMD, Ingenix/CareTracker, IOS/Medios, iSALUS/OfficeEMR, Medical Informatics Engineering/WebChart, and SuiteMed/IMS.)

<[QM]>—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.

Given the EHR angst that many of us have been feeling about whether to go electronic and how to make the decision, it is timely that data.gov recently published raw data on which electronic health records physicians are using to receive their health IT stimulus money.

The Office of the National Coordinator for Health Information Technology (ONC) released the spreadsheet of all the eligible providers (Medicare and Medicaid) who attested to Stage 1 Meaningful Use (MU) of certified electronic health records (EHRs). I downloaded the results and did some pivot table magic to see which EHRs are being used by physicians identifying their specialty as “Psychiatry.”

There were 285 of these people who said they were compliant with Stage 1 MU. Interestingly, there were others who identified themselves in other ways. Three were “Community Mental Health Centers,” even though HITECH specifically excluded them (but a doc there can attest, so I guess it’s OK); they used Meditech and HCA. Five identified as “Psychiatric” (Cerner, Design Clinicals, Siemens, and Wellsoft). And 16 as “Psychiatric Unit” (Epic, Cerner, NextGen, McKesson, GE, HCA, Meditech, Midas+, Siemens). Below are the data on the 285 identified as “psychiatry.”

After discounting the large system products (eg, Epic, Cerner), you can get an idea about the EHR products being used in outpatient private practices. Some of these are primarily for electronic prescribing. I haven’t looked to see which of these have iPad apps (Epic has Canto), but if you know about or have experience with any of these or other products, please comment below or on my blog at hitshrink.blogspot.com.

The APA will soon have a tool for members to compare EHRs and comment on their experiences. I will let you know when that is available.

This table lists the vendors in descending order of popularity among those psychiatrists attesting for Stage 1 Meaningful Use through the end of 2011. Links are provided for convenience only. (Disclosure: I have no financial interests in nor have I received money from any EHR vendor.)

(The following had only one user each: ADP AdvancedMD, athenahealth/athenaClinicals, DrChrono, GE/Centricity, HealthFusion/MediTouch, Henry Schein/MicroMD, Ingenix/CareTracker, IOS/Medios, iSALUS/OfficeEMR, Medical Informatics Engineering/WebChart, and SuiteMed/IMS.)

<[QM]>—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.

We all know the stereotype of the extroverted personality: someone who is the life of the party, dynamic, the center of attention, someone who is creative and charismatic. Then there is the introvert: the photographic negative, the person who is odd and isolated, creepy and potentially dangerous.

As a resident I was taught about Eysenck’s theory of personality, in which extroverts and introverts are framed in terms of emotional stability and response to consequences. I learned that introverts were easily demoralized and sensitive to failure, while extroverts shrugged off criticism and weren’t deterred by negative consequences. I had a chance to listen to lectures by Paul Costa and Robert McCrae, creators of the NEO five factor personality inventory, and learned that extreme introversion and extroversion traits tended to be both heritable and fixed. Of more personal relevance, I learned that being an introvert in a training program surrounded by extroverts was a challenging environment to learn in.

With this background in mind, I was intrigued to read a new book by former Wall Street attorney Susan Cain entitled, “Quiet: The Power of Introverts in a World That Can’t Stop Talking.” While I get bombarded with requests from publicists to review books, this was the first time I was ever tempted to request a review copy for myself. But I didn’t. As an introvert of the highest caliber, that would have felt far too pushy. Besides, after reading it, I think Cain deserves every penny she gets for writing this book. I bought and downloaded a Kindle version.

The book began with an anecdote about a young female attorney left to her own devices for the first time in the context of a high-pressure mediation session. Her opponent, a loud and blustery fellow, began the session with demands and an attempt at intimidation. The young introverted attorney remained calm, and focused on facts and logic as she firmly and consistently made her points. The session concluded successfully with an agreed settlement. The next day, the opposing attorney offered her a job. Of course, that young attorney was Cain herself.

Cain used that example to illustrate the powers of the introvert: intense powers of concentration, a tendency to rely upon logic rather than intuition, good listening skills, and a sense of caution. She discussed the transition of American society from one based upon individual character to a society that valued self-promotion and personal flair. She used examples from Harvard Business School and a charismatic megachurch to illustrate the way that higher education and religion have shaped themselves around extroversion-centric ideals.

Fortuitously, shortly before this book came out, former Harvard President Lawrence Summers wrote an op-ed piece in the New York Times about reform in higher education. He encouraged the use of more group educational activities, stating that businesses value the ability to collaborate more than GMAT scores and college transcripts. I hope he reads Quiet, since some of the students and researchers interviewed for this book are from Harvard, as is Cain herself, and the impact of forced collaborative learning is described vividly in the book.

In later chapters, Cain gave examples of successful introvert-extrovert teams to illustrate how introverts can thrive when extroverts allow them to express their natural strengths. The first examples she used were the founders of Apple Computer, Steve Wozniak and Steve Jobs. Wozniak, whose autobiography I was reading coincidentally at the same time as Quiet, was the self-effacing genius who spent his high school years holed up in his bedroom designing computers he couldn’t afford to build. Jobs was the master showman and sales pitchman who fascinated the media at every quarterly reporting season when he announced each new product with a pseudo-humble signature statement, “Oh…and just one more thing.” Together, Jobs’ extroversion and Wozniak’s quiet intellectualism created a company that now makes up most of the value of the S&P 500. Cain presented other case studies of introvert management strategies to conclude that introverts are most successful and productive when they aren’t forced to behave and work like extroverts.

The book did a good job of drawing the distinction between pathology and personality vulnerabilities, but at times it had the oversimplified feel of a planned rebranding campaign. Cain’s own website has a banner logo promoting the book, which exclaims: “Join the Quiet revolution!” as though introversion were about to become the next biggest thing since Napolean Dynamite donned nerd glasses. Nevertheless, extroverted readers looking for information on the care and feeding of their favorite introvert will find this book to be a useful guide.

<[QM]>—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.

<[QM]>

We all know the stereotype of the extroverted personality: someone who is the life of the party, dynamic, the center of attention, someone who is creative and charismatic. Then there is the introvert: the photographic negative, the person who is odd and isolated, creepy and potentially dangerous.

As a resident I was taught about Eysenck’s theory of personality, in which extroverts and introverts are framed in terms of emotional stability and response to consequences. I learned that introverts were easily demoralized and sensitive to failure, while extroverts shrugged off criticism and weren’t deterred by negative consequences. I had a chance to listen to lectures by Paul Costa and Robert McCrae, creators of the NEO five factor personality inventory, and learned that extreme introversion and extroversion traits tended to be both heritable and fixed. Of more personal relevance, I learned that being an introvert in a training program surrounded by extroverts was a challenging environment to learn in.

With this background in mind, I was intrigued to read a new book by former Wall Street attorney Susan Cain entitled, “Quiet: The Power of Introverts in a World That Can’t Stop Talking.” While I get bombarded with requests from publicists to review books, this was the first time I was ever tempted to request a review copy for myself. But I didn’t. As an introvert of the highest caliber, that would have felt far too pushy. Besides, after reading it, I think Cain deserves every penny she gets for writing this book. I bought and downloaded a Kindle version.

The book began with an anecdote about a young female attorney left to her own devices for the first time in the context of a high-pressure mediation session. Her opponent, a loud and blustery fellow, began the session with demands and an attempt at intimidation. The young introverted attorney remained calm, and focused on facts and logic as she firmly and consistently made her points. The session concluded successfully with an agreed settlement. The next day, the opposing attorney offered her a job. Of course, that young attorney was Cain herself.

Cain used that example to illustrate the powers of the introvert: intense powers of concentration, a tendency to rely upon logic rather than intuition, good listening skills, and a sense of caution. She discussed the transition of American society from one based upon individual character to a society that valued self-promotion and personal flair. She used examples from Harvard Business School and a charismatic megachurch to illustrate the way that higher education and religion have shaped themselves around extroversion-centric ideals.

Fortuitously, shortly before this book came out, former Harvard President Lawrence Summers wrote an op-ed piece in the New York Times about reform in higher education. He encouraged the use of more group educational activities, stating that businesses value the ability to collaborate more than GMAT scores and college transcripts. I hope he reads Quiet, since some of the students and researchers interviewed for this book are from Harvard, as is Cain herself, and the impact of forced collaborative learning is described vividly in the book.

In later chapters, Cain gave examples of successful introvert-extrovert teams to illustrate how introverts can thrive when extroverts allow them to express their natural strengths. The first examples she used were the founders of Apple Computer, Steve Wozniak and Steve Jobs. Wozniak, whose autobiography I was reading coincidentally at the same time as Quiet, was the self-effacing genius who spent his high school years holed up in his bedroom designing computers he couldn’t afford to build. Jobs was the master showman and sales pitchman who fascinated the media at every quarterly reporting season when he announced each new product with a pseudo-humble signature statement, “Oh…and just one more thing.” Together, Jobs’ extroversion and Wozniak’s quiet intellectualism created a company that now makes up most of the value of the S&P 500. Cain presented other case studies of introvert management strategies to conclude that introverts are most successful and productive when they aren’t forced to behave and work like extroverts.

The book did a good job of drawing the distinction between pathology and personality vulnerabilities, but at times it had the oversimplified feel of a planned rebranding campaign. Cain’s own website has a banner logo promoting the book, which exclaims: “Join the Quiet revolution!” as though introversion were about to become the next biggest thing since Napolean Dynamite donned nerd glasses. Nevertheless, extroverted readers looking for information on the care and feeding of their favorite introvert will find this book to be a useful guide.

<[QM]>—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.

<[QM]>

We all know the stereotype of the extroverted personality: someone who is the life of the party, dynamic, the center of attention, someone who is creative and charismatic. Then there is the introvert: the photographic negative, the person who is odd and isolated, creepy and potentially dangerous.

As a resident I was taught about Eysenck’s theory of personality, in which extroverts and introverts are framed in terms of emotional stability and response to consequences. I learned that introverts were easily demoralized and sensitive to failure, while extroverts shrugged off criticism and weren’t deterred by negative consequences. I had a chance to listen to lectures by Paul Costa and Robert McCrae, creators of the NEO five factor personality inventory, and learned that extreme introversion and extroversion traits tended to be both heritable and fixed. Of more personal relevance, I learned that being an introvert in a training program surrounded by extroverts was a challenging environment to learn in.

With this background in mind, I was intrigued to read a new book by former Wall Street attorney Susan Cain entitled, “Quiet: The Power of Introverts in a World That Can’t Stop Talking.” While I get bombarded with requests from publicists to review books, this was the first time I was ever tempted to request a review copy for myself. But I didn’t. As an introvert of the highest caliber, that would have felt far too pushy. Besides, after reading it, I think Cain deserves every penny she gets for writing this book. I bought and downloaded a Kindle version.

The book began with an anecdote about a young female attorney left to her own devices for the first time in the context of a high-pressure mediation session. Her opponent, a loud and blustery fellow, began the session with demands and an attempt at intimidation. The young introverted attorney remained calm, and focused on facts and logic as she firmly and consistently made her points. The session concluded successfully with an agreed settlement. The next day, the opposing attorney offered her a job. Of course, that young attorney was Cain herself.

Cain used that example to illustrate the powers of the introvert: intense powers of concentration, a tendency to rely upon logic rather than intuition, good listening skills, and a sense of caution. She discussed the transition of American society from one based upon individual character to a society that valued self-promotion and personal flair. She used examples from Harvard Business School and a charismatic megachurch to illustrate the way that higher education and religion have shaped themselves around extroversion-centric ideals.

Fortuitously, shortly before this book came out, former Harvard President Lawrence Summers wrote an op-ed piece in the New York Times about reform in higher education. He encouraged the use of more group educational activities, stating that businesses value the ability to collaborate more than GMAT scores and college transcripts. I hope he reads Quiet, since some of the students and researchers interviewed for this book are from Harvard, as is Cain herself, and the impact of forced collaborative learning is described vividly in the book.

In later chapters, Cain gave examples of successful introvert-extrovert teams to illustrate how introverts can thrive when extroverts allow them to express their natural strengths. The first examples she used were the founders of Apple Computer, Steve Wozniak and Steve Jobs. Wozniak, whose autobiography I was reading coincidentally at the same time as Quiet, was the self-effacing genius who spent his high school years holed up in his bedroom designing computers he couldn’t afford to build. Jobs was the master showman and sales pitchman who fascinated the media at every quarterly reporting season when he announced each new product with a pseudo-humble signature statement, “Oh…and just one more thing.” Together, Jobs’ extroversion and Wozniak’s quiet intellectualism created a company that now makes up most of the value of the S&P 500. Cain presented other case studies of introvert management strategies to conclude that introverts are most successful and productive when they aren’t forced to behave and work like extroverts.

The book did a good job of drawing the distinction between pathology and personality vulnerabilities, but at times it had the oversimplified feel of a planned rebranding campaign. Cain’s own website has a banner logo promoting the book, which exclaims: “Join the Quiet revolution!” as though introversion were about to become the next biggest thing since Napolean Dynamite donned nerd glasses. Nevertheless, extroverted readers looking for information on the care and feeding of their favorite introvert will find this book to be a useful guide.

<[QM]>—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.

<[QM]>

In my very first post here on Shrink Rap News, I talked about The Accessible Psychiatry Project that Anne Hanson, Steve Daviss and I have been working on for nearly 6 years now. The most interactive component of this project has been our Shrink Rap blog, now with over 1,640 posts.

If you’ve ever thought about starting a psychiatry blog, let me tell you that it’s a very interesting experience. We started with the idea that we would write about our work and converse with other psychiatrists, “a blog by psychiatrist, for psychiatrists,” or so our masthead reads. We soon discovered that with an open, unmoderated comment section, and no requirement for identification or registration, our audience of readers was not limited to psychiatrists. Our readers included other mental health professionals, physicians, and nurses in a variety of fields, people from all over the world comparing notes on mental health care policy, and many people who’ve been treated for psychiatric disorders and have a lot to say about their treatments.

Why would we want to interact with patients on a blog – for free, and after hours, no less – when we talk to patients all day? That’s a really good question, one that I still don’t have a complete answer for. What I can say is that the experience has been surprisingly enlightening, rewarding, and for the vast majority of the time, fun. It’s added an entirely new dimension to our work as psychiatrists, and there is something gratifying about a discussion that includes intelligent, articulate people from all over the world, and the playing field for the conversations is more level than the conversations that are had in the context of a doctor-patient interaction.

We’ll write a blog post and other mental health care providers will come and comment about their experiences, similar or not so similar. Patients come and talk about the same event from the perspective of the patient. They may share their affection for their doctors, or talk about what their psychiatrist has done in similar situations, and they tell their stories with a poignancy that is sometimes quite moving. With time, they’ve come to relate to us, the bloggers, in interesting ways and they interact with the other commenters on the blog, sometimes offering support, and sometimes being very critical. The relationships themselves can be quite complex – one lovely nurse has sent us links to YouTube videos of her musical performances as well as to a video she made demonstrating the deep brain stimulator she’d had placed for intractable migraines. Of course, I didn’t have to watch, but I found it fascinating.

Many of the comments we’ve gotten over the year have been warm and supportive. Some have expressed appreciation for our work, and that is always nice. But one of the interesting aspects of a psychiatry blog is that visitors are not all friendly, and some come to discuss the difficulties they’ve had with their care and the criticisms they have about the delivery of psychiatric treatments.

As a clinical psychiatrist, my patients come because they want help and they understand that I am on their side. Usually, they are happy to see me, and if not, I suppose they cancel their appointments, but very few patients come to be angry with me. Not so on Shrink Rap. Readers may come to tell stories of how they’ve been wronged by psychiatrists and the treatments we offer. Many are angry that they’ve had horrible side effects to medications, suffered memory loss during ECT, been humiliated by involuntary hospitalizations, or simply been addressed with unkind and insensitive words in a way that leaves them wounded.

After years of visiting psychiatry blogs, I’m well aware that this is not unique to Shrink Rap, but that all psychiatry blogs attract a cohort of injured readers. They can be a harsh with their words towards us and towards the other commenters. In addition, there are a subgroup of commenters who are known on the Internet as “trolls.” Wikipedia defines a troll as, “someone who posts inflammatory, extraneous, or off-topic messages in an online community.” Trolls often have a message they are trying to get across, and on psychiatry blogs these include anti-psychiatry sentiments, for example the idea that medications are harmful for everyone, or ECT should never be used.

Many psychiatry blogs, including this one on Clinical Psychiatry News, discourage these sentiments by requiring registration with identifying information, and by moderating the comments and only posting those the blog administrator wants made public. On Shrink Rap, we have gone back and forth on this, and for the most part, we’ve allowed anonymous, un-moderated comments. We’ve felt that it allows for a more open on-line discussion, and that when comments are moderated it leaves us vulnerable to the accusation that psychiatrists are only wiling to acknowledge information that supports their way of thinking and are unwilling to hear criticisms of their profession. At the same time, it’s been a difficult line to tread, as strident commenters sometimes scare away those who would like to express opposing opinions. Last week, for the second time in Shrink Rap’s history, we began moderating comments – hopefully only for a brief time.

Have you ever considered starting a blog? Have you thought about whether you’d take all commenters or filter out the voices that are hard to hear? There many medical blogs on the Internet, but surprisingly few psychiatrist-run blogs. The Internet remains a place where mainstream psychiatry and the good it may do, get lost in a loud avalanche of sentiments that cover us in mud.

<[QM]>—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.

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

In my very first post here on Shrink Rap News, I talked about The Accessible Psychiatry Project that Anne Hanson, Steve Daviss and I have been working on for nearly 6 years now. The most interactive component of this project has been our Shrink Rap blog, now with over 1,640 posts.

If you’ve ever thought about starting a psychiatry blog, let me tell you that it’s a very interesting experience. We started with the idea that we would write about our work and converse with other psychiatrists, “a blog by psychiatrist, for psychiatrists,” or so our masthead reads. We soon discovered that with an open, unmoderated comment section, and no requirement for identification or registration, our audience of readers was not limited to psychiatrists. Our readers included other mental health professionals, physicians, and nurses in a variety of fields, people from all over the world comparing notes on mental health care policy, and many people who’ve been treated for psychiatric disorders and have a lot to say about their treatments.

Why would we want to interact with patients on a blog – for free, and after hours, no less – when we talk to patients all day? That’s a really good question, one that I still don’t have a complete answer for. What I can say is that the experience has been surprisingly enlightening, rewarding, and for the vast majority of the time, fun. It’s added an entirely new dimension to our work as psychiatrists, and there is something gratifying about a discussion that includes intelligent, articulate people from all over the world, and the playing field for the conversations is more level than the conversations that are had in the context of a doctor-patient interaction.

We’ll write a blog post and other mental health care providers will come and comment about their experiences, similar or not so similar. Patients come and talk about the same event from the perspective of the patient. They may share their affection for their doctors, or talk about what their psychiatrist has done in similar situations, and they tell their stories with a poignancy that is sometimes quite moving. With time, they’ve come to relate to us, the bloggers, in interesting ways and they interact with the other commenters on the blog, sometimes offering support, and sometimes being very critical. The relationships themselves can be quite complex – one lovely nurse has sent us links to YouTube videos of her musical performances as well as to a video she made demonstrating the deep brain stimulator she’d had placed for intractable migraines. Of course, I didn’t have to watch, but I found it fascinating.

Many of the comments we’ve gotten over the year have been warm and supportive. Some have expressed appreciation for our work, and that is always nice. But one of the interesting aspects of a psychiatry blog is that visitors are not all friendly, and some come to discuss the difficulties they’ve had with their care and the criticisms they have about the delivery of psychiatric treatments.

As a clinical psychiatrist, my patients come because they want help and they understand that I am on their side. Usually, they are happy to see me, and if not, I suppose they cancel their appointments, but very few patients come to be angry with me. Not so on Shrink Rap. Readers may come to tell stories of how they’ve been wronged by psychiatrists and the treatments we offer. Many are angry that they’ve had horrible side effects to medications, suffered memory loss during ECT, been humiliated by involuntary hospitalizations, or simply been addressed with unkind and insensitive words in a way that leaves them wounded.

After years of visiting psychiatry blogs, I’m well aware that this is not unique to Shrink Rap, but that all psychiatry blogs attract a cohort of injured readers. They can be a harsh with their words towards us and towards the other commenters. In addition, there are a subgroup of commenters who are known on the Internet as “trolls.” Wikipedia defines a troll as, “someone who posts inflammatory, extraneous, or off-topic messages in an online community.” Trolls often have a message they are trying to get across, and on psychiatry blogs these include anti-psychiatry sentiments, for example the idea that medications are harmful for everyone, or ECT should never be used.

Many psychiatry blogs, including this one on Clinical Psychiatry News, discourage these sentiments by requiring registration with identifying information, and by moderating the comments and only posting those the blog administrator wants made public. On Shrink Rap, we have gone back and forth on this, and for the most part, we’ve allowed anonymous, un-moderated comments. We’ve felt that it allows for a more open on-line discussion, and that when comments are moderated it leaves us vulnerable to the accusation that psychiatrists are only wiling to acknowledge information that supports their way of thinking and are unwilling to hear criticisms of their profession. At the same time, it’s been a difficult line to tread, as strident commenters sometimes scare away those who would like to express opposing opinions. Last week, for the second time in Shrink Rap’s history, we began moderating comments – hopefully only for a brief time.

Have you ever considered starting a blog? Have you thought about whether you’d take all commenters or filter out the voices that are hard to hear? There many medical blogs on the Internet, but surprisingly few psychiatrist-run blogs. The Internet remains a place where mainstream psychiatry and the good it may do, get lost in a loud avalanche of sentiments that cover us in mud.

<[QM]>—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.

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

In my very first post here on Shrink Rap News, I talked about The Accessible Psychiatry Project that Anne Hanson, Steve Daviss and I have been working on for nearly 6 years now. The most interactive component of this project has been our Shrink Rap blog, now with over 1,640 posts.

If you’ve ever thought about starting a psychiatry blog, let me tell you that it’s a very interesting experience. We started with the idea that we would write about our work and converse with other psychiatrists, “a blog by psychiatrist, for psychiatrists,” or so our masthead reads. We soon discovered that with an open, unmoderated comment section, and no requirement for identification or registration, our audience of readers was not limited to psychiatrists. Our readers included other mental health professionals, physicians, and nurses in a variety of fields, people from all over the world comparing notes on mental health care policy, and many people who’ve been treated for psychiatric disorders and have a lot to say about their treatments.

Why would we want to interact with patients on a blog – for free, and after hours, no less – when we talk to patients all day? That’s a really good question, one that I still don’t have a complete answer for. What I can say is that the experience has been surprisingly enlightening, rewarding, and for the vast majority of the time, fun. It’s added an entirely new dimension to our work as psychiatrists, and there is something gratifying about a discussion that includes intelligent, articulate people from all over the world, and the playing field for the conversations is more level than the conversations that are had in the context of a doctor-patient interaction.

We’ll write a blog post and other mental health care providers will come and comment about their experiences, similar or not so similar. Patients come and talk about the same event from the perspective of the patient. They may share their affection for their doctors, or talk about what their psychiatrist has done in similar situations, and they tell their stories with a poignancy that is sometimes quite moving. With time, they’ve come to relate to us, the bloggers, in interesting ways and they interact with the other commenters on the blog, sometimes offering support, and sometimes being very critical. The relationships themselves can be quite complex – one lovely nurse has sent us links to YouTube videos of her musical performances as well as to a video she made demonstrating the deep brain stimulator she’d had placed for intractable migraines. Of course, I didn’t have to watch, but I found it fascinating.

Many of the comments we’ve gotten over the year have been warm and supportive. Some have expressed appreciation for our work, and that is always nice. But one of the interesting aspects of a psychiatry blog is that visitors are not all friendly, and some come to discuss the difficulties they’ve had with their care and the criticisms they have about the delivery of psychiatric treatments.

As a clinical psychiatrist, my patients come because they want help and they understand that I am on their side. Usually, they are happy to see me, and if not, I suppose they cancel their appointments, but very few patients come to be angry with me. Not so on Shrink Rap. Readers may come to tell stories of how they’ve been wronged by psychiatrists and the treatments we offer. Many are angry that they’ve had horrible side effects to medications, suffered memory loss during ECT, been humiliated by involuntary hospitalizations, or simply been addressed with unkind and insensitive words in a way that leaves them wounded.

After years of visiting psychiatry blogs, I’m well aware that this is not unique to Shrink Rap, but that all psychiatry blogs attract a cohort of injured readers. They can be a harsh with their words towards us and towards the other commenters. In addition, there are a subgroup of commenters who are known on the Internet as “trolls.” Wikipedia defines a troll as, “someone who posts inflammatory, extraneous, or off-topic messages in an online community.” Trolls often have a message they are trying to get across, and on psychiatry blogs these include anti-psychiatry sentiments, for example the idea that medications are harmful for everyone, or ECT should never be used.

Many psychiatry blogs, including this one on Clinical Psychiatry News, discourage these sentiments by requiring registration with identifying information, and by moderating the comments and only posting those the blog administrator wants made public. On Shrink Rap, we have gone back and forth on this, and for the most part, we’ve allowed anonymous, un-moderated comments. We’ve felt that it allows for a more open on-line discussion, and that when comments are moderated it leaves us vulnerable to the accusation that psychiatrists are only wiling to acknowledge information that supports their way of thinking and are unwilling to hear criticisms of their profession. At the same time, it’s been a difficult line to tread, as strident commenters sometimes scare away those who would like to express opposing opinions. Last week, for the second time in Shrink Rap’s history, we began moderating comments – hopefully only for a brief time.

Have you ever considered starting a blog? Have you thought about whether you’d take all commenters or filter out the voices that are hard to hear? There many medical blogs on the Internet, but surprisingly few psychiatrist-run blogs. The Internet remains a place where mainstream psychiatry and the good it may do, get lost in a loud avalanche of sentiments that cover us in mud.

<[QM]>—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.

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

I was going to write about the Stop Online Piracy Act and why such a law would be bad for freedom of expression and for the collective mental health of the Internet, but ketamine got in the way.

It’s been a few years since I first heard about the use of i.v. ketamine leading to instant relief of depression symptoms, relief that lasts longer than the ketamine does. It sounds like a miracle cure. Dr. William B. Lawson wrote a Commentary about the drug here in Clinical Psychiatry News, and a subsequent news article about an open-label pilot study also was published here by CPN. This week I’ve been hearing about it nearly daily, especially on National Public Radio (NPR).

While turning to Google and PubMed to examine the latest evidence, I am simultaneously wondering why I’ve not heard of anyone I know using it to treat depression. After all, ketamine is a Food and Drug Administration-approved drug, and thus can be used off-label. It is available as an oral drug, which I know mostly because “Special K” has been used as a rave drug for years. And people are out there with treatment-resistant depression who could benefit from it if the risks are not too high. Note: The dose used for depression is only 1/10th (0.5mg/kg) of the common hallucinogenic dose used on the street (350 mg according to Erowid.)

As it turns out, ketamine has been featured on many of NPR’s various shows over the past week. Jon Hamilton’s story on Morning Edition features a man who has had numerous medications to treat his major depression, which he rattled off. “Klonopin, Ativan, Valium, Xanax, Remeron, Gabapentin, Buspar, and Depakote.” I actually heard this story in the car and thought to myself that only one of those eight drugs is actually considered to be an antidepressant. That’s one of the problems we face: inadequate depression treatment. Either the wrong drug (Xanax) or the wrong dose (50 mg of Zoloft).

Neal Conan on NPR’s Talk of the Nation did a whole show about ketamine this week. The transcript is worth reading (or listening to). This most recent blast of publicity about ketamine is likely fueled by Dr. Carlos A. Zarate Jr.’s recent article in Biological Psychiatry using ketamine in a double-blind, placebo-controlled trial with 15 people who have severe bipolar depression. Seventy-nine percent had a “rapid and robust antidepressant response,” while placebo had no effect.

While ketamine’s effects could be related to its glutamate receptor antagonism, another potential mechanism has been invoked. The mammalian target of rapamycin (mTOR) is activated by ketamine, and preventing its activation also prevents the antidepressant effects (at least, in animals). See this 2010 full-text review by Zarate et al. on possible ketamine mechanisms of action in depression.

Anyway, Dr. Zarate, of the National Institute of Mental Health, is featured in some of the NPR stories, and he thinks that ketamine’s tendency to induce hallucinations will prevent it from being widely used for depression. But, until we have another FDA-approved NMDA antagonist to use, there are surely many people “living with the black dog” who would gladly risk a bad trip to cut the dog’s leash. A Yale study used open-label ketamine for acute depression with suicidal ideation in the ER. Which makes me wonder how many psychiatrists reading this article have tried using ketamine on their patients, or how many patients out there have tried it, whether in its prescribed or illicit form. Comment here or on Shrink Rap to let us know.

<[QM]—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.

I was going to write about the Stop Online Piracy Act and why such a law would be bad for freedom of expression and for the collective mental health of the Internet, but ketamine got in the way.

It’s been a few years since I first heard about the use of i.v. ketamine leading to instant relief of depression symptoms, relief that lasts longer than the ketamine does. It sounds like a miracle cure. Dr. William B. Lawson wrote a Commentary about the drug here in Clinical Psychiatry News, and a subsequent news article about an open-label pilot study also was published here by CPN. This week I’ve been hearing about it nearly daily, especially on National Public Radio (NPR).

While turning to Google and PubMed to examine the latest evidence, I am simultaneously wondering why I’ve not heard of anyone I know using it to treat depression. After all, ketamine is a Food and Drug Administration-approved drug, and thus can be used off-label. It is available as an oral drug, which I know mostly because “Special K” has been used as a rave drug for years. And people are out there with treatment-resistant depression who could benefit from it if the risks are not too high. Note: The dose used for depression is only 1/10th (0.5mg/kg) of the common hallucinogenic dose used on the street (350 mg according to Erowid.)

As it turns out, ketamine has been featured on many of NPR’s various shows over the past week. Jon Hamilton’s story on Morning Edition features a man who has had numerous medications to treat his major depression, which he rattled off. “Klonopin, Ativan, Valium, Xanax, Remeron, Gabapentin, Buspar, and Depakote.” I actually heard this story in the car and thought to myself that only one of those eight drugs is actually considered to be an antidepressant. That’s one of the problems we face: inadequate depression treatment. Either the wrong drug (Xanax) or the wrong dose (50 mg of Zoloft).

Neal Conan on NPR’s Talk of the Nation did a whole show about ketamine this week. The transcript is worth reading (or listening to). This most recent blast of publicity about ketamine is likely fueled by Dr. Carlos A. Zarate Jr.’s recent article in Biological Psychiatry using ketamine in a double-blind, placebo-controlled trial with 15 people who have severe bipolar depression. Seventy-nine percent had a “rapid and robust antidepressant response,” while placebo had no effect.

While ketamine’s effects could be related to its glutamate receptor antagonism, another potential mechanism has been invoked. The mammalian target of rapamycin (mTOR) is activated by ketamine, and preventing its activation also prevents the antidepressant effects (at least, in animals). See this 2010 full-text review by Zarate et al. on possible ketamine mechanisms of action in depression.

Anyway, Dr. Zarate, of the National Institute of Mental Health, is featured in some of the NPR stories, and he thinks that ketamine’s tendency to induce hallucinations will prevent it from being widely used for depression. But, until we have another FDA-approved NMDA antagonist to use, there are surely many people “living with the black dog” who would gladly risk a bad trip to cut the dog’s leash. A Yale study used open-label ketamine for acute depression with suicidal ideation in the ER. Which makes me wonder how many psychiatrists reading this article have tried using ketamine on their patients, or how many patients out there have tried it, whether in its prescribed or illicit form. Comment here or on Shrink Rap to let us know.

<[QM]—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.

I was going to write about the Stop Online Piracy Act and why such a law would be bad for freedom of expression and for the collective mental health of the Internet, but ketamine got in the way.

It’s been a few years since I first heard about the use of i.v. ketamine leading to instant relief of depression symptoms, relief that lasts longer than the ketamine does. It sounds like a miracle cure. Dr. William B. Lawson wrote a Commentary about the drug here in Clinical Psychiatry News, and a subsequent news article about an open-label pilot study also was published here by CPN. This week I’ve been hearing about it nearly daily, especially on National Public Radio (NPR).

While turning to Google and PubMed to examine the latest evidence, I am simultaneously wondering why I’ve not heard of anyone I know using it to treat depression. After all, ketamine is a Food and Drug Administration-approved drug, and thus can be used off-label. It is available as an oral drug, which I know mostly because “Special K” has been used as a rave drug for years. And people are out there with treatment-resistant depression who could benefit from it if the risks are not too high. Note: The dose used for depression is only 1/10th (0.5mg/kg) of the common hallucinogenic dose used on the street (350 mg according to Erowid.)

As it turns out, ketamine has been featured on many of NPR’s various shows over the past week. Jon Hamilton’s story on Morning Edition features a man who has had numerous medications to treat his major depression, which he rattled off. “Klonopin, Ativan, Valium, Xanax, Remeron, Gabapentin, Buspar, and Depakote.” I actually heard this story in the car and thought to myself that only one of those eight drugs is actually considered to be an antidepressant. That’s one of the problems we face: inadequate depression treatment. Either the wrong drug (Xanax) or the wrong dose (50 mg of Zoloft).

Neal Conan on NPR’s Talk of the Nation did a whole show about ketamine this week. The transcript is worth reading (or listening to). This most recent blast of publicity about ketamine is likely fueled by Dr. Carlos A. Zarate Jr.’s recent article in Biological Psychiatry using ketamine in a double-blind, placebo-controlled trial with 15 people who have severe bipolar depression. Seventy-nine percent had a “rapid and robust antidepressant response,” while placebo had no effect.

While ketamine’s effects could be related to its glutamate receptor antagonism, another potential mechanism has been invoked. The mammalian target of rapamycin (mTOR) is activated by ketamine, and preventing its activation also prevents the antidepressant effects (at least, in animals). See this 2010 full-text review by Zarate et al. on possible ketamine mechanisms of action in depression.

Anyway, Dr. Zarate, of the National Institute of Mental Health, is featured in some of the NPR stories, and he thinks that ketamine’s tendency to induce hallucinations will prevent it from being widely used for depression. But, until we have another FDA-approved NMDA antagonist to use, there are surely many people “living with the black dog” who would gladly risk a bad trip to cut the dog’s leash. A Yale study used open-label ketamine for acute depression with suicidal ideation in the ER. Which makes me wonder how many psychiatrists reading this article have tried using ketamine on their patients, or how many patients out there have tried it, whether in its prescribed or illicit form. Comment here or on Shrink Rap to let us know.

<[QM]—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.

Modern medical education is rife with requirements for measurable outcomes. The Accreditation Council for Graduate Medical Education wants to know how many of our residents finish their training on time, how many pass the boards, and how many are able to achieve numerical milestones of competency throughout each year of training.

I started thinking about this recently after I had the opportunity to teach forensic psychiatry to a small group of first-year residents. It was a wonderful experience. Even post-call, they were alert, enthusiastic, and questioning. I remembered being at that stage of my career, feeling that I had a very short time to learn everything I would need to know as a psychiatrist. I remembered feeling torn between specialties as my interests changed with each rotation, from consultation liaison and later to emergency psychiatry before I finally decided to go into forensic work.

As I was speaking to the young residents, I knew that most would not become forensic psychiatrists, so I had to find a way to make my subject relevant to general adult practice. I thought about the clinical experiences they had been exposed to up to that point. Most had worked in the emergency room either as a consulting psychiatrist or as an intern, all had inpatient experience, all were working with primarily an impoverished inner city group of patients. They were familiar with patients facing addiction, legal issues, homelessness, and serious mental illness. Whether they realized it or not, they were working with my forensic patients. That was my connection.

What I wanted them to know was how much they were needed by these patients. I knew from my own training experience that psychiatry residents risk becoming jaded and cynical after seeing substance-abusing patients seek repeated admissions for detoxification, or not-so-mentally ill patients who seem to come to appointments only when their disability paperwork needed to be updated. Success stories are rare and usually happen only after years of therapeutic effort.

It doesn’t surprise me that some residents graduate and quickly flee to the neuroimaging lab or the comfortable private therapy office. My job was to catch them before they got caught up in concerns about insurance reimbursement, conference presentations, publications, and electronic health information systems, and to open their eyes to options they may not have considered such as work in a public mental health clinic or correctional facility.

I feel I need to do this, because teaching is more than the transmission of a curriculum. It involves helping residents recognize where they are needed, what needs to be changed or improved in a health care system, and the role they can play in that change. Professional engagement with the public mental health system can only happen if professionals feel they can make a change.

Community and forensic psychiatrists are in the forefront of public mental health services, and we should encourage our trainees to become involve through direct clinical care and participation in professional organizations. This is particularly important as non-physician subscribers use the psychiatrist shortage as a reason to seek prescribing privileges. Work in the public sector benefits our profession as well as our patients.

<[QM—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.

Modern medical education is rife with requirements for measurable outcomes. The Accreditation Council for Graduate Medical Education wants to know how many of our residents finish their training on time, how many pass the boards, and how many are able to achieve numerical milestones of competency throughout each year of training.

I started thinking about this recently after I had the opportunity to teach forensic psychiatry to a small group of first-year residents. It was a wonderful experience. Even post-call, they were alert, enthusiastic, and questioning. I remembered being at that stage of my career, feeling that I had a very short time to learn everything I would need to know as a psychiatrist. I remembered feeling torn between specialties as my interests changed with each rotation, from consultation liaison and later to emergency psychiatry before I finally decided to go into forensic work.

As I was speaking to the young residents, I knew that most would not become forensic psychiatrists, so I had to find a way to make my subject relevant to general adult practice. I thought about the clinical experiences they had been exposed to up to that point. Most had worked in the emergency room either as a consulting psychiatrist or as an intern, all had inpatient experience, all were working with primarily an impoverished inner city group of patients. They were familiar with patients facing addiction, legal issues, homelessness, and serious mental illness. Whether they realized it or not, they were working with my forensic patients. That was my connection.

What I wanted them to know was how much they were needed by these patients. I knew from my own training experience that psychiatry residents risk becoming jaded and cynical after seeing substance-abusing patients seek repeated admissions for detoxification, or not-so-mentally ill patients who seem to come to appointments only when their disability paperwork needed to be updated. Success stories are rare and usually happen only after years of therapeutic effort.

It doesn’t surprise me that some residents graduate and quickly flee to the neuroimaging lab or the comfortable private therapy office. My job was to catch them before they got caught up in concerns about insurance reimbursement, conference presentations, publications, and electronic health information systems, and to open their eyes to options they may not have considered such as work in a public mental health clinic or correctional facility.

I feel I need to do this, because teaching is more than the transmission of a curriculum. It involves helping residents recognize where they are needed, what needs to be changed or improved in a health care system, and the role they can play in that change. Professional engagement with the public mental health system can only happen if professionals feel they can make a change.

Community and forensic psychiatrists are in the forefront of public mental health services, and we should encourage our trainees to become involve through direct clinical care and participation in professional organizations. This is particularly important as non-physician subscribers use the psychiatrist shortage as a reason to seek prescribing privileges. Work in the public sector benefits our profession as well as our patients.

<[QM—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.

Modern medical education is rife with requirements for measurable outcomes. The Accreditation Council for Graduate Medical Education wants to know how many of our residents finish their training on time, how many pass the boards, and how many are able to achieve numerical milestones of competency throughout each year of training.

I started thinking about this recently after I had the opportunity to teach forensic psychiatry to a small group of first-year residents. It was a wonderful experience. Even post-call, they were alert, enthusiastic, and questioning. I remembered being at that stage of my career, feeling that I had a very short time to learn everything I would need to know as a psychiatrist. I remembered feeling torn between specialties as my interests changed with each rotation, from consultation liaison and later to emergency psychiatry before I finally decided to go into forensic work.

As I was speaking to the young residents, I knew that most would not become forensic psychiatrists, so I had to find a way to make my subject relevant to general adult practice. I thought about the clinical experiences they had been exposed to up to that point. Most had worked in the emergency room either as a consulting psychiatrist or as an intern, all had inpatient experience, all were working with primarily an impoverished inner city group of patients. They were familiar with patients facing addiction, legal issues, homelessness, and serious mental illness. Whether they realized it or not, they were working with my forensic patients. That was my connection.

What I wanted them to know was how much they were needed by these patients. I knew from my own training experience that psychiatry residents risk becoming jaded and cynical after seeing substance-abusing patients seek repeated admissions for detoxification, or not-so-mentally ill patients who seem to come to appointments only when their disability paperwork needed to be updated. Success stories are rare and usually happen only after years of therapeutic effort.

It doesn’t surprise me that some residents graduate and quickly flee to the neuroimaging lab or the comfortable private therapy office. My job was to catch them before they got caught up in concerns about insurance reimbursement, conference presentations, publications, and electronic health information systems, and to open their eyes to options they may not have considered such as work in a public mental health clinic or correctional facility.

I feel I need to do this, because teaching is more than the transmission of a curriculum. It involves helping residents recognize where they are needed, what needs to be changed or improved in a health care system, and the role they can play in that change. Professional engagement with the public mental health system can only happen if professionals feel they can make a change.

Community and forensic psychiatrists are in the forefront of public mental health services, and we should encourage our trainees to become involve through direct clinical care and participation in professional organizations. This is particularly important as non-physician subscribers use the psychiatrist shortage as a reason to seek prescribing privileges. Work in the public sector benefits our profession as well as our patients.

<[QM—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.

“I used to be close to my son. We spoke a few times a week and he called me whenever he had a problem. Now, he wants nothing to do with me. When we talk – maybe it’s a few times a year –  every interaction is tense.”

Surely you’ve known people who are estranged from their adult children. It’s not a new phenomena, but in the past few years, I hear many more of these stories from my patients, as well as from people I know in my personal life. The adult children want distance – a lot of distance – and either the parent doesn’t know why, or she is presented with a list of personality characteristics she possesses and can’t quite change to suit her offspring. “Critical” and “judgmental” are often high on the list.

Heard from the perspective of the heart-broken and distressed parent, the adult children have been well-loved and cared for; they are not the victims of physical or sexual abuse or extreme deprivation, and the parent wants to share her life. The parent – usually, but not always, the mother – feels she’s made sacrifices for her child and has done an adequate (if not superb) job of parenting, and is perplexed by the estrangement.

It’s a hard story to hear. I tell my patients I wish their son or daughter would come with them to a session – but they won’t, or so the parent says – so that I can have some understanding of what their parent has done to warrant this often-sudden divorce. Of course, there is another side to the story, and I am surprised at how often the parents do not seem to understand their adult child’s decision. Instead, the parents devise theories, and often these theories don’t really work as adequate explanations. Somehow, all meaningful communications have come to a halt and even the most well-meant words from one party may be interpreted by the other as having manipulative intentions. 

In May 2010, The New York Times’s Well blog reported on this phenomenon. Health blogger Tara Parker-Pope wrote:

“Joshua Coleman, a San Francisco psychologist who is an expert on parental estrangement, says it appears to be growing more and more common, even in families who haven’t experienced obvious cruelty or traumas like abuse and addiction. Instead, parents often report that a once-close relationship has deteriorated after a conflict over money, a boyfriend or built-up resentments about a parent’s divorce or remarriage.

“ ‘We live in a culture that assumes if there is an estrangement, the parents must have done something really terrible,’ ” said Dr. Coleman, whose book When Parents Hurt (William Morrow, 2007) focuses on estrangement. But this is not a story of adult children cutting off parents who made egregious mistakes. It’s about parents who were good parents, who made mistakes that were certainly within normal limits.’ ”

The column received 1,788 comments – a lot, even for The New York Times.

I don’t know why this has become a surprisingly common story in my practice. I have a theory that children and parents approach their expectations of the parental role differently. I imagine the adult children see their parents’ criticism as as destructive and wearing, and they justify the pain they inflict with their silence as something the parents deserve. The parents, on the other hand, often truly are critical and seem to be unaware that their disapproval is both obvious and distressing. It’s hard, if one disapproves of a behavior, a career, a tattoo, or a spouse, to fake genuine approval, and that is what the script often calls for.

Parents, I believe, start with the idea that a child comes in to the world with nothing, and their efforts add to a baseline of zero. Homemade cookies after school, add two points. Driving friends to an amusement park and paying for admission for the whole gang, eight points. Forgoing career opportunities so a child won’t be uprooted by a move, 15 points, at least. Parents look at what they’ve done for a child and the sacrifices they’ve made, which often are considerable. Children, on the other hand, are raised in a child-centric world where there is an assumption that their needs and desires will come first. They start the counter at 100%. There are no brownie points, and deductions are taken when parents deviate from an expected level. Missing a little league game, minus one. Being overly strict, minus eight. Being critical, minus 10. There may be larger point deductions for mean things yelled out in anger, even if the child’s behavior provoked such a reaction, and while some people remember generalities, others recall specific slights and have a very long memory.

Obviously, I’m being facetious and this point system is a creation of my own imagination. Children do have every right to an expectation that they will be raised in a loving, warm, and accepting environment, but it does seem that we’ve all come to have very high expectations of parents. Parents will Monday-morning quarterback their own parenting, while children rarely dwell on how their words and behaviors may have injured their parents. And certainly, there are people who are very appreciative of the efforts their parents put into raising them and who don’t focus on every inept word or action with a scoreboard running. It is the temperament of the child, as much as the objective acts of parenting, that is crucial to any individual’s perceptions of how they were raised.

Do adult children who divorce their parents dwell on minor slights from their childhood? Probably not, but the mindset may persist that it is the parent’s role to oblige and to provide that unconditional positive regard we’ve come to value so highly. 

No science here, just my observations and unproven theories. If you have thoughts about this, please do comment. I will also put up a post on our original Shrink Rap blog for those who’d rather comment there.

<[QM]>—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 Shrink Rap at http://psychiatrist-blog.blogspot.com/2012/01/when-adult-children-shun-their-parents.html.

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

“I used to be close to my son. We spoke a few times a week and he called me whenever he had a problem. Now, he wants nothing to do with me. When we talk – maybe it’s a few times a year –  every interaction is tense.”

Surely you’ve known people who are estranged from their adult children. It’s not a new phenomena, but in the past few years, I hear many more of these stories from my patients, as well as from people I know in my personal life. The adult children want distance – a lot of distance – and either the parent doesn’t know why, or she is presented with a list of personality characteristics she possesses and can’t quite change to suit her offspring. “Critical” and “judgmental” are often high on the list.

Heard from the perspective of the heart-broken and distressed parent, the adult children have been well-loved and cared for; they are not the victims of physical or sexual abuse or extreme deprivation, and the parent wants to share her life. The parent – usually, but not always, the mother – feels she’s made sacrifices for her child and has done an adequate (if not superb) job of parenting, and is perplexed by the estrangement.

It’s a hard story to hear. I tell my patients I wish their son or daughter would come with them to a session – but they won’t, or so the parent says – so that I can have some understanding of what their parent has done to warrant this often-sudden divorce. Of course, there is another side to the story, and I am surprised at how often the parents do not seem to understand their adult child’s decision. Instead, the parents devise theories, and often these theories don’t really work as adequate explanations. Somehow, all meaningful communications have come to a halt and even the most well-meant words from one party may be interpreted by the other as having manipulative intentions. 

In May 2010, The New York Times’s Well blog reported on this phenomenon. Health blogger Tara Parker-Pope wrote:

“Joshua Coleman, a San Francisco psychologist who is an expert on parental estrangement, says it appears to be growing more and more common, even in families who haven’t experienced obvious cruelty or traumas like abuse and addiction. Instead, parents often report that a once-close relationship has deteriorated after a conflict over money, a boyfriend or built-up resentments about a parent’s divorce or remarriage.

“ ‘We live in a culture that assumes if there is an estrangement, the parents must have done something really terrible,’ ” said Dr. Coleman, whose book When Parents Hurt (William Morrow, 2007) focuses on estrangement. But this is not a story of adult children cutting off parents who made egregious mistakes. It’s about parents who were good parents, who made mistakes that were certainly within normal limits.’ ”

The column received 1,788 comments – a lot, even for The New York Times.

I don’t know why this has become a surprisingly common story in my practice. I have a theory that children and parents approach their expectations of the parental role differently. I imagine the adult children see their parents’ criticism as as destructive and wearing, and they justify the pain they inflict with their silence as something the parents deserve. The parents, on the other hand, often truly are critical and seem to be unaware that their disapproval is both obvious and distressing. It’s hard, if one disapproves of a behavior, a career, a tattoo, or a spouse, to fake genuine approval, and that is what the script often calls for.

Parents, I believe, start with the idea that a child comes in to the world with nothing, and their efforts add to a baseline of zero. Homemade cookies after school, add two points. Driving friends to an amusement park and paying for admission for the whole gang, eight points. Forgoing career opportunities so a child won’t be uprooted by a move, 15 points, at least. Parents look at what they’ve done for a child and the sacrifices they’ve made, which often are considerable. Children, on the other hand, are raised in a child-centric world where there is an assumption that their needs and desires will come first. They start the counter at 100%. There are no brownie points, and deductions are taken when parents deviate from an expected level. Missing a little league game, minus one. Being overly strict, minus eight. Being critical, minus 10. There may be larger point deductions for mean things yelled out in anger, even if the child’s behavior provoked such a reaction, and while some people remember generalities, others recall specific slights and have a very long memory.

Obviously, I’m being facetious and this point system is a creation of my own imagination. Children do have every right to an expectation that they will be raised in a loving, warm, and accepting environment, but it does seem that we’ve all come to have very high expectations of parents. Parents will Monday-morning quarterback their own parenting, while children rarely dwell on how their words and behaviors may have injured their parents. And certainly, there are people who are very appreciative of the efforts their parents put into raising them and who don’t focus on every inept word or action with a scoreboard running. It is the temperament of the child, as much as the objective acts of parenting, that is crucial to any individual’s perceptions of how they were raised.

Do adult children who divorce their parents dwell on minor slights from their childhood? Probably not, but the mindset may persist that it is the parent’s role to oblige and to provide that unconditional positive regard we’ve come to value so highly. 

No science here, just my observations and unproven theories. If you have thoughts about this, please do comment. I will also put up a post on our original Shrink Rap blog for those who’d rather comment there.

<[QM]>—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 Shrink Rap at http://psychiatrist-blog.blogspot.com/2012/01/when-adult-children-shun-their-parents.html.

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

“I used to be close to my son. We spoke a few times a week and he called me whenever he had a problem. Now, he wants nothing to do with me. When we talk – maybe it’s a few times a year –  every interaction is tense.”

Surely you’ve known people who are estranged from their adult children. It’s not a new phenomena, but in the past few years, I hear many more of these stories from my patients, as well as from people I know in my personal life. The adult children want distance – a lot of distance – and either the parent doesn’t know why, or she is presented with a list of personality characteristics she possesses and can’t quite change to suit her offspring. “Critical” and “judgmental” are often high on the list.

Heard from the perspective of the heart-broken and distressed parent, the adult children have been well-loved and cared for; they are not the victims of physical or sexual abuse or extreme deprivation, and the parent wants to share her life. The parent – usually, but not always, the mother – feels she’s made sacrifices for her child and has done an adequate (if not superb) job of parenting, and is perplexed by the estrangement.

It’s a hard story to hear. I tell my patients I wish their son or daughter would come with them to a session – but they won’t, or so the parent says – so that I can have some understanding of what their parent has done to warrant this often-sudden divorce. Of course, there is another side to the story, and I am surprised at how often the parents do not seem to understand their adult child’s decision. Instead, the parents devise theories, and often these theories don’t really work as adequate explanations. Somehow, all meaningful communications have come to a halt and even the most well-meant words from one party may be interpreted by the other as having manipulative intentions. 

In May 2010, The New York Times’s Well blog reported on this phenomenon. Health blogger Tara Parker-Pope wrote:

“Joshua Coleman, a San Francisco psychologist who is an expert on parental estrangement, says it appears to be growing more and more common, even in families who haven’t experienced obvious cruelty or traumas like abuse and addiction. Instead, parents often report that a once-close relationship has deteriorated after a conflict over money, a boyfriend or built-up resentments about a parent’s divorce or remarriage.

“ ‘We live in a culture that assumes if there is an estrangement, the parents must have done something really terrible,’ ” said Dr. Coleman, whose book When Parents Hurt (William Morrow, 2007) focuses on estrangement. But this is not a story of adult children cutting off parents who made egregious mistakes. It’s about parents who were good parents, who made mistakes that were certainly within normal limits.’ ”

The column received 1,788 comments – a lot, even for The New York Times.

I don’t know why this has become a surprisingly common story in my practice. I have a theory that children and parents approach their expectations of the parental role differently. I imagine the adult children see their parents’ criticism as as destructive and wearing, and they justify the pain they inflict with their silence as something the parents deserve. The parents, on the other hand, often truly are critical and seem to be unaware that their disapproval is both obvious and distressing. It’s hard, if one disapproves of a behavior, a career, a tattoo, or a spouse, to fake genuine approval, and that is what the script often calls for.

Parents, I believe, start with the idea that a child comes in to the world with nothing, and their efforts add to a baseline of zero. Homemade cookies after school, add two points. Driving friends to an amusement park and paying for admission for the whole gang, eight points. Forgoing career opportunities so a child won’t be uprooted by a move, 15 points, at least. Parents look at what they’ve done for a child and the sacrifices they’ve made, which often are considerable. Children, on the other hand, are raised in a child-centric world where there is an assumption that their needs and desires will come first. They start the counter at 100%. There are no brownie points, and deductions are taken when parents deviate from an expected level. Missing a little league game, minus one. Being overly strict, minus eight. Being critical, minus 10. There may be larger point deductions for mean things yelled out in anger, even if the child’s behavior provoked such a reaction, and while some people remember generalities, others recall specific slights and have a very long memory.

Obviously, I’m being facetious and this point system is a creation of my own imagination. Children do have every right to an expectation that they will be raised in a loving, warm, and accepting environment, but it does seem that we’ve all come to have very high expectations of parents. Parents will Monday-morning quarterback their own parenting, while children rarely dwell on how their words and behaviors may have injured their parents. And certainly, there are people who are very appreciative of the efforts their parents put into raising them and who don’t focus on every inept word or action with a scoreboard running. It is the temperament of the child, as much as the objective acts of parenting, that is crucial to any individual’s perceptions of how they were raised.

Do adult children who divorce their parents dwell on minor slights from their childhood? Probably not, but the mindset may persist that it is the parent’s role to oblige and to provide that unconditional positive regard we’ve come to value so highly. 

No science here, just my observations and unproven theories. If you have thoughts about this, please do comment. I will also put up a post on our original Shrink Rap blog for those who’d rather comment there.

<[QM]>—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 Shrink Rap at http://psychiatrist-blog.blogspot.com/2012/01/when-adult-children-shun-their-parents.html.

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

I think Clinical Psychiatry News readers will enjoy this round-up of the most popular Shrink Rap posts.

These are all posts written in 2011; another post lists the top posts of all time (since we started in 2006). These posts below are listed with the most popular (i.e., most pageviews) one at the top.

1.       Questions for Clink

2.       Shrink Rap Survey on Attitudes Towards Psychiatry

3.       What Makes A Good Therapist?

4.       The Duck Was Nixed!

5.       Doctors Who Write

6.       Summer Solstice: "Hot" Grand Rounds on Shrink Rap

7.       A Brief Psychological Analysis of the Angry Birds

8.       Google+ Button Added

9.       Doctors to Go to Jail for Asking Patients About Guns in the Home

10.    Kindle versus Nook?

11.    The Patient Who Didn't Like the Doc. On-Line.

12.    The Top Ten or More Things That Annoy Me About Psychiatry Haters

13.    What is Bipolar Disorder?

14.    Talk Doesn't Come Cheap

15.    Diagnostic Labels That Change Lives

16.    The Unwilling Patient: New Yorker Article

17.    Howard Dully's Lobotomy

18.    Guest Blogger Jesse: When Patients Don't Pay

19.    Hate A Shrink: They Ask For It, After All

20.    No More Xanax

21.    How to be a Successful College Student

22.    Please Pass the Fat Cream

23.    Are We Not Thugs?

24.    Psych Meds are THE Problem: A Post for Duane Sherry

25.    Happy Shrinks!

You also might be interested in reading our "Top Posts" lists from prior years, too. Here they are: ..

2010...2008...2007...2006

<[QM]>—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.

I think Clinical Psychiatry News readers will enjoy this round-up of the most popular Shrink Rap posts.

These are all posts written in 2011; another post lists the top posts of all time (since we started in 2006). These posts below are listed with the most popular (i.e., most pageviews) one at the top.

1.       Questions for Clink

2.       Shrink Rap Survey on Attitudes Towards Psychiatry

3.       What Makes A Good Therapist?

4.       The Duck Was Nixed!

5.       Doctors Who Write

6.       Summer Solstice: "Hot" Grand Rounds on Shrink Rap

7.       A Brief Psychological Analysis of the Angry Birds

8.       Google+ Button Added

9.       Doctors to Go to Jail for Asking Patients About Guns in the Home

10.    Kindle versus Nook?

11.    The Patient Who Didn't Like the Doc. On-Line.

12.    The Top Ten or More Things That Annoy Me About Psychiatry Haters

13.    What is Bipolar Disorder?

14.    Talk Doesn't Come Cheap

15.    Diagnostic Labels That Change Lives

16.    The Unwilling Patient: New Yorker Article

17.    Howard Dully's Lobotomy

18.    Guest Blogger Jesse: When Patients Don't Pay

19.    Hate A Shrink: They Ask For It, After All

20.    No More Xanax

21.    How to be a Successful College Student

22.    Please Pass the Fat Cream

23.    Are We Not Thugs?

24.    Psych Meds are THE Problem: A Post for Duane Sherry

25.    Happy Shrinks!

You also might be interested in reading our "Top Posts" lists from prior years, too. Here they are: ..

2010...2008...2007...2006

<[QM]>—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.

I think Clinical Psychiatry News readers will enjoy this round-up of the most popular Shrink Rap posts.

These are all posts written in 2011; another post lists the top posts of all time (since we started in 2006). These posts below are listed with the most popular (i.e., most pageviews) one at the top.

1.       Questions for Clink

2.       Shrink Rap Survey on Attitudes Towards Psychiatry

3.       What Makes A Good Therapist?

4.       The Duck Was Nixed!

5.       Doctors Who Write

6.       Summer Solstice: "Hot" Grand Rounds on Shrink Rap

7.       A Brief Psychological Analysis of the Angry Birds

8.       Google+ Button Added

9.       Doctors to Go to Jail for Asking Patients About Guns in the Home

10.    Kindle versus Nook?

11.    The Patient Who Didn't Like the Doc. On-Line.

12.    The Top Ten or More Things That Annoy Me About Psychiatry Haters

13.    What is Bipolar Disorder?

14.    Talk Doesn't Come Cheap

15.    Diagnostic Labels That Change Lives

16.    The Unwilling Patient: New Yorker Article

17.    Howard Dully's Lobotomy

18.    Guest Blogger Jesse: When Patients Don't Pay

19.    Hate A Shrink: They Ask For It, After All

20.    No More Xanax

21.    How to be a Successful College Student

22.    Please Pass the Fat Cream

23.    Are We Not Thugs?

24.    Psych Meds are THE Problem: A Post for Duane Sherry

25.    Happy Shrinks!

You also might be interested in reading our "Top Posts" lists from prior years, too. Here they are: ..

2010...2008...2007...2006

<[QM]>—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.

Many insanity acquittees have a history of psychiatric treatment prior to their offenses, and the insanity defense is usually raised when a defense attorney becomes aware of this. The defendant may have been hospitalized previously, have a known history of psychosis or suicide attempts, or a history of outpatient rehabilitation for chemical dependency and mental health issues.

Not all insanity acquittees have this history, however. Some crimes are committed by individuals with no previous history of violence during the course of a first psychotic episode. When this happens, the general public often wonders why the defendant was allowed to be symptomatic for so long before the offense without receiving treatment. A representative of NAMI recently wrote a letter to the editor of my local newspaper raising this question. She suggested that the offenses represented a failure of the mental health system and indicated a need for outpatient commitment laws and less stringent standards for involuntary treatment.

Certainly, financial concerns and lack of insurance coverage are reasons why many people don’t seek mental health care, but for insanity acquittees, I don’t think this is the sole cause. Many areas of the country have no inpatient psychiatric facilities – or even a psychiatrist. Even when patients are willing to be transported for care, traveling for hundreds of miles with a seriously psychotic person is a risky venture. Sitting in a crowded, noisy, chaotic emergency room is also a challenge for someone in the midst of paranoia.

Lack of insight, or anosognosia, is often cited as a reason why the mentally ill resist treatment. This problem is confounded when there is poor premorbid family dynamics or prejudices. If the caregiver himself has a history of mental illness, he may be reluctant to take someone to treatment if he had a negative experience with it. If there is premorbid family conflict, an oppositional or defiant relationship between the patient and the caregiver will undermine treatment attempts. Finally, family members may deny or resist the thought that a once-promising young adult has been afflicted with a disabling mental disease.

Some psychotic episodes appear gradually, and subtle prodromal symptoms can be missed or overlooked. Negative symptoms such as emotional flattening or apathy may be mistaken for depression. Social withdrawal, loss of appetite, and insomnia may be attributed to stressful life events such as trouble at work, financial difficulties, strained family relationships, or other meaningful events. Poor concentration or difficulties on the job can be written off by employers as evidence that the patient is having personal problems or possibly substance abuse issues. The offense may be motivated by a delusional belief that has been hidden from others and is only uncovered after the fact during a pretrial evaluation. In situations like this, family members or employers may not recognize there is a problem until grossly disorganized or bizarre behavior appears.

Finally, caregivers may not seek care if they underestimate or dismiss the risk of violence posed by the psychotic patient. This is because the treatment-naive offender typically has no co-existing personality disorder, little or no past legal history, and no previous dangerous behaviors. The offense represents a dramatic deviation from the patient’s usual personality and behavior, which is why insanity defenses are often successful in these cases.

Outpatient commitment laws and relaxed civil commitment standards are no substitute for improved access to care. Psychiatrists also need to educate the public about the symptoms of mental illness and available treatments. Early mental health intervention can be an effective crime prevention tool.

<[QM]—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.

Many insanity acquittees have a history of psychiatric treatment prior to their offenses, and the insanity defense is usually raised when a defense attorney becomes aware of this. The defendant may have been hospitalized previously, have a known history of psychosis or suicide attempts, or a history of outpatient rehabilitation for chemical dependency and mental health issues.

Not all insanity acquittees have this history, however. Some crimes are committed by individuals with no previous history of violence during the course of a first psychotic episode. When this happens, the general public often wonders why the defendant was allowed to be symptomatic for so long before the offense without receiving treatment. A representative of NAMI recently wrote a letter to the editor of my local newspaper raising this question. She suggested that the offenses represented a failure of the mental health system and indicated a need for outpatient commitment laws and less stringent standards for involuntary treatment.

Certainly, financial concerns and lack of insurance coverage are reasons why many people don’t seek mental health care, but for insanity acquittees, I don’t think this is the sole cause. Many areas of the country have no inpatient psychiatric facilities – or even a psychiatrist. Even when patients are willing to be transported for care, traveling for hundreds of miles with a seriously psychotic person is a risky venture. Sitting in a crowded, noisy, chaotic emergency room is also a challenge for someone in the midst of paranoia.

Lack of insight, or anosognosia, is often cited as a reason why the mentally ill resist treatment. This problem is confounded when there is poor premorbid family dynamics or prejudices. If the caregiver himself has a history of mental illness, he may be reluctant to take someone to treatment if he had a negative experience with it. If there is premorbid family conflict, an oppositional or defiant relationship between the patient and the caregiver will undermine treatment attempts. Finally, family members may deny or resist the thought that a once-promising young adult has been afflicted with a disabling mental disease.

Some psychotic episodes appear gradually, and subtle prodromal symptoms can be missed or overlooked. Negative symptoms such as emotional flattening or apathy may be mistaken for depression. Social withdrawal, loss of appetite, and insomnia may be attributed to stressful life events such as trouble at work, financial difficulties, strained family relationships, or other meaningful events. Poor concentration or difficulties on the job can be written off by employers as evidence that the patient is having personal problems or possibly substance abuse issues. The offense may be motivated by a delusional belief that has been hidden from others and is only uncovered after the fact during a pretrial evaluation. In situations like this, family members or employers may not recognize there is a problem until grossly disorganized or bizarre behavior appears.

Finally, caregivers may not seek care if they underestimate or dismiss the risk of violence posed by the psychotic patient. This is because the treatment-naive offender typically has no co-existing personality disorder, little or no past legal history, and no previous dangerous behaviors. The offense represents a dramatic deviation from the patient’s usual personality and behavior, which is why insanity defenses are often successful in these cases.

Outpatient commitment laws and relaxed civil commitment standards are no substitute for improved access to care. Psychiatrists also need to educate the public about the symptoms of mental illness and available treatments. Early mental health intervention can be an effective crime prevention tool.

<[QM]—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.

Many insanity acquittees have a history of psychiatric treatment prior to their offenses, and the insanity defense is usually raised when a defense attorney becomes aware of this. The defendant may have been hospitalized previously, have a known history of psychosis or suicide attempts, or a history of outpatient rehabilitation for chemical dependency and mental health issues.

Not all insanity acquittees have this history, however. Some crimes are committed by individuals with no previous history of violence during the course of a first psychotic episode. When this happens, the general public often wonders why the defendant was allowed to be symptomatic for so long before the offense without receiving treatment. A representative of NAMI recently wrote a letter to the editor of my local newspaper raising this question. She suggested that the offenses represented a failure of the mental health system and indicated a need for outpatient commitment laws and less stringent standards for involuntary treatment.

Certainly, financial concerns and lack of insurance coverage are reasons why many people don’t seek mental health care, but for insanity acquittees, I don’t think this is the sole cause. Many areas of the country have no inpatient psychiatric facilities – or even a psychiatrist. Even when patients are willing to be transported for care, traveling for hundreds of miles with a seriously psychotic person is a risky venture. Sitting in a crowded, noisy, chaotic emergency room is also a challenge for someone in the midst of paranoia.

Lack of insight, or anosognosia, is often cited as a reason why the mentally ill resist treatment. This problem is confounded when there is poor premorbid family dynamics or prejudices. If the caregiver himself has a history of mental illness, he may be reluctant to take someone to treatment if he had a negative experience with it. If there is premorbid family conflict, an oppositional or defiant relationship between the patient and the caregiver will undermine treatment attempts. Finally, family members may deny or resist the thought that a once-promising young adult has been afflicted with a disabling mental disease.

Some psychotic episodes appear gradually, and subtle prodromal symptoms can be missed or overlooked. Negative symptoms such as emotional flattening or apathy may be mistaken for depression. Social withdrawal, loss of appetite, and insomnia may be attributed to stressful life events such as trouble at work, financial difficulties, strained family relationships, or other meaningful events. Poor concentration or difficulties on the job can be written off by employers as evidence that the patient is having personal problems or possibly substance abuse issues. The offense may be motivated by a delusional belief that has been hidden from others and is only uncovered after the fact during a pretrial evaluation. In situations like this, family members or employers may not recognize there is a problem until grossly disorganized or bizarre behavior appears.

Finally, caregivers may not seek care if they underestimate or dismiss the risk of violence posed by the psychotic patient. This is because the treatment-naive offender typically has no co-existing personality disorder, little or no past legal history, and no previous dangerous behaviors. The offense represents a dramatic deviation from the patient’s usual personality and behavior, which is why insanity defenses are often successful in these cases.

Outpatient commitment laws and relaxed civil commitment standards are no substitute for improved access to care. Psychiatrists also need to educate the public about the symptoms of mental illness and available treatments. Early mental health intervention can be an effective crime prevention tool.

<[QM]—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.

On our main Shrink Rap blog, we write for anyone who wants to read. Here, we try to tailor our writing to an audience of psychiatrists, and each week we write new material. This can be a challenge with three blogs, our families, and our real-life careers. It’s the week between Christmas and New Year’s, a time when people traditionally visit family and take some time off. I thought that this week I would take it easy, and rather than write something new, I’m reprinting an article that appeared on Shrink Rap back in January and also on KevinMD. It’s not about psychiatry, and it’s a bit more whimsical than what we usually write here, but I thought you might like a bit of an escape while you enjoy some holiday cheer.

Joe Frisch is a staff scientist at the SLAC National Accelerator Laboratory at Stanford University. Dr. Frisch writes:

I wonder when we will start seeing really addictive games banned? I don’t know what makes games addictive,  though. Civ is easy – you start to feel empathy for the people you are “guiding” and as you play more, you gain more things that can help them.

Angry birds is a mystery to me – there is no ongoing story line, you don’t really gain any abilities as the game goes on, so WHY DO I WANT TO SMASH THE PIGGIES????

Isn't there some sort of conditioning to fix this –  electric shocks or something?

----

I’m now on Level 4-19 of 2. Mighty Hoax. It took me days to finish Poached Eggs. Am I losing my mind? I am way too old for this. I’m slinging virtual animated birds while I leave ClinkShrink to cure the criminals of this world and Roy to index our book. What has gotten in to me?

So I want to write a post about the psychology of Angry Birds, but I need to start with a disclaimer. I haven’t tried many video games. My experience is limited, and the few games I’ve tried, I’ve liked. I was once a very accomplished Tetris Player. But with limited exposure, it’s hard for me to say why Angry Birds is more compelling than any other game. Civ? No clue.

But I’ll take a stab at it. Please feel free to add your thoughts.

1. There’s the challenge of trying to smash all the Piggies. Practice helps: the more you play, the better you get. It takes a little while, especially at first, but there is this enormous sense of accomplishment when those piggies smash – especially if you don’t use all your birds and get an extra 10,000 points/leftover bird.

2. The games are short: you move through one and then can go on to the next. There is variety to the difficulty and landscape. Each scenario has different birds: the black bomber guys who explode are my favorite. The red do-nothings are my least favorite. The gray guys who divide into three would be better if they were more powerful. There’s an option to buy some eagle guy, but I haven’t done that. It’s challenging, but not impossible. Okay, I did watch some YouTube tutorial videos but only for the first level.

3. Each game can be won with 1 to 3 stars. This allows the game to accommodate the player’s personality. You can proceed with just one star. To me, that feels like getting a C and I was never happy with Cs. At the same time, if I needed to get 3 stars on every single game, I’d never eat or sleep, so I’m content to get 2 or 3 stars on each game, depending on how impossible it seems. Joe tells me he can move on with one-star wins.

4. It clears my mind and occupies my time in a relatively angst-free way. It’s what I imagine that other people get out of TV, but most TV shows feel like work for me. They don’t hold my attention and I have to make myself concentrate.

5. It feels important. That’s really crazy, isn’t it? I had the same sense with Tetris.

6. Somehow, I don’t feel the least bit guilty spending hours of my day doing this. Hopefully that will change if I’m still at it in a few weeks. I typically am very efficient with, and protective of, my time, and it seems like it should be fine to devote some time to pure, mindless entertainment. I suppose the question is how many years and at the expense of what? So my kids have had to order pizza every night for the past week – is that a problem? They like pizza.

7. Empathy? I'm supposed to feel empathy during video games? I’m a psychiatrist – I empathize all day long. I don’t care about the birds or the little green piggies. They aren’t real. And I had no empathy for the falling geometric shapes in Tetris. Maybe you’re spending too much time in that accelerator, Joe.

8. Shock treatments for video game addiction? Hmmm ... we could do a study here. I don’t think we’d get past any research review boards if we proposed ECT as a treatment for video game addictions (ah, it didn’t make it past APA as a diagnosable psychiatric disorder, for one thing), but I imagine we could do a before-and-after survey of people having ECT for depression to see if their coincidental interest in Angry Birds changed with treatment. Get me the funding and I’m there.

9. Let’s talk about the anger. Are the birds really angry? The human player flings them at the structures in an attempt to vaporize the green piggies. So who’s angry: the birds, the human player, or is anger even part of this equation? Joe tells me the piggies are evil. They steal eggs. I haven’t seen them steal eggs. They just sort of sit their in their structures, waiting to see if the birds will vaporize them. I would contend that there really isn’t much emotion of any kind involved here on the part of the animated little players. Would the game be as good if the human was flinging colored balls rather than birds? If the object of destruction were a plate or a star or a non-green-piggy object? I think so.

Our audience of psychiatrist readers will be pleased to know that my Angry Birds addiction was fun, but short-lived.

Wishing you all a wonderful holiday season and a happy and healthy new year from the Shrink Rappers.

<[QM]>—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.

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

On our main Shrink Rap blog, we write for anyone who wants to read. Here, we try to tailor our writing to an audience of psychiatrists, and each week we write new material. This can be a challenge with three blogs, our families, and our real-life careers. It’s the week between Christmas and New Year’s, a time when people traditionally visit family and take some time off. I thought that this week I would take it easy, and rather than write something new, I’m reprinting an article that appeared on Shrink Rap back in January and also on KevinMD. It’s not about psychiatry, and it’s a bit more whimsical than what we usually write here, but I thought you might like a bit of an escape while you enjoy some holiday cheer.

Joe Frisch is a staff scientist at the SLAC National Accelerator Laboratory at Stanford University. Dr. Frisch writes:

I wonder when we will start seeing really addictive games banned? I don’t know what makes games addictive,  though. Civ is easy – you start to feel empathy for the people you are “guiding” and as you play more, you gain more things that can help them.

Angry birds is a mystery to me – there is no ongoing story line, you don’t really gain any abilities as the game goes on, so WHY DO I WANT TO SMASH THE PIGGIES????

Isn't there some sort of conditioning to fix this –  electric shocks or something?

----

I’m now on Level 4-19 of 2. Mighty Hoax. It took me days to finish Poached Eggs. Am I losing my mind? I am way too old for this. I’m slinging virtual animated birds while I leave ClinkShrink to cure the criminals of this world and Roy to index our book. What has gotten in to me?

So I want to write a post about the psychology of Angry Birds, but I need to start with a disclaimer. I haven’t tried many video games. My experience is limited, and the few games I’ve tried, I’ve liked. I was once a very accomplished Tetris Player. But with limited exposure, it’s hard for me to say why Angry Birds is more compelling than any other game. Civ? No clue.

But I’ll take a stab at it. Please feel free to add your thoughts.

1. There’s the challenge of trying to smash all the Piggies. Practice helps: the more you play, the better you get. It takes a little while, especially at first, but there is this enormous sense of accomplishment when those piggies smash – especially if you don’t use all your birds and get an extra 10,000 points/leftover bird.

2. The games are short: you move through one and then can go on to the next. There is variety to the difficulty and landscape. Each scenario has different birds: the black bomber guys who explode are my favorite. The red do-nothings are my least favorite. The gray guys who divide into three would be better if they were more powerful. There’s an option to buy some eagle guy, but I haven’t done that. It’s challenging, but not impossible. Okay, I did watch some YouTube tutorial videos but only for the first level.

3. Each game can be won with 1 to 3 stars. This allows the game to accommodate the player’s personality. You can proceed with just one star. To me, that feels like getting a C and I was never happy with Cs. At the same time, if I needed to get 3 stars on every single game, I’d never eat or sleep, so I’m content to get 2 or 3 stars on each game, depending on how impossible it seems. Joe tells me he can move on with one-star wins.

4. It clears my mind and occupies my time in a relatively angst-free way. It’s what I imagine that other people get out of TV, but most TV shows feel like work for me. They don’t hold my attention and I have to make myself concentrate.

5. It feels important. That’s really crazy, isn’t it? I had the same sense with Tetris.

6. Somehow, I don’t feel the least bit guilty spending hours of my day doing this. Hopefully that will change if I’m still at it in a few weeks. I typically am very efficient with, and protective of, my time, and it seems like it should be fine to devote some time to pure, mindless entertainment. I suppose the question is how many years and at the expense of what? So my kids have had to order pizza every night for the past week – is that a problem? They like pizza.

7. Empathy? I'm supposed to feel empathy during video games? I’m a psychiatrist – I empathize all day long. I don’t care about the birds or the little green piggies. They aren’t real. And I had no empathy for the falling geometric shapes in Tetris. Maybe you’re spending too much time in that accelerator, Joe.

8. Shock treatments for video game addiction? Hmmm ... we could do a study here. I don’t think we’d get past any research review boards if we proposed ECT as a treatment for video game addictions (ah, it didn’t make it past APA as a diagnosable psychiatric disorder, for one thing), but I imagine we could do a before-and-after survey of people having ECT for depression to see if their coincidental interest in Angry Birds changed with treatment. Get me the funding and I’m there.

9. Let’s talk about the anger. Are the birds really angry? The human player flings them at the structures in an attempt to vaporize the green piggies. So who’s angry: the birds, the human player, or is anger even part of this equation? Joe tells me the piggies are evil. They steal eggs. I haven’t seen them steal eggs. They just sort of sit their in their structures, waiting to see if the birds will vaporize them. I would contend that there really isn’t much emotion of any kind involved here on the part of the animated little players. Would the game be as good if the human was flinging colored balls rather than birds? If the object of destruction were a plate or a star or a non-green-piggy object? I think so.

Our audience of psychiatrist readers will be pleased to know that my Angry Birds addiction was fun, but short-lived.

Wishing you all a wonderful holiday season and a happy and healthy new year from the Shrink Rappers.

<[QM]>—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.

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

On our main Shrink Rap blog, we write for anyone who wants to read. Here, we try to tailor our writing to an audience of psychiatrists, and each week we write new material. This can be a challenge with three blogs, our families, and our real-life careers. It’s the week between Christmas and New Year’s, a time when people traditionally visit family and take some time off. I thought that this week I would take it easy, and rather than write something new, I’m reprinting an article that appeared on Shrink Rap back in January and also on KevinMD. It’s not about psychiatry, and it’s a bit more whimsical than what we usually write here, but I thought you might like a bit of an escape while you enjoy some holiday cheer.

Joe Frisch is a staff scientist at the SLAC National Accelerator Laboratory at Stanford University. Dr. Frisch writes:

I wonder when we will start seeing really addictive games banned? I don’t know what makes games addictive,  though. Civ is easy – you start to feel empathy for the people you are “guiding” and as you play more, you gain more things that can help them.

Angry birds is a mystery to me – there is no ongoing story line, you don’t really gain any abilities as the game goes on, so WHY DO I WANT TO SMASH THE PIGGIES????

Isn't there some sort of conditioning to fix this –  electric shocks or something?

----

I’m now on Level 4-19 of 2. Mighty Hoax. It took me days to finish Poached Eggs. Am I losing my mind? I am way too old for this. I’m slinging virtual animated birds while I leave ClinkShrink to cure the criminals of this world and Roy to index our book. What has gotten in to me?

So I want to write a post about the psychology of Angry Birds, but I need to start with a disclaimer. I haven’t tried many video games. My experience is limited, and the few games I’ve tried, I’ve liked. I was once a very accomplished Tetris Player. But with limited exposure, it’s hard for me to say why Angry Birds is more compelling than any other game. Civ? No clue.

But I’ll take a stab at it. Please feel free to add your thoughts.

1. There’s the challenge of trying to smash all the Piggies. Practice helps: the more you play, the better you get. It takes a little while, especially at first, but there is this enormous sense of accomplishment when those piggies smash – especially if you don’t use all your birds and get an extra 10,000 points/leftover bird.

2. The games are short: you move through one and then can go on to the next. There is variety to the difficulty and landscape. Each scenario has different birds: the black bomber guys who explode are my favorite. The red do-nothings are my least favorite. The gray guys who divide into three would be better if they were more powerful. There’s an option to buy some eagle guy, but I haven’t done that. It’s challenging, but not impossible. Okay, I did watch some YouTube tutorial videos but only for the first level.

3. Each game can be won with 1 to 3 stars. This allows the game to accommodate the player’s personality. You can proceed with just one star. To me, that feels like getting a C and I was never happy with Cs. At the same time, if I needed to get 3 stars on every single game, I’d never eat or sleep, so I’m content to get 2 or 3 stars on each game, depending on how impossible it seems. Joe tells me he can move on with one-star wins.

4. It clears my mind and occupies my time in a relatively angst-free way. It’s what I imagine that other people get out of TV, but most TV shows feel like work for me. They don’t hold my attention and I have to make myself concentrate.

5. It feels important. That’s really crazy, isn’t it? I had the same sense with Tetris.

6. Somehow, I don’t feel the least bit guilty spending hours of my day doing this. Hopefully that will change if I’m still at it in a few weeks. I typically am very efficient with, and protective of, my time, and it seems like it should be fine to devote some time to pure, mindless entertainment. I suppose the question is how many years and at the expense of what? So my kids have had to order pizza every night for the past week – is that a problem? They like pizza.

7. Empathy? I'm supposed to feel empathy during video games? I’m a psychiatrist – I empathize all day long. I don’t care about the birds or the little green piggies. They aren’t real. And I had no empathy for the falling geometric shapes in Tetris. Maybe you’re spending too much time in that accelerator, Joe.

8. Shock treatments for video game addiction? Hmmm ... we could do a study here. I don’t think we’d get past any research review boards if we proposed ECT as a treatment for video game addictions (ah, it didn’t make it past APA as a diagnosable psychiatric disorder, for one thing), but I imagine we could do a before-and-after survey of people having ECT for depression to see if their coincidental interest in Angry Birds changed with treatment. Get me the funding and I’m there.

9. Let’s talk about the anger. Are the birds really angry? The human player flings them at the structures in an attempt to vaporize the green piggies. So who’s angry: the birds, the human player, or is anger even part of this equation? Joe tells me the piggies are evil. They steal eggs. I haven’t seen them steal eggs. They just sort of sit their in their structures, waiting to see if the birds will vaporize them. I would contend that there really isn’t much emotion of any kind involved here on the part of the animated little players. Would the game be as good if the human was flinging colored balls rather than birds? If the object of destruction were a plate or a star or a non-green-piggy object? I think so.

Our audience of psychiatrist readers will be pleased to know that my Angry Birds addiction was fun, but short-lived.

Wishing you all a wonderful holiday season and a happy and healthy new year from the Shrink Rappers.

<[QM]>—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.

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

The Substance Abuse and Mental Health Services Administration held a meeting in October entitled “2011 Consensus-Building Summit on Electronic Health Records for Behavioral Health.” Invited to the day-long meeting were many national leaders and organizational representatives from numerous relevant organizations. The purpose was “to address the issue of consensus building for data sharing for continuity of care between providers.

Highlights of the meeting, organized by Valerie Mills, Ph.D., included discussions on SAMHSA’s vision for advancing health information technology and EHRs in the behavioral health community, the integration of behavioral health with primary care, concerns and strategies from behavioral health providers, and confidentiality issues concerning the adoption of HIT/EHRs and the consumer. Other discussions focused on differences in clinical experiences with primary care patients versus behavioral health clients, and priority elements to include as core clinical data for EHRs and continuity of care documents (CCDs) in recovery-oriented services, treatment for addictions, and treatment for serious mental illness.

The director of SAMHSA’s Center for Substance Abuse Treatment, Dr. Westley Clark, summarized the day’s goal as “working towards consensus on specific elements of information that should be included in a uniform or standard EHR that has a behavioral health focus and the CCD that we share with the rest of the delivery system.” The CCD, or continuity of care document, is a standard way to represent and summarize clinical data from an episode of care, written in XML (eXtensible Markup Language). Building upon three regional HIT meetings held over the past summer, much of this meeting was spent discussing which types of information are needed by primary care providers, by behavioral health providers, and by patients. Given past discussion in this column about privacy concerns with HIT in mental health and addictions, Dr. Clark underscored SAMHSA’s intent to have behavioral health providers fully participate in the adoption and integration of Health IT within the general health care delivery system.

Michael Lardiere, from the National Council for Community Behavioral Healthcare (NCCBHC), stressed the importance of integration of behavioral health and primary care communication and collaboration. Toward that goal, he described an HIT adoption survey currently underway by the National Council. He also reviewed the 17 components of the current CCD standard, which are:

1. Patient Demographics

2, Immunizations

3. Vital Signs

4, Problems & Diagnoses

5. Insurance Information

6. Health Care Providers

7. Encounter Information

8. Allergies/Alerting Data

9. Appropriate Results

10, Medication

11. Procedures

12. Results

13. Necessary Medical Equipment

14. Social History

15. Statistics

16. Family History

17. Care Plan

At this time, no behavioral health-specific elements are in the CCD. There is an HL7 work group, lead by Madan Gopal from the Arizona Health Department, that is currently developing draft specifications for such elements. This draft is expected to be voted on by HL7 around February 2012.

There were several other presentations before breaking into small groups to develop specific suggestions regarding the psychiatric elements to be included in a CCD. Sherri Morgan, from the National Association of Social Workers, spoke about implementation of HIT in small practices, many of whom are using consumer-oriented software instead of expensive niche products. Anne Watt and Patty Craig, both from The Joint Commission, discussed performance measures including new substance abuse measures for 2012. Vendor incorporation of these and future measures will be facilitated by their Measure Authoring Tool using the Health Quality Measures Format, or HQMF. Bettye Harrison, spoke about CARF’s recent activities, while I represented the American Psychiatric Association and spoke about risks and benefits of HIT implementation for behavioral health specialists. Finally, Lynn Bufka, Ph.D., from the American Psychological Association, led a discussion about confidentiality, the need for data segmentation and other challenges in behavioral health IT.

Three break-out groups developed consensus on which core clinical data are needed to be included in the CCD for serious mental illnesses, addictions, and recovery-oriented services. The strongest themes to emerge centered around building in granular consent management metadata within the CCD document, and greater consumer access to and control of their health information.

From the summary document, nine cross-cutting issues emerged from all three break-out work groups:

1. Vested self-interest in working together

2, Work only within the framework of the CCD/ HL7

3. Linkage of providers to services to problems to results to continuing care plan

4. Usability – work needed on how to read the record, how usable it will be, what views will be there (use of metadata tagging) (an issue to still be addressed/resolved)

5. Need for resolution of data segmentation

6. Granular consent management.

7. Need for contextualized content (diagnosis, measure of change, results, last treatment/discharge status, treatment compliance)

8. Need to see all open care plans/system involvement

9. Housing and stability

Additional information can be found on SAMHSA’s website at http://www.samhsa.gov/healthIT/.

<[QM]—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, co0chair 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 Substance Abuse and Mental Health Services Administration held a meeting in October entitled “2011 Consensus-Building Summit on Electronic Health Records for Behavioral Health.” Invited to the day-long meeting were many national leaders and organizational representatives from numerous relevant organizations. The purpose was “to address the issue of consensus building for data sharing for continuity of care between providers.

Highlights of the meeting, organized by Valerie Mills, Ph.D., included discussions on SAMHSA’s vision for advancing health information technology and EHRs in the behavioral health community, the integration of behavioral health with primary care, concerns and strategies from behavioral health providers, and confidentiality issues concerning the adoption of HIT/EHRs and the consumer. Other discussions focused on differences in clinical experiences with primary care patients versus behavioral health clients, and priority elements to include as core clinical data for EHRs and continuity of care documents (CCDs) in recovery-oriented services, treatment for addictions, and treatment for serious mental illness.

The director of SAMHSA’s Center for Substance Abuse Treatment, Dr. Westley Clark, summarized the day’s goal as “working towards consensus on specific elements of information that should be included in a uniform or standard EHR that has a behavioral health focus and the CCD that we share with the rest of the delivery system.” The CCD, or continuity of care document, is a standard way to represent and summarize clinical data from an episode of care, written in XML (eXtensible Markup Language). Building upon three regional HIT meetings held over the past summer, much of this meeting was spent discussing which types of information are needed by primary care providers, by behavioral health providers, and by patients. Given past discussion in this column about privacy concerns with HIT in mental health and addictions, Dr. Clark underscored SAMHSA’s intent to have behavioral health providers fully participate in the adoption and integration of Health IT within the general health care delivery system.

Michael Lardiere, from the National Council for Community Behavioral Healthcare (NCCBHC), stressed the importance of integration of behavioral health and primary care communication and collaboration. Toward that goal, he described an HIT adoption survey currently underway by the National Council. He also reviewed the 17 components of the current CCD standard, which are:

1. Patient Demographics

2, Immunizations

3. Vital Signs

4, Problems & Diagnoses

5. Insurance Information

6. Health Care Providers

7. Encounter Information

8. Allergies/Alerting Data

9. Appropriate Results

10, Medication

11. Procedures

12. Results

13. Necessary Medical Equipment

14. Social History

15. Statistics

16. Family History

17. Care Plan

At this time, no behavioral health-specific elements are in the CCD. There is an HL7 work group, lead by Madan Gopal from the Arizona Health Department, that is currently developing draft specifications for such elements. This draft is expected to be voted on by HL7 around February 2012.

There were several other presentations before breaking into small groups to develop specific suggestions regarding the psychiatric elements to be included in a CCD. Sherri Morgan, from the National Association of Social Workers, spoke about implementation of HIT in small practices, many of whom are using consumer-oriented software instead of expensive niche products. Anne Watt and Patty Craig, both from The Joint Commission, discussed performance measures including new substance abuse measures for 2012. Vendor incorporation of these and future measures will be facilitated by their Measure Authoring Tool using the Health Quality Measures Format, or HQMF. Bettye Harrison, spoke about CARF’s recent activities, while I represented the American Psychiatric Association and spoke about risks and benefits of HIT implementation for behavioral health specialists. Finally, Lynn Bufka, Ph.D., from the American Psychological Association, led a discussion about confidentiality, the need for data segmentation and other challenges in behavioral health IT.

Three break-out groups developed consensus on which core clinical data are needed to be included in the CCD for serious mental illnesses, addictions, and recovery-oriented services. The strongest themes to emerge centered around building in granular consent management metadata within the CCD document, and greater consumer access to and control of their health information.

From the summary document, nine cross-cutting issues emerged from all three break-out work groups:

1. Vested self-interest in working together

2, Work only within the framework of the CCD/ HL7

3. Linkage of providers to services to problems to results to continuing care plan

4. Usability – work needed on how to read the record, how usable it will be, what views will be there (use of metadata tagging) (an issue to still be addressed/resolved)

5. Need for resolution of data segmentation

6. Granular consent management.

7. Need for contextualized content (diagnosis, measure of change, results, last treatment/discharge status, treatment compliance)

8. Need to see all open care plans/system involvement

9. Housing and stability

Additional information can be found on SAMHSA’s website at http://www.samhsa.gov/healthIT/.

<[QM]—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, co0chair 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 Substance Abuse and Mental Health Services Administration held a meeting in October entitled “2011 Consensus-Building Summit on Electronic Health Records for Behavioral Health.” Invited to the day-long meeting were many national leaders and organizational representatives from numerous relevant organizations. The purpose was “to address the issue of consensus building for data sharing for continuity of care between providers.

Highlights of the meeting, organized by Valerie Mills, Ph.D., included discussions on SAMHSA’s vision for advancing health information technology and EHRs in the behavioral health community, the integration of behavioral health with primary care, concerns and strategies from behavioral health providers, and confidentiality issues concerning the adoption of HIT/EHRs and the consumer. Other discussions focused on differences in clinical experiences with primary care patients versus behavioral health clients, and priority elements to include as core clinical data for EHRs and continuity of care documents (CCDs) in recovery-oriented services, treatment for addictions, and treatment for serious mental illness.

The director of SAMHSA’s Center for Substance Abuse Treatment, Dr. Westley Clark, summarized the day’s goal as “working towards consensus on specific elements of information that should be included in a uniform or standard EHR that has a behavioral health focus and the CCD that we share with the rest of the delivery system.” The CCD, or continuity of care document, is a standard way to represent and summarize clinical data from an episode of care, written in XML (eXtensible Markup Language). Building upon three regional HIT meetings held over the past summer, much of this meeting was spent discussing which types of information are needed by primary care providers, by behavioral health providers, and by patients. Given past discussion in this column about privacy concerns with HIT in mental health and addictions, Dr. Clark underscored SAMHSA’s intent to have behavioral health providers fully participate in the adoption and integration of Health IT within the general health care delivery system.

Michael Lardiere, from the National Council for Community Behavioral Healthcare (NCCBHC), stressed the importance of integration of behavioral health and primary care communication and collaboration. Toward that goal, he described an HIT adoption survey currently underway by the National Council. He also reviewed the 17 components of the current CCD standard, which are:

1. Patient Demographics

2, Immunizations

3. Vital Signs

4, Problems & Diagnoses

5. Insurance Information

6. Health Care Providers

7. Encounter Information

8. Allergies/Alerting Data

9. Appropriate Results

10, Medication

11. Procedures

12. Results

13. Necessary Medical Equipment

14. Social History

15. Statistics

16. Family History

17. Care Plan

At this time, no behavioral health-specific elements are in the CCD. There is an HL7 work group, lead by Madan Gopal from the Arizona Health Department, that is currently developing draft specifications for such elements. This draft is expected to be voted on by HL7 around February 2012.

There were several other presentations before breaking into small groups to develop specific suggestions regarding the psychiatric elements to be included in a CCD. Sherri Morgan, from the National Association of Social Workers, spoke about implementation of HIT in small practices, many of whom are using consumer-oriented software instead of expensive niche products. Anne Watt and Patty Craig, both from The Joint Commission, discussed performance measures including new substance abuse measures for 2012. Vendor incorporation of these and future measures will be facilitated by their Measure Authoring Tool using the Health Quality Measures Format, or HQMF. Bettye Harrison, spoke about CARF’s recent activities, while I represented the American Psychiatric Association and spoke about risks and benefits of HIT implementation for behavioral health specialists. Finally, Lynn Bufka, Ph.D., from the American Psychological Association, led a discussion about confidentiality, the need for data segmentation and other challenges in behavioral health IT.

Three break-out groups developed consensus on which core clinical data are needed to be included in the CCD for serious mental illnesses, addictions, and recovery-oriented services. The strongest themes to emerge centered around building in granular consent management metadata within the CCD document, and greater consumer access to and control of their health information.

From the summary document, nine cross-cutting issues emerged from all three break-out work groups:

1. Vested self-interest in working together

2, Work only within the framework of the CCD/ HL7

3. Linkage of providers to services to problems to results to continuing care plan

4. Usability – work needed on how to read the record, how usable it will be, what views will be there (use of metadata tagging) (an issue to still be addressed/resolved)

5. Need for resolution of data segmentation

6. Granular consent management.

7. Need for contextualized content (diagnosis, measure of change, results, last treatment/discharge status, treatment compliance)

8. Need to see all open care plans/system involvement

9. Housing and stability

Additional information can be found on SAMHSA’s website at http://www.samhsa.gov/healthIT/.

<[QM]—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, co0chair 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.