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Talk Is Cheap, Unless It’s Talk Therapy


Gardiner Harris had a [recent] article in the New York Times called “Talk Doesn’t Pay So Psychiatrists Turn to Drug Therapy.” The article is a twist on an old Shrink Rap topic, “Why your Shrink Doesn’t Take Your Insurance.” Only in this article the shrink does take your insurance, he just doesn’t talk to you.

With his life and second marriage falling apart, a man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Dr. Levin sees 40 patients a day. And he’ss 68 years old. This guy is amazing. There’s no way I could see 40 patients a day for even one day. He’s worried about his retirement, but I wouldn’t make it to retirement at that pace. (Should we make a bet on whether Dr. Levin has a blog?)

The article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn’t say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was overemphasized in the days of old? The patients don’t complain of being short-changed, and if Dr. Levin can get 40 patients a day better for — your guess is as good as mine, but let’s say — $60 a pop, and they only have to come every one to three months, and there’s a shortage of psychiatrists, then what’s the problem? Why in the world would anyone pay to have regular psychotherapy sessions? Read more »

*This blog post was originally published at Shrink Rap*

Chronic Fatigue Syndrome: Can Psychotherapy And Exercise Help?



[Recently] in The New York Times, David Tuller [wrote] about a study published in The Lancet that shows that psychotherapy is an effective treatment for chronic fatigue syndrome. In his article ”Psychotherapy Eases Chronic Fatigue, Study Shows,” Tuller writes:

The new study, conducted at clinics in Britain and financed by that country’s government, is expected to lend ammunition to those who think the disease is primarily psychological or related to stress.

The authors note that the goal of cognitive behavioral therapy, the type of psychotherapy tested in the study, is to change the psychological factors “assumed to be responsible for perpetuation of the participant’s symptoms and disability.”

In the long-awaited study, patients who were randomly assigned to receive cognitive behavioral therapy or exercise therapy, in combination with specialized medical care, reported reduced fatigue levels and greater improvement in physical functioning than those receiving the medical care alone — or getting the medical care along with training in how to recognize the onset of fatigue and to adjust their activities accordingly.

Interesting. Generally I like to stay away from the “it’s all in your head” debates. I’ll let the commenters do the talking here.

*This blog post was originally published at Shrink Rap*

Treating Depression: The “Shock Value” Of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is considered to be a highly effective treatment for depression. The story goes that roughly 90 percent of patients respond. The downside is that it requires general anesthesia with all its attendant risks, and patients may suffer from headaches and memory loss. The memory loss is often mild, but there are cases where it is profound and very troubling.

As with any psychiatric treatment — or so it seems — there are those who say it saved them and those who say it destroyed them. Because the risks aren’t minor, the procedure is expensive and often done on an inpatient unit, and people generally don’t like the idea of having an IV line placed, being put under, then shocked through their brain until they seize, only to wake up groggy and perhaps disoriented with an aching head, it’s often considered to be the treatment of last resort, when all else has failed. This makes the 90 percent response rate even more powerful.

I’m no expert on ECT. I haven’t administered it since I was a resident and I don’t work with inpatients where I see people before and after. I’ve rarely recommended it, and then I’ve been met with a resounding, “NO.” My memory of it was that it worked, and that most people didn’t complain of problems. One woman read a novel during her inpatient stay. I asked if she had trouble following the plot (ECT in the morning, novel reading in the afternoon), and she said no.

The Food and Drug Administration (FDA) has been looking at the safety and efficacy of the machines used to perform ECT. It’s a fairly complex story where the FDA advisory panel was considering whether to keep ECT machines categorized as “Class III” machines, which would now require machine manufacturers to prove their efficacy and safety. A reclassification as Class II (and therefore lower risk) would not require this stringent proof. Read more »

*This blog post was originally published at Shrink Rap*

At-Home Psychotherapy For The Super Bowl FAN (Football Attention Neurosis)

So it’s Super Bowl Sunday and the fans are psychiatric patients waiting to happen — the beer and the beer and the beer, and maybe the fights will break out, and they’ll all end up in therapy. Oh, the angst and the panic, and the pre-game anxiety, and the post-game euphoria or depression.

New York Times reporter Benedict Carey talks about treatment options in his article, ”A Home Treatment Kit for Super Bowl Suffering.” Mr. Carey suggests:

Breathing exercises are highly recommended and become increasingly important as the football contest nears the fourth quarter, when events on the field are likely to prompt strong physiological reactions, like a pounding heart, hyperventilation, even dizziness. These internal cues, as they’re called, can escalate the feeling of panic, a self-reinforcing cycle resulting in groans and cries that can be frightening to small children, pets and sometimes neighbors.

In the final minutes of the game, be forewarned: Many patients will move beyond the reach of therapy. Their faces may change, their breathing appear to stop. Researchers have not determined whether this state is closer to Buddhist meditation or to the experience of freefall from an airplane. All that is known is that, once in it, patients will fall back on primal coping methods, behaviors learned in childhood within the cultural context of their family.

Like emitting screams. Or leaping in an animated way, as if the floor were on fire. Or falling on their back and moving their arms and legs like an overturned beetle, in celebratory fashion.

This post is dedicated to my husband and son.

*This blog post was originally published at Shrink Rap*

Meditation: How It May Change The Brain

Meditation sounds like a great idea from the perspective of a psychiatrist: Anything that calms and focuses the mind is a good thing (and without pharmaceuticals, even better).

Personally, I tried transcendental meditation as a kid (more to do with my mother than with me) and found it to be boring. I have trouble keeping my thoughts still. They wander to what I want for dinner, and should I write about this on Shrink Rap, and will Clink and Victor ever eat crabcakes with me again, and did I remember to give my last patient informed consent, and a zillion other things. Holding my thoughts still is work.

The New York Times Well blog has an article on meditation and brain changes. In “How Meditation May Change the Brain,” Sindya N. Bhanoo writes:

The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

Lower stress, lower blood pressure, higher empathy. I may have to give meditation another try.

*This blog post was originally published at Shrink Rap*

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