The .Plan

I.

“It’s all bipolar,” he declared. “It’s all due to ‘the’ bipolar.”

Mr. Smith had “degrees from prestigious institutions” (bachelor’s from Idaho State [*], culinary certificate from a private school of hospitality in Montana), however, despite having “the natural abilities” that would suit him for “really important positions” he felt his illness was “keeping me from getting a job”. In particular, his “bipolar” has caused “anger outbursts” that have made it hard for him to get along with people. He had been serially fired from several jobs and had now been unemployed for nearly a year and a half. When queried about “anger outbursts” that had occurred in the past month, Mr. Smith described one incident that occurred at the public library last week as he was filling out a job application online (”for a really important job”) and asking the desk secretary for help, and I could not help but think to myself that his tantrum — which eventually necessitated a mild response from library security — far outweighed the magnitude of the infraction, real or imagined.

But, he added, “I know it’s ‘the’ bipolar”.

Careful review of his past history did not reveal any events that were even suggestive of distinct mood episodes, nor was there any (quasi-) objective evidence of disability such as emergent psychiatric hospitalization or workplace absenteeism. To my examination, his “bipolar” appeared to be invoked (rather, conjured), prodded by an intrapsychic strategy designed to defend his narcissistic self against the crushing realization that, now homeless and looking every bit his 58 years of age, he had not achieved the lofty goals he had set for himself; and, moreover, this was an invocation reinforced by the prescribing behavior of poorly trained, uncritical psychiatrists and covertly blessed by an approving, disease-mongering pharmaceutical industry. (For more, see “The Latest Mania: Selling Bipolar Disorder” by David Healy.)

Sigh. The previous psychiatry resident had already started him on Abilify(R) (aripiprazole). He expected me to increase the dose. The attending expected me to increase the dose. Clearly the medication wasn’t “working” because it had been quite loosely prescribed. But what else could I do?

I scribbled on my notepad.

“Plan: 1. Increase aripiprazole to 30mg PO QD. 2. Return to clinic in one month.”

I hate my job.

II.

Mr. Parker first encountered the mental health care system some 10 or 20 years ago, when the city police had to drag him from his apartment kicking and screaming. His landlord had called the police because the rent had been overdue and there was a terrible smell emanating from the apartment. And his mother had become increasingly worried about him. Over the course of the year he had turned to drinking, but what worried her more were the increasingly bizarre things he would tell her during their sporadic telephone conversations, many of them occurring in the wee hours of the morning. In order to enter Mr. Parker’s apartment, the police needed to cut through some 3 or 4 types of razor and barbed wire that he had strung up around the door. The inside of the unit was littered with trash, urine, and feces, and the report made it sound like Mr. Parker hadn’t eaten in a month. He was muttering aloud and clearly responding to internal stimuli.

Now in his 40s, Mr. Parker has been doing as well as one could expect for someone with a chronic, debilitating mental illness characterized by extreme cognitive deficits and poor social functioning. He has been clean and sober for many years; he lives in a single room occupancy hotel one block away from the downtown street corner where “you can get anything you want” (according to my actively heroin-injecting, Vicodin-popping, alcohol-drinking patients); he has no friends; he spends most of his time in his room, but when he is able to tolerate it he will take the bus to the outpatient mental health building and participate in a “board games group”; and he has a case manager who meets with him weekly, safeguards the meager check he receives from the state, and sometimes helps him buy things like bread and milk (at one of the three bodegas in the entire downtown area that do not sell alcoholic beverages). He is very disorganized and rarely able to fully track with a conversing adult.

I hate the one-patient-per-30-minutes, assembly-line attitude that my outpatient clinic instills in me. I only have a few elementary tools to combat it. Beyond the cookie-cutter questions that medical students are taught to ask their patients (”hearing any voices lately?”, “have you had any thoughts of hurting yourself?”), I try, when appropriate, to ask about the experiential aspects of mental illness.

Today, Mr. Parker’s reply was stunning (although I’ve only seen him twice).

“I bought milk — gave him a twenty. He gave me change for a five.”

What is it like to be cognitively debilitated, yet to have a glimmer of insight that something is rotten in Denmark and therefore to live in the shadow of the knowledge that if you raise a fuss in a clearly unjust situation, your assailant will call the police and have you carted off to the hospital?

I love my job.

–
[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

Preach it, Sister Satel:

Characterizing addiction as a brain disease misappropriates language more properly used to describe conditions such as multiple sclerosis or schizophrenia—afflictions that are neither brought on by sufferers themselves nor modifiable by their desire to be well. Also, the brain disease rhetoric is fatalistic, implying that users can never fully free themselves of their drug or alcohol problems. Finally, and most important, it threatens to obscure the vast role personal agency plays in perpetuating the cycle of use and relapse to drugs and alcohol…

Finally, dare we ask: Why is stigma bad? It is surely unfortunate if it keeps people from getting help (although we believe the real issue is not embarrassment but fear of a breach of confidentiality). The push to destigmatize overlooks the healthy role that shame can play, by motivating many otherwise reluctant people to seek treatment in the first place and jolting others into quitting before they spiral down too far.
–Sally Satel and Scott Lilienfeld, “Medical Misnomer”, Slate, July 25, 2007

Easterly nails it:

Plans, strategies, and frameworks are favored activities in foreign aid—this is what aid bureaucracy does. Then the bureaucracies “coordinate” their respective strategies with the others. One bureaucracy’s output serves as another bureaucracy’s input, with the output of the second bureaucracy then feeding back as an input into the first bureaucracy’s output.

For example, the World Bank announces that its plan to fight AIDS is to produce more plans. It advocates

… strengthening national HIV/AIDS strategies, to ensure they are truly prioritized and strategic, integrated into development planning…. The World Bank will focus intensively on improving national HIV/AIDS strategies and annual action plans. … Support for a network of country practitioners will be provided to help countries to develop strategic, prioritized national plans…. Enhanced Country Assistance Strategy (CAS) and Poverty Reduction Strategy (PRSP) guidelines and assessment criteria will aim to support better integration of HIV/ AIDS into national development planning and better aligned national AIDS responses…. The Bank will continue to provide financial and technical support…to enhance country capacity and systems to implement national HIV/AIDS plans…[and] work with countries and Bank project teams to further improve planning.[8]

This repetitive exposition on how strategies should be strategic is to be found in the short version, or executive summary, of a seventy-eight-page report. Those who can, act; those who can’t, produce plans.
–William Easterly, “How, and How Not, to Stop AIDS in Africa”, New York Review of Books, August 16, 2007

Irritable Bowel Syndrome.
Migraine headache.
Bipolar Affective Disorder Type II.
Gastro-esophageal Reflux Disease.
Depression.
Adult Attention Deficit-Hyperactivity Syndrome.
Fibromyalgia.
Chronic Low Back Pain.
Anxiety.

As the pharmaceutical industry fuels the colonization of ever more aspects of human life, I realize that I hate prescribing under duress. Back in the day, when the only medication in the psychiatrist’s pharmacological armamentarium was the tricyclic antidepressant (a medication that had many unpleasant side effects and could be easily toxic with a minor overdose), primary care physicians’ reluctance to prescribe such medications must have been a psychiatrist’s dream. But these days, because medications like serotonin specific reuptake inhibitors are comparatively safe even when taken in overdose, outside physicians dispense these medications like cotton candy. Prodded into action by their patients who are in turn prodded into action by drug advertisements, these uncritical physicians hand out diagnoses like “bipolar depression type II” when it is quite clear that these fully functional individuals have never had a true destructive hypomanic episode in their lives.

Then the patients come to us expecting the same.

This week I was strongly persuaded by an attending to prescribe antidepressants for several patients whose problems were likely interpersonal and characterological in nature, and I was gently chided for being a pharmacological Calvinist. Today, when it came to another patient who came in with primary complaints of “anxiety” and “depression” despite having no objective signs of being in a vegetative affective state, I held the line. No Valium for you. Boy did that make him angry. And hostile. And verbally abusive. And threatening. I was surreptitiously reaching for the panic button (which doesn’t really help me much, it just means that a patient can only beat on me for about 5 minutes before the security guards finally show up) when he just picked up his 240 pound body and left abruptly.

Don’t go away mad. Just go away.

This is going to be a long three years.

–
[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

…as he picks up on the common historical theme: everyone and their mother has a plan for the health care morass. But when we can’t agree on a compromise plan, then we default to plan B: do nothing.

Our health-care morass is like the problems of global warming and the national debt—the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems. Large majorities profess support for fundamental change. Yet when it comes to specific solutions we balk. A big reason is the cost… Then we get bogged down in the innumerable, wearying complexities: whether abortions will be covered, whether states will be allowed to design their own systems, what’s an acceptable co-payment for drugs—and on and on…

If, in 2009, we actually swear in a President committed to universal health care, the fight will turn ugly…

People on the right will attack the plan as a tax-and-spend nightmare, because it will have to include some mixture of increases in business and personal-income taxes. And they’ll say that it dictates your medical choices and gives government too much control. People on the left—Moore included—will attack the plan as a boondoggle for insurance companies, because it isn’t single-payer, and will say that it gives government too little control. Others will attack it for what it does or doesn’t do about malpractice litigation, birth control, acupuncture, and so forth. The debate will become angry and murky and mind-numbingly complicated, and the temptation will be to put off reform yet again.
–Atul Gawande, “Sick and Twisted”, The New Yorker, July 23, 2007

Judith [*], one of the residents in my program, is absurdly hott (spelled with two T’s). And by this I do not simply mean that she is pretty, or voluptuous, or has dark brown eyes, or looks good in boots. She belongs on a Maxim cover.

~

Last week over drinks, another one of the residents in my program — let’s call her Sally — was describing to me some of the tribulations of being a female psychiatry resident. Her first therapy case was a rather smarmy guy. When she first met him, before he even said hello, he studied her for some 10-15 seconds and the first sentence out of his mouth was, “You’re very attractive”.

Sally also told me about a new therapy case she inherited from one of the departing senior residents. At the end of her very first session with him, he said, “You know, Dr. Smith would give me a hug at the end of every session. Could we do that, too? I found that very therapeutic.” Sally initially froze and then kind of gave him a half-hug that turned into one of those awkward sideways hugs. She found the entire situation very uncomfortable.

Later that evening, Sally’s embarrassment turned to indignance when she found out from the departing resident that there never had been any such policy in her therapy sessions with that patient.

While I was watching Sally tell her story, I observed that she is, indeed, fairly attractive. She wasn’t wearing an excessive amount of makeup at the time, just a touch of Lipstick Queen Saint Rose perhaps. She isn’t absurdly hott, but I do think that most men would be captivated by her giggle, adorned with a smile, upon meeting her at a party — and for the rest of the night would be dimly aware of her presence as she made her way around the room.

At this point my thoughts drifted to Judith. How in the world does Judith manage to function as a psychiatry resident? It must be so debilitating.

Well. I suspect this is one of those questions that I will never have answered.

–
[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

My friends Craig and Liesl from South Africa sent me a photo of their children. Zackey, Lizey, and baby Vivy are too cute for me not to post this:

By the rivers of Babylon,
there we sat down and wept,
when we remembered Zion. (Ps 137:1)

God is constant. But life is not. And full worship, as Walter Bruggemann teaches us in his The Message of the Psalms, requires participation in all seasons of faith: orientation, disorientation, and reorientation. Life for the psalmist rarely dwells for long in the season of disorientation; he is always on the move. And the old season of disorientation (eventually) becomes the new season of orientation. To the faithful, these are all truisms.

Yet the movement to reorientation is more difficult for some of us than for others. The dominant ideology is the avoidance of hurt, the commitment to continuity, and the maintenance of success. In this context, it seems appropriate that some of us flail about in the foreign land, and the former lucidity of one’s communion with God seems much murkier. We are mature enough to know that we ought to assess the current unfamiliarity of things through the lens of dislocation, but we more often than not are unable to see the new ways in which God touches our lives. We’re just a little bit behind the curve.

I did learn a new thing yesterday. Take a conventional Mark Bittman recipe for macaroni and cheese: cook the macaroni al dente, bake it with butter, flour, bread crumbs, and cheddar cheese. Make some minor modifications: substitute extra extra sharp cheddar. Add monterey jack and colby, even gruyere. Nutmeg. And… a pound of dungeness crab meat. That extra $12 will mean the difference between “this is pretty good” and “dude. this is money“.

There’s a reason why they call it comfort food.

How can we sing the LORD’s song
in a foreign land?

Charles Fishman posts an illuminating article in the latest Fast Company describing the $15 billion bottled water industry. Near the end of the article, he insightfully writes the following:

Bottled water is not a sin. But it is a choice.
–Charles Fishman, “Message in a Bottle”, Fast Company, July 2007

I’m glad I didn’t go to medical school in the 70’s…

The concept of the standardized patient has been around for decades, but only in recent years have medical schools made training with them a regular part of their curriculum. I talked to a 50-ish physician friend about my experiences, and he said when he was in medical school and it was time for the first rectal/genital exam, the students were told to pair off and examine each other. “So, do you pick someone you like, or someone you don’t like?” he recalled. “Either way, it’s lose-lose.”
–Emily Yoffe, “Playing Doctor”, Slate, July 4, 2007