AN RANCISCO EDICINE S F M VOL.83 NO.10 December 2010
JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Psychiatry for the Nonpsychiatric Physician
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In This Issue
SAN FRANCISCO MEDICINE December 2010 Volume 83, Number 10 Psychiatry for the Nonpsychiatric Physician
4 Membership Matters
12 Recognizing Addiction: An Addiction Primer for the Primary Care Physician David Pating, MD
5 SFMS Election Results
13 Childhood Psychiatric Disorders: An Overview Albert Hamilton Hold, MD, and Victoria Mycue, MFT
7 Executive Memo Mary Lou Licwinko, JD, MHSA
15 Common Sleep Disorders: A Guide to Recognizing Causes of Poor Sleep Rachel Manber, PhD
9 President’s Message Michael Rokeach, MD
17 Treating Obesity: Don’t Ignore Stress! Elissa Epel, PhD
11 Editorial Stephen J. Walsh, MD
20 Recognizing Bipolar Disorder: A Description of the Primary Symptoms William Prey, MD
39 Hospital News
42 In Memoriam Nancy Thomson, MD
22 Psychiatry in the Oncology Setting: A Practical Guide Alan Maloney, MD 24 Helping Grief Along: A Road Map for Mourning Mardi J. Horowitz, MD
Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129
25 Mindfulness-Based Cognitive Therapy: Curbing the Tendency to Engage in Negative Thought Patterns Tracy Peng, MD
Phone: (415) 561-0850 extension 261 e-mail: firstname.lastname@example.org Web: www.sfms.org Advertising information is available by request.
27 Psychiatric Consultation: When Is It Time to Refer? J. Jewel Shim, MD
29 Emotional Competence: Giving Your Practice a Tune-up Loma K. Flowers, MD 30 Coercion and Compassion: A View from the Streets Emily Baldwin, MD
32 “Get This Patient Out of My ER!”: A New, Humane, and Efficient Local Approach to Managing Psychiatric Crises Keith Loring, MD 33 Contemporary Psychoanalysis: An Update Mardi J. Horowitz, MD
34 Psychiatry and Ethics: A Whirlwind Tour Steven Reidbord, MD
35 Everyday Dream Work: Using Dreams to Identify Stress Factors in Medical Practice Gayle Delaney, PhD 37 A New Approach to Mental Health Care: Coming This Winter to the Presidio Amy Berlin, MD 38 Book Review: A “Messy” Specialty Steve Heilig, MPH
41 2010 CMA HOD Report: Policy Making in the Belly of the Beast Stephen Follansbee, MD, and Steve Heilig, MPH www.sfms.org
December 2010 San Francisco Medicine 3
Membership Matters December 2010 A Sampling of Activities and Actions of Interest to SFMS Members
Volume 83, Number 10 Guest Editor Stephen J Walsh Managing Editor Amanda Denz Copy Editor Mary VanClay
Editorial Board Obituarist Nancy Thomson Stephen Askin
Linda Hawes Clever
Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman SFMS Executive Staff Executive Director Mary Lou Licwinko Assistant Executive Director Steve Heilig Director of Administration Posi Lyon Director of Communications Amanda Denz Marketing Specialist and Membership Development Associate Jonathan Kyle Board of Directors Term: Jan 2010-Dec 2012
Gary L. Chan
Thomas H. Lee
Donald C. Kitt
Richard A. Podolin
Cynthia A. Point
Rodman S. Rogers
Adam Rosenblatt Lily M. Tan
Term: Jan 2008-Dec 2010
Jennifer H. Do
William A. Miller Jeffrey Newman
Term: Jan 2009-Dec 2011
Thomas J. Peitz
Daniel M. Raybin
Andrew F. Calman
Michael H. Siu
Lawrence Cheung CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate
Welcome to San Franciscoâ€™s New Director of Health The SFMS welcomes Barbara Garcia as the new San Francisco Director of Public Health. She has some big (tennis) shoes to fill in succeeding Mitch Katz in this crucial role, but having been SFDPH deputy director for many years, she is well-prepared for the role and widely admired for her expertise and ability to work with a wide range of people on complex issues. In fact, for one example, see the article on page 32 of this journal! Congratulations to Ms. Garcia, and the SFMS looks forward to continuing our close and productive relationship under her leadership.
SFMS Annual Dinner January 27th This yearâ€™s annual dinner will take place on January 27, 2011, at the Concordia Argonaut Club in San Francisco. George Fouras, MD, a child psychiatrist who specializes in adolescents in the foster care system, will be installed as 2011 SFMS President. We have an engaging lineup of speakers this year, along with the usual delicious dinner and camaraderie with colleagues. SFMS members: Watch your mailbox for an invitation in December. For more information, or to RSVP, contact Posi Lyon, (415) 561-0850 extension 260, or email@example.com.
Dinner Lecture on Strategies in the Surgical Treatment of Advanced Heart Failure New date! February 10, 2011. Please join us for a complimentary dinner and a medical education discussion with G. James Avery, MD, surgical director of the Heart Failure and Transplant Program at California Pacific Medical Center. A 1.0 category CME 1 credit hour is available for attending this event. The dinner and lecture will take place at Town Hall Restaurant, 342 Howard Street, San Francisco, from 6:30 p.m. to 8:30 p.m.
4 San Francisco Medicine December 2010
on February 10. RSVP required to Posi Lyon, firstname.lastname@example.org or (415) 5610850 extension 260.
SFMS Symphony Night
The San Francisco Medical Society is pleased to announce the return of the San Francisco Symphony Night on Wednesday, February 9, 2011. Come see world-renowned conductor Ton Koopman bring his Bach and Schubert program to San Francisco! The show starts at 8:00 p.m. and an SFMS member reception will begin at 6:00 p.m. in the Green Room. Food and drinks will be provided and members will have access to the room until just before showtime. Guests are welcome. If you would like to attend, please contact Jonathan Kyle at (415) 561-0850 extension 240 or jkyle@ sfms.org. Keep your eyes open for more information about ticket prices and seating availability. We hope to see you there!
Rolland Lowe, MD, Receives L i f e t i m e A c h i e v e m e n t i n Philanthropy Award
Rolland Lowe, MD, past-president of the SFMS and of the CMA and CMA Foundation Board Chair, received the prestigious Lifetime Achievement in Philanthropy Award. The award, given by the Association of Fundraising Professionals, Golden Gate Chapter, honors exceptional work in the nonprofit and philanthropy sectors for the past year. It recognizes individuals and organizations whose philanthropic achievements have made an impact on society, whether local, national or international. Dr. Lowe, who was the first Asian American president of CMA, has worked for decades to get physicians more involved in their communities. He has worked to provide low-income immigrants with high quality health care and advocated for better health care within the Chinese American community. www.sfms.org
CalHIPSO Tops Nation in Signups of Doctors Getting Electronic Health Records CalHIPSO, a federally funded, nonprofit regional agency founded in part by the CMA, has signed up more than 2,100 providers seeking assistance in selecting and implementing electronic health records in their practices. The success of CalHIPSO makes it the No. 1 such Regional Extension Center (REC) in the nation, having enrolled more than any other REC. Physicians who are considering the transition to electronic health records (EHRs) should contact Jon Kyle at the San Francisco Medical Society, (415) 561-0850 extension 241 or email@example.com, to learn how to sign up with CalHIPSO and the local extension center (LEC) for assistance. CalHIPSO through the LEC helps San Francisco physicians choose and implement the most appropriate EHR system and provides assistance in gaining access to federal grant funding. SFMS is working closely with CalHIPSO and the LEC to provide information and assistance to our members on adopting EHR systems.
The Second Opinion Seeks Volunteer Physicians
The mission of thesecondopinion is to provide free multidisciplinary second opinions to adults in diagnosed with cancer. The organization recently announce d the appointment of Dr. Howard Kleckner to the position of Medical Director. Dr. Kleckner, a native of Chicago, joined the Kaiser Medical Center in Hayward as chief of Hermatology/Oncology in July 1976 and held the post until May 2007. He simultaneously served as Medical Director of the Kaiser GSAA Hospice from 1978 to 2001. Under Dr. Klecknerâ€™s leadership, thesecondopinion is seeking more physicians to volunteer every six weeks on our cancer review panels. For more information, please visit www.thesecondopinion.org or contact Dr. Kleckner at (415) 775-9956. www.sfms.org
2010 SFMS Election Results 2011 Officers (one-year term) President-Elect: Peter J. Curran, MD Secretary: Lawrence Cheung, MD Treasurer: Shannon Udovic-Constant, MD Editor: Gordon L. Fung, MD
2010 President-Elect, George A. Fouras, MD, will automatically succeed to the office of President. 2010 President, Michael Rokeach, MD, will automatically succeed to the office of Immediate Past President. Board of Directors (seven elected for three-year term 2011-2013) Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD
Nominations Committee (four elected for two-year term 2011-2012) Luis A. Bonilla, MD Jason Dimsdale, MD Lisa W. Tang, MD Andrew Wang, MD Young Physicians Section Alternate (one-year term 2011) Thomas K. Haddad, MD
Solo/Small Group Practice Delegate (two-year term 2011-2012) Eric Tabas, MD
Solo/Small Group Practice Alternate (two-year term 2011-2012) Eric H. Denys, MD
Delegates to the CMA House of Delegates (First four are delegates; next five are alternates. PeterÂ J. Curran, MD, President-Elect, will serve as the fifth Delegate according to the SFMS Bylaws. Two-year term 2011-2012) Delegates Gordon L. Fung, MD Michael Rokeach, MD Shannon Udovic-Constant, MD H. Hugh Vincent, MD Alternates Elizabeth A. Andrews, MD Lawrence Cheung, MD Steven H. Fugaro, MD Man-Kit Leung, MD Andrea M. Wagner December 2010 San Francisco Medicine 5
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Executive Memo Mary Lou Licwinko, JD, MHSA
A Farewell and Thank-You Letter to Dr. Mitch Katz
s many readers already know, Dr. Mitchell Katz, the Director of the San Francisco Department of Public Health for the last thirteen years, has decided to move on to a new position. He will be leaving the Bay Area to become health director for Los Angeles County. Over the years, Dr. Katz has worked with the San Francisco Medical Society on a number of tasks to improve the public health of our residents. SFMS Leadership would like to thank Dr. Katz for his service. The following letter was sent to Dr. Katz in November. Dear Dr. Katz, On behalf of the San Francisco Medical Society (SFMS), we would like to thank you for your many years of service as director of the San Francisco Department of Public Health. We want to take this opportunity to acknowledge your contributions to the citizens of San Francisco as well as your friendship and support of the SFMS. Your accomplishments in improving health and health care in San Francisco are too numerous to list here, but we especially
salute you for your efforts to gain support for the rebuilding of Laguna Honda and San Francisco General Hospitals. These alone would have been major achievements during your tenure, but you also designed and implemented Healthy San Francisco and banned the sale of tobacco in pharmacies. Even with your extraordinarily busy schedule, you found the time to attend SFMS Board meetings and keep the members apprised of public health activities in the nation, state, and county. We appreciate that you have always made yourself available to us and sought our counsel when appropriate. We recognize that you have a big task in front of you in Los Angeles and hope that you will always know that we are available if we can ever be of assistance. We wish you success in your new endeavor. Sincerely yours, Michael Rokeach, MD, SFMS President Mary Lou Licwinko, JD, MHSA, SFMS Executive Director
On behalf of all SFMS physicians, the San Francisco Medical Society con-
ever-stronger protections from secondhand smoke, for removal of tobacco prod-
SFMS ADVOCACY UPDATE: Advocacy for Physicians, Patients, and Our Community tinues its commitment to the following agenda:
• Preserving the health care safety net and public health programs in
times of severe budget cuts. Fighting cuts in Medi-Cal and other programs.
• Developing and sponsoring the San Francisco Health Information
Exchange to electronically link health records of institutions and physicians in San Francisco. With the Local Extension Center, assisting physicians in
ucts from pharmacy settings, for higher taxes on tobacco products, and more.
HIV PREVENTION AND TREATMENT: The SFMS was at the center of
medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more.
SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a city-
adopting electronic medical records and reaching meaningful use in order to
wide school health education and condom program, removed questionable
San Francisco program and participating in lawsuit to preserve the program.
ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts
receive federal funding.
• Working with Mayoral Task Force to develop and support the Healthy • Providing physicians for medical consultation for the San Francisco
Unified School District.
• Participating as a partner in the Hepatitis B Free program in San
Francisco and educating physicians and patients on prevention and treatment.
Other Ongoing SFMS Community Health Activities
ACCESS TO CARE: SFMS leaders have long advocated that every San Fran-
drug education efforts from high schools, and worked on improving school nutritional standards.
include establishing a nationwide educational network on scientific approaches
to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures.
REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and
national leader in advocating for women’s reproductive health and choice, including access to all medically indicated services.
PUBLICATIONS: The SFMS’ award-winning journal, San Francisco Medi-
ciscan should have access to quality medical care, and our representatives served
cine, has long been recognized as one of the very best local medical publications.
the banning of tobacco smoking in San Francisco restaurants; we advocate for
December 2010 San Francisco Medicine 7
on the Mayoral Task Force that designed the Healthy San Francisco program.
ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in
We also send e-alerts and maintain a blog.
For more information, see www.sfms.org or call (415) 561-0850.
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President’s Message Michael Rokeach, MD
A Farewell Message
t’s hard to believe my year as SFMS President is rapidly coming to an end. This will be my last Presidents’ column for this award-winning journal. It has been a most satisfying and productive year for me personally. Our medical society has truly accomplished much. Prominent in my mind are the birth of the San Francisco Health Information Exchange, a very successful four days in Sacramento for the CMA House of Delegates (as chronicled in this issue by Stephen Follansbee and Steve Heilig), numerous appearances before the Board of Supervisors to present organized medicine’s view on important local legislation, and another successful local election Candidate’s Night, just to name a few events. Being a member of this organization has allowed me to be heard in support of all physicians, not just members; all hospitals, not just my hospital; and all types of medical practices, not just emergency medicine. And because of that effort and energy, our patients are the true beneficiaries. We have put together another terrific San Francisco Medicine issue for our readers. This month’s topic is psychiatry for the nonpsychiatrist. It’s really a handbook for nonpsychiatric practitioners. Being a nonpsychiatrist myself, I see how these tools can be used on a daily basis. As one example, I just learned about the new comprehensive and affordable mental health center for children opening this month in the Presidio. The Masonic Center for Youth and Families will be a tremendous asset for physicians and their patients. Mental health services continue to be difficult to obtain in the City, especially for youth. The article by David Pating, MD, on recognizing addiction in primary care, is simple and straightforward. Many physicians fall short in evaluating their patients for drug and alcohol overuse by not knowing how to elicit the information. The article also highlights the relationship between substance abuse and mental health disorders, most commonly depression, and the need to screen for both simultaneously. Other important articles in this issue touch on relevant topics, such as when to refer to a mental health specialist. Up to one-third of primary care patients have a diagnosable psychiatric disorder. The article by Dr. Shim from UCSF highlights how common this is in the average primary care practice, as well as the relationship between medical illnesses and psychiatric disorders. This is especially relevant to patients with medically unexplained symptoms. These patients often have poorer medical outcomes and higher medical costs. I do hope the health care
reform gurus in Washington will read this issue! Also included for our readers are timely articles on the psychiatric aspects of treating patients with sleep disorders, cancer, obesity, and grief. This is nicely summarized by our guest editor, Dr. Stephen Walsh, longtime member and former President of the SFMS, and this year’s recipient of the Royer Award for Community Psychiatry. I want to thank Dr. Walsh for putting together this excellent final 2010 issue of San Francisco Medicine. Add this to the impressive list of issues published this year, including those on nutrition, the electronic health record, newer specialties, medical ethics, and addiction. As my presidential year comes to a close all too quickly, I must take a moment to recognize those hardworking and dedicated staff members at the SFMS who make this job so satisfying and enjoyable. My heartfelt thanks go to Mary Lou Licwinko, the Executive Director; Posi Lyon, Administrative Director; Steve Helig, Assistant Executive Director; Amanda Denz, our Director of Communications and Managing Editor of San Francisco Medicine; and Jonathan Kyle, our new Assistant Director of Marketing and Membership. Great organizations require great people, and we certainly are fortunate to have these people working on behalf of all physicians and patients in San Francisco. My hat goes off to you. What a great year it has been. Keep up the tradition. Thank you again for the opportunity to be your president, even if it only is for one year, and have a wonderful holiday season.
December 2010 San Francisco Medicine 9
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Editorial Stephen J. Walsh, MD
Psychiatry in Medicine
sychiatry is a wonderfully relevant and diverse specialty within medicine. Embedded in the clinical work with patients of all physicians are stress-related symptoms, sleep problems, psychogenic somatization and pain disorders, anxiety-related phenomena, intrapsychic conflict states, mood and thinking alterations, troubled interpersonal relationships relevant to patient complaints, and the fundamentally important doctor-patient relationship. All of this and more are of central interest to psychiatrists. I practiced general medicine for several years before my residency in psychiatry. I noticed vividly how ubiquitous in medical and surgical patients are prominent biopsychosocial interactions determining presentations and outcomes, and how useful some good working knowledge of psychiatric symptoms and disorders can be. It is no secret anymore that psychiatry is squarely in the mainstream of medicine. As guest editor for this final San Francisco Medicine issue of 2010, I and our editorial board have organized articles around the theme “Practical Psychiatry for Nonpsychiatrists.” We want this issue to be a resource usable by most of our diverse physician readership for at least some part of the spectrum of patients you all see. Herein are articles on psychiatric aspects of treating patients with cancer, sleep problems, obesity, alcoholism and addictions, grief and complicated grief, and the ubiquitous symptoms of anxiety and mood spectrum disorders. Additional articles discuss when to obtain psychiatric consultation and how to use the new mindfulness-based cognitive approaches to alter patients’ pathogenic negative thinking patterns. Other pieces describe how to handle briefly and helpfully the dreams and nightmares patients tell you, and how to usefully evaluate the mental health status of children and adolescents. We have included an article on a new sliding-scale psychiatric resource in the Presidio for children and their families. Another article concerns emotional education for physicians regarding organizing their offices in a more helpful, patient-friendly manner. The use of psychotherapy is alive and well in San Francisco psychiatric practices. We have included an update on developments in psychoanalysis/psychoanalytic therapies confirming the healing value of examining closely the here-and-now doctorpatient relationship, using that unique interpersonal experience to develop patients’ sense of a coherent identity, trust, selfefficacy, and more mutually satisfying relationships outside of therapy. One of the very useful local psychotherapy enterprises www.sfms.org
in the past four years at UCSF is a psychiatrist-run psychotherapy second-opinion service for the community. This service uses the experiences of senior faculty and clinical faculty psychiatrists and is a learning opportunity for advanced psychiatric residents. Referrals have been received from psychiatrists, psychoanalysts, and other community psychotherapists, with highly useful help given for problematic psychotherapies needing fresh input. More about this will be published in this journal later. Completing this month’s issue are pieces on psychiatric ethics, the severely mentally ill and outpatient commitment (Laura’s Law), a review of an interesting book written by a local emergency room psychiatrist, and other articles of general interest. Past studies have revealed that psychiatrists tend to enjoy what they do more, and practice longer, than other physician specialists. I want all of our physician readership to increase their enjoyment and their value to patients by reading as much as possible what our excellent writer-psychiatrists and psychologists are presenting here. Happy holidays to you all. Stephen J. Walsh, MD, is a past president of SFMS, of the Northern California Psychiatric Society, and of UCSF’s Association of the Clinical Faculty. He is a clinical professor of psychiatry at UCSF, a past editor of San Francisco Medicine, and a member of our editorial board. He is in the private practice of psychiatry in San Francisco and Mill Valley. He is this year’s recipient of UCSF’s Royer Award to a private psychiatrist in the community.
December 2010 San Francisco Medicine 11
Psychiatry for the Nonpsychiatric Physician
Recognizing Addiction An Addiction Primer for the Primary Care Physician
David Pating, MD
en years ago, 650 national physicians were asked to diagnose a thirtyeight-year-old married woman who complained of abdominal pain, gastritis on gastroscopy, hypertension, job-related anxiety, and insomnia. Among the responses received were peptic ulcer, gastic reflux, irritable bowel syndrome, and depression. In this survey, only 6 percent of physicians mentioned possible alcohol abuse. While it’s a truism that “common disorders are common,” in this survey, less than onethird of primary care physicians said they routinely screened for alcohol abuse; most admitted they were uncomfortable asking about drug or alcohol use, particularly with older patients or those they may have known a long time. The reasons: “I’m too busy,” “I don’t know how,” or “I don’t feel comfortable with addicted patients in my practice.” This is a sad state of affairs, particularly when the National Institute of Health (NIH) has identified that one in five patients in primary care drink amounts that put them at risk for health and social consequences; another six percent, in the last month, used an illicit drug—usually marijuana but increasingly prescription drugs and opiates. The cost for failing to recognize alcohol and drug abuse in our medical practices is enormous. Patients with alcohol or drug problems have onethird more emergency room visits and account for up to 40 percent of hospitalizations and 50 to 70 percent of suicide attempts. On an outpatient basis, patients who drink above nationally recognized safe-drinking guidelines were found to have 50 percent more office visits and greater medication nonadherence. Recognizing physician reluctance to
ask about substance use, the NIH issued, in 2005, simplified guidelines for screening for alcohol and drug use as a new “vital sign.”1 The NIH defines safe drinking for men as no more than 4 standard drinks (measured as a 12-ounce beer, 5-ounce glass of wine or 1.5 ounces of liquor) at one time, or 14 drinks per week (or on average no more than 2 drinks a day). For women or older adults above age 65, safe drinking is no more than 3 standard drinks at one time or 7 drinks per week. Patients who drink above these amounts are “atrisk” drinkers and should be advised to “cut back” to “moderate” or “safe” use. For patients who used an illicit drug in the last month, they should be advised to quit. Screening and brief intervention (SBI) for alcohol and drug abuse is this simple: “How much alcohol do you drink? Would you be willing to cut back?” These standards are now adopted by the National Committee for Quality Assurance (NCQA) and endorsement of similar standards by the Joint Commission is anticipated. Of course, the diagnosis of alcohol or drug abuse is greatly simplified in the unfortunate circumstance that your patient arrives at your office doorstep intoxicated or in withdrawal. For simple alcohol withdrawal, those who manifest moderate anxiety and tremor with mildly elevated blood pressure and pulse, I encourage you to offer medical detoxification with a benzodiazepine. Alcohol withdrawal can be dangerous and life-threatening due to the rare risks of seizure or delirium tremens. More important, mounting evidence indicates that multiple episodes of untreated alcohol withdrawal contribute to increased seizure risk and dementia. In my substance abuse clinic, we try never to send away
12 San Francisco Medicine December 2010
a patient in alcohol withdrawal without adequate benzodiazepines. Most withdrawal from other illicit drugs is less worrisome. In my personal experience, most acute psychosis from stimulants resolves with sleep. Opiate withdrawal, while uncomfortable, is not usually life-threatening. My advice for the primary care clinician concerned with the management of opiate withdrawal is to be more prudent in prescribing opiates in the first place. Prescription drugs, including Oxycontin, are the fastest-growing drugs of abuse. While only 10 percent of patients abuse prescription drugs, including both benzodiazepines and opiates, when they are prescribed by a physician, those with family history or premorbid history of alcohol or drug abuse are at greater risk of abuse. My second advice for clinicians managing patients in opiate withdrawal is to consider obtaining DEA certification to use the new opioid agonist-antagonist buprenorphine in their office practice. Online training for buprenorphine is available at the American Society of Addiction Medicine (www.asam. org) or the American Academy of Addiction Psychiatry (www.aaap.org). Last, as a reminder, when addressing alcohol or drug use in your patients, it’s important to know that one-half of those with substance abuse also have a mental health disorder, most commonly depression. If you simply remember to ask about depression every time you ask about alcohol use, or ask about alcohol use whenever you ask about depression, you will catapult your practice into “best practice” compliance. “Have you had more than four (three Continued on page 14 . . . www.sfms.org
Psychiatry for the Nonpsychiatric Physician
Childhood Psychiatric Disorders An Overview
Albert Hamilton Hold, MD, and Victoria Mycue, MFT
onpsychiatrist health care providers are often called upon by families and schools to help with concerns about children’s behavior, development, and learning. These requests come because the medical provider may be a known and trusted ally, because there may not be timely access to mental health specialists, or because of remaining fear and stigma about mental health services. In light of these demands on nonpsychiatrists, this article presents some considerations in assessing child and adolescent mental health concerns. Children are rarely diagnosed in a single visit to a provider, because there is a need to obtain information regarding the child in at least two areas of functioning. Children may react strongly to specific environmental influences, which affects diagnostic considerations. Feedback from caregivers, family members, teachers, and other providers are crucial in getting a clear clinical picture and in making a diagnosis. Arriving at a consensus about the problem is the cornerstone of intervention. Treating a child is a collaborative endeavor in which responsibility for addressing problems is shared by many. Health care providers have demands on their time that may make assuming a central role in treatment impossible. In these cases, the health care provider’s follow-up with those more closely involved will improve the child’s outcome. Usually, the symptoms with which a child presents are fairly clear, but the underlying causes of those symptoms are more elusive. Symptoms such as oppositionality, irritability, or inattention www.sfms.org
are common complaints that may be rooted in exposure to trauma, learning problems, or language disorders. For this reason, a careful screening for exposure to trauma/abuse and consideration of a child’s receptive and expressive language capacity are vital. Early detection and intervention offer the best chance to decrease the morbidity associated with mental illness. Additionally, early detection alerts the family and providers to the potential for substance abuse, which frequently accompanies many of the disorders listed below. In older children and adolescents, substance abuse may be a contributor to or cause of symptoms. Keeping the importance of early detection ion mind, it may be helpful to review common clusters of symptoms that children present with. Anxiety disorders: These are frequently first present in childhood or adolescence. The most common are separation anxiety (excessive fears of being away from caregivers) and specific phobias. Both of these typically respond well to cognitive behavioral therapy. Other anxiety disorders present with symptoms of sleep problems, nightmares, avoidance, repetitive behaviors, or intrusive thoughts. As with many childhood psychiatric disorders, the symptoms are frequently expressed as physical complaints. If there is a history of trauma or abuse, or if the child lives in a dangerous neighborhood, a diagnosis of PTSD must be considered. In cases of severe impairment, longerterm treatments are usually necessary. If the duration of impairment is significant and refractory to nonpharmacological
interventions, then medication may be recommended. Inattention, with or without hyperactivity/impulsivity: These problems are also common. In the absence of trauma, mood, or anxiety symptoms, a diagnosis of ADHD is more likely. Schoolbased modifications, parent training, and treatment with stimulant medications are often enormously helpful. Learning disorders: These may come to a provider’s attention because of oppositionality or withdrawal that results from a child being frustrated or sad about being unable to complete tasks that are expected. Developmental disorders: These are a broad class of diagnoses that may involve speech and language disorders, cognitive challenges, learning disabilities, and/or social impairment. When children with significant delay in language acquisition also show marked difficulties in social interaction and reciprocal play, a diagnosis of autism is strongly considered. It is important to remain vigilant about distinguishing receptive/expressive language disorders from autism by assessing the desire for social interaction and attachment. Treatment of speech and language problems is quite different from those for treating autism. Mood disorders: In children and adolescents, these may also be expressed as irritability, somatic complaints, oppositionality or conduct problems, a decline in school functioning, or withdrawal from usual activities. It’s rare for young children to have the vocabulary to fully describe sadness in the way that Continued on following page . . .
December 2010 San Francisco Medicine 13
Childhood Psychiatric Disorders Continued from previous page . . . adolescents or adults will. Play therapy may be helpful in eliciting these feelings and in helping children to develop a sense of mastery around coping. Age-appropriate cognitive behavioral therapy has also been shown to be effective for pediatric depression. In many cases, mood disorders in children are later seen as difficulties in adjustment to stressful life events, school, or family circumstances. If these external stressors are able to improve, the mood symptoms will usually diminish. Unfortunately, the opposite may be true if the stressors are prolonged, as may be the case for a child coping with others’ reactions to sexual orientation or gender identity differences. A strong family history of mood disorders is a clue that mood symptoms in the child or adolescent may be more sustained and serious. The diagnosis of pediatric bipolar disorder is controversial even among child and adolescent psychiatrists, and it shares many of the same symptoms as ADHD and anxiety disorders. In adolescence, bipolar disorder typically more closely resembles the symptoms seen in adults. Psychotic disorders: In younger children, these are exceedingly rare, usually emerging in adolescence or early adulthood. The diagnosis of a psychotic disorder is almost always an evolving process in which a child is no longer able to mask unusual thoughts or reactions to hallucinations or delusions. As with most psychiatric disorders, the role of substance abuse as a cause or contributor to the symptoms must be examined. Health care providers are sometimes asked whether medications will be helpful in the treatment of psychiatric disorders in children and adolescents. In some cases, medication may be a key component of effective treatment when adequate nonpharmacological interventions have been tried and failed, or when symptom severity warrants earlier medication trial. Some medications have been FDA-approved for treating childhood disorders, but many are used “off-label”
and with limited research data to support their use. However, nonpsychiatrists are often able to give substantial help to the children they treat for common disorders, such as ADHD. Dr. Albert Hamilton Holt is a boardcertified child and adolescent psychiatrist and the medical director of the Primary Care Interface Program. The Program offers behavioral health consultation, triage, and brief treatment to patients within the primary care setting. He is also the medical director of the Southeast Child/Family Therapy Center, located in Visitacion Valley. He graduated from the University of North Carolina School of Medicine in 2000 and did his residency training at NYU before coming to work for DPH in 2005. Victoria Mycue, MFT, is a licensed bilingual (Spanish) marriage and family therapist who also works in the Primary Care Interface Program. She has worked for DPH since 2008. Prior to this, she spent many years serving families in both the public and private sectors. She received her master’s in psychology from the University of Notre Dame de Namur in Belmont, California.
Resources • San Francisco Access Line: (415) 255-3737 • Child Crisis: (415) 970-3800 • Support for Families of Children with Disabilities: (415) 282-7494, (415) 920-5040 • Parent Talk Line: (415) 441-KIDS or (415) 441-5437 • Child Protective Services: (415) 558-2650
14 San Francisco Medicine December 2010
Recognizing Addiction Continued from page 12 . . . for women) drinks at any one time, or more than fourteen (seven for women) drinks a week?” or “Have you been sad or blue, or have you experienced loss of interest, for greater than two weeks or more?” If yes, “Would you like some help?” Help for alcohol and drug abuse comes in many forms. Help can be a referral to an outpatient or residential substance-abuse treatment program or a referral to a selfhelp meeting such as Alcoholic’s Anonymous, or it can consist of simple advice in your office. For the latter, the NIH website http://rethinkingdrinking.niaaa.nih.gov is an excellent resource of online tips, selfhelp tools, and resources to help patients drink safely. In general, when a physician gives simple advice recommending that an at-risk drinker cut back, one in five patients will reduce their drinking to moderate levels within six months, and another two in five will have considered the feedback and may respond to further encouragement. For other drugs, such as methamphetamines or cocaine, novel programs like the STOP program at San Francisco General Hospital have demonstrated remarkable results; and methadone clinics remain the standard referral for heroin dependence. In short, in this day of modern, electronically connected medicine, there is no longer a reason to not ask and advise about alcohol or drug abuse. It’s the new state of the art in primary care. David Pating, MD, is chief of addiction medicine and Kaiser Medical Center, San Francisco, and assistant clinical professor in the Department of Psychiatry at UCSF. Currently, Pating serves as an appointed Commissioner of California’s Mental Health Services Oversight and Accountability Commission (Proposition 63), where he chairs the Services Committee.
Resource National Institute of Alcohol Abuse and Addiction. Health patients who drink too much: A clinician’s guide. Updated 2005 edition. http://pubs.niaaa.nih.gov/ publications/practitioner/cliniciansguide2005/clinicians_guide.htm. www.sfms.org
Psychiatry for the Nonpsychiatric Physician
Common Sleep Disorders A Guide to Recognizing Causes of Poor Sleep
Rachel Manber, PhD
mong individuals who experience difficulties initiating and maintaining sleep, the most common presentation is insomnia experienced in the context of a psychiatric disorder. Many patients with psychiatric disorders experience poor sleep and, in fact, disturbed sleep is a diagnostic symptom of some mood and anxiety disorders, such as depression, generalized anxiety disorders, and posttraumatic stress disorder. Poor sleep can predate a psychiatric disorder or emerge as one of its symptoms. In the case of depression, the most frequent pattern is for insomnia symptoms to emerge before major depressive disorder (41 percent); whereas in the case of anxiety disorders, the most frequent pattern is for insomnia to emerge at the same time as or after the anxiety disorder. Disturbed sleep can also at times emerge as a side effect of psychoactive medications used for treating the psychiatric disorder. For example, selective serotonin reuptake inhibitors, which are the first-line pharmaceutical approach for depression and anxiety, may cause restless leg syndrome and lead to sleep continuity disturbances. Poor sleep is often confused with the sleep disorder insomnia. The two are related in that difficulties falling or staying asleep are indeed symptoms of an insomnia disorder, but the diagnosis of the disorder requires that, in addition to these nocturnal symptoms, the individual also reports associated daytime impairment or distress. In many cases, insomnia begins with disturbed sleep caused by a normal reaction to stress. However, some people continue to experience sleep difwww.sfms.org
ficulties even after the stressful period is over. This often involves conditioned insomnia, which means that the bed has become a cue for wakefulness and arousal rather than sleep. Conditioning results from repeated pairing of the bed with the frustration and anxiety about not sleeping. When people react to the experience of poor sleep with alarm and increase their efforts to sleep, they tend to adapt habits that, though intended to promote sleep, end up interfering with it. For example, they may spend more time in bed than they used to when they slept well, hoping to get more sleep. However, continued extended time in bed increases the probability of conditioned insomnia and weakens the homeostatic drive for sleep, further contributing to insomnia. This may explain how sleep difficulties that emerge as a symptom of a psychiatric disorder or its treatment might with time develop into a co-occurring insomnia disorder. Historically it was assumed that sleep problems that are experienced along with a psychiatric illness are caused by the psychiatric disorder and will resolve when the disorder is adequately treated. Recent data suggest that the relationship between sleep disturbance and psychiatric disorders is more complex. These data demonstrate that disturbed sleep can be a risk factor for the development of psychiatric disorders and often doesnâ€™t fully resolve with effective psychiatric and psychological treatments of the psychiatric disorder. Therefore, when psychiatric patients present with clinically significant insomnia symptoms, which is often the case, the insomnia should be considered a comorbid disorder that merits focused
treatment, rather than being considered just a symptom that waxes and wanes with the psychiatric illness. This is particularly important for depressive illness, because untreated insomnia contributes to the global severity of depressive disorders. For example, depressed patients who cannot stay asleep have more suicidal ideation than depressed patients without sleep disturbance. Insomnia also adversely affects the course of standard antidepressant therapy; itâ€™s associated with slower and lower rates of remission from depression, less stable treatment response, and increased risk for relapse among remitted patients. Two common strategies are used in the clinical management of insomnia in depressed patients. One is to select an antidepressant that is sedating and/ or improves sleep continuity. Such antidepressants include those that block postsynaptic serotonin (5-HT) receptors and those that have pronounced antihistaminic effects (such as amitriptyline, trazodone, nefazodone, mirtazapine, doxepin, and trimipramine). This approach is limited, as very little is known about the relationship between the effect of a given antidepressant on sleep and its effect on depression. Another commonly used strategy is to coadminister a hypnotic or another sedating medication, such as antihistamines or trazodone, with an antidepressant medication. Sedative hypnotics appear to improve the sleep of depressed patients without hindering short-term antidepressant response. One clinical trial has directly evaluated the effects of combining an antidepressant and a hypnotic compared with a treatment Continued on the following page . . .
December 2010 San Francisco Medicine 15
Continued from previous page . . . that combined the antidepressant with a placebo hypnotic. This trial showed that after eight weeks of treatment, a fluoxetine-eszopiclone combination resulted in greater improvement in insomnia and depression than the fluoxetine-placebo combination. A sleep-focused therapy for insomnia offers an alternative approach to the treatment of insomnia experienced in the context of psychiatric disorders. Lasting less than ten sessions, insomnia-focused nonpharmacological therapy produces improvements in primary insomnia that are equivalent to hypnotic medications, with some evidence that it’s effective even for those with less-than-satisfactory responses to hypnotic medications. Insomnia-focused psychotherapy has fewer side effects and better long-term efficacy than hypnotic medications, such as temazepam, zolpidem, and zopiclone, after treatment is discontinued. Most important, sleep improvements achieved during sleep-focused psychotherapy last up to two years after the course of treatment is completed, whereas the effects of sedative-hypnotic medications are either shorter-lasting or untested. Because treated depressed patients who remain insomnia-free are likely to remain depression-free for longer periods of time than those in whom insomnia recurs, an insomnia treatment with better long-term outcome is also likely to lead to longer depression-free periods. Research has shown that, for patients with insomnia and depression, treatment that combines an antidepressant medication with an insomnia-focused psychotherapy leads to better sleep and better depression outcome than treatment with an antidepressant medication alone. A list of therapists certified by the American Board of Sleep Medicine to deliver sleep-focused psychotherapy is published on line at http://www.absm. org/BSMSpecialists.htm. Rachel Manber, PhD, is a professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, where she is the director of the Insomnia and Behavioral Sleep Medicine Program at
the Stanford Sleep Disorders Clinic. She is certified by the American Academy of Sleep Medicine in the practice of behavioral sleep medicine. She received a PhD in clinical psychology from the University of Arizona in 1993. Dr. Manber is the author of more than sixty peer-reviewed publications and is the coauthor of the book Quiet Your Mind and Get to Sleep.
Fava M, McCall WV, Krystal A, Wessel T, Rubens R, Caron J et al. Eszopiclone coadministered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biol Psychiatry. 2006; 59(11):1052-1060. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA. 1989; 262(11):14791484. Johnson EO, RothT, Breslau N. The association of insomnia with anxiety disorders and depression: Exploration of the direction of risk. J Psychiatr Res. 2006; 40(8):700-708. Krystal AD, Thakur M, Roth T. Sleep disturbance in psychiatric disorders: Effects on function and quality of life in mood disorders, alcoholism, and schizophrenia. Ann Clin Psychiatry. 2008; 20(1):39-46.
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Manber R, Rush AJ, Thase ME, Arnow B, Klein D, Trivedi MH et al. The effects of psychotherapy, nefazodone, and their combination on subjective sleep in chronic depression. Sleep. 2003; 5(2):130-136. Nierenberg AA, Keefe BR, Leslie VC, Alpert JE, Pava JA, Worthington JJ et al. Residual symptoms in depressed patients who respond acutely to fluoxetine. J of Clin Psychiatry. 1999; 60(4):221-225. Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res. 2003. 37(1):9-15. Perlis ML, Giles DE, Buysee DJ, Tu X, Kupfer DJ. Self-reported sleep disturbance as a prodormal symptom in recurrent depression. J of Affective Disorders. 1997; 42:209-212. Pigeon WR, Hegel M, Unutzer J, Fan MY, Sateia MJ, Lyness JM et al. Is insomnia a perpetuating factor for late-life depression in the IMPACT cohort? Sleep. 2008; 31(4):481-488. Riemann D, Berger M, Voderholzer U. Sleep and depression: Results from psychobiological studies: An overview. Biol Psychol. 2001; 57(1-3):67-103. Zayfert C, DeViva JC. Residual insomnia following cognitive behavioral therapy for PTSD. J Trauma Stress. 2004; 17(1):69-73.
Having trouble sleeping? Do you: Have a racing mind when you should be sleeping? Enjoy activities less than usual? Feel tired? Can’t concentrate? Feel sad, unhappy, empty, or helpless? If you have some of these symptoms, you may be eligible for a 16-week research study including free: • Diagnostic overnight sleep study • Psychotherapy for insomnia • Medication for depression Interested adults ages 18 to 75, please call (650) 723-2641. For further information regarding questions, concerns, or complaints about research, research-related injury, and questions about the rights of research participants, please call (650) 723-5244 or call, toll-free, (866) 680-2906 or write the Administrative Panel on Human Subjects in Medical Research, Administrative Panels Office, Stanford University, Stanford, CA 94305-5401. www.sfms.org
Psychiatry for the Nonpsychiatric Physician
Treating Obesity Don’t Ignore Stress!
Elissa Epel, PhD “We are what we eat—as well as what is eating us.” vereating can be seen as the clash between the food environment and our neurobiology. In this epidemic of obesity, it helps to understand that there are multiple etiologies and thus treatment needs to be customized as well. This article focuses on the invisible but pervasive role of emotional stress in overeating, why stress matters, and adjuvant treatment strategies for obesity. Stress shapes eating behavior for most people and is a primary cause of obesity for some.
How did we become an obese society?
The simple answer is “positive energy balance”—or eating more than we burn through each day, determined by lifestyle. But it’s not as simple as a balanced equation. There are other factors, such as genetics and emotional health, that enter this equation. For evolutionary reasons, we crave dense calories, those with high fat, and of course some of us more than others are blessed genetically with this thrifty genotype that makes us seek dense calories and store them so efficiently. The food environment poses a challenge to our energy balance homeostasis. Mere exposure to junk food creates a neurobiological dependence on it. For some, the dependence on dense calories feels like an addictive process. For a long time, people have described feeling that food controls them, and that they eat against their will, in the face of negative consequences. It is not surprising then, that recent rat studies now show that junk food exposure mimics brain changes involved www.sfms.org
in drug addiction. Obesity is increasingly recognized as a neurobiological rewardbased disorder, not a disorder of behavior or low will power. Besides the abundance of highly palatable food, and how our brain responds to it, there is an effect of our mental state, and specifically of our level of psychological stress on energy balance. As described below, stress shifts the equation toward higher intake of dense calories, and greater storage in the belly.
Why does stress matter for health?
We now know that stress is not just “in the head” but has major physiological consequences for every regulatory system. Chronic stress creates large changes in physiological regulation that slow wound healing, and it is linked to earlier mortality. We also know some of the molecular mechanisms of stress effects. For example, states of chronic stress affect gene expression, determining which proteins are made, and particularly egging on those regulating proinflammatory pathways. Stress can promote premature aging of dividing cells, at least of immune cells, as indexed by telomere shortening (the protective caps at the tips of our chromosomes). This stress-induced shortening is seen in states of high perceived stress, depression, and trauma exposure.
Why does stress matter for obesity specifically?
Stress causes stress eating. Some people eat less during severe stress, but most people, under moderate stress, find they eat more. High cortisol stimulates appetite and promotes eating, especially of highly palatable foods (those high in
fat, sugar, and/or salt, also called “comfort foods”). The second reason stress promotes overeating is that it activates the powerful reward circuitry in the brain, which causes strong drives for seeking rewarding activities that stimulate opioids. Opioids come from engaging in healthy activities, like exercise, but they also come from intake of palatable food (what we call a “natural reward” to the brain) and any substances of abuse (cigarettes, alcohol, or recreational drugs). Stress causes abdominal fat distribution. The regulation of stress overlaps with the regulation of energy storage, both the neural networks and the peripheral hormones, so the two are tightly coregulated. For example, very low energy stores, as found in people with anorexia or on caloric restriction, stimulate chronically high cortisol. In turn, states of chronic psychological stress cause high cortisol and high insulin, and together these promote fat storage in the visceral cavity, the “toxic belly fat.” Visceral fat cells are very sensitive to cortisol, being covered by glucocorticoid receptors. High cortisol and high insulin activate lipoprotein lipase, causing fat storage, particularly of visceral fat cells. So whether one eats less or more during stress, whether one is lean or obese, stress and cortisol shift fat stores toward the abdominal area. Anorexics and people with Cushing’s disease both have high cortisol and both have exaggerated levels of intraabdominal fat distribution. So putting this all together, there is a chain from mind to fat cell: When we are stressed, we choose comfort foods, those with dense calories. This releases a load of triglycerides and the hormonal combiContinued on the following page . . .
December 2010 San Francisco Medicine 17
Continued from previous page . . . nation—high insulin and cortisol—that creates a perfect formula for overstuffing the visceral fat cells. Visceral fat cells, in turn, tend to release more cortisol and proinflammatory cytokines into the blood. This type of fat is highly mobilized and stored and is thus always circulating from our blood back to the fat cell. We’ve got a catastrophic clash between our primitive brain and our modern food environment. For our ancestors, this abdominal fat storage served a survival purpose. During stress we stored calories in the “stress fat” layer (abdominal fat), and these calories were easily mobilized for the fight/flight response—running from predators, for example. In modern times, we live with chronic stress arousal in our brain and blood, excess belly fat, and thus excess lipids, glucose, and inflammatory factors in our blood. Stress eating may help with mood, but only for a short while. Stress eating may in the short term make us feel better, dosing us up with opioids and feelings of pleasure, thus damping down our physiological discomfort (reducing further cortisol reactivity). It can numb psychological distress with distraction. Binge eating (eating a very large amount in a short period) can even create a short-term state of dissociation, allowing one to escape negative thoughts about oneself. Some people may suffer from feeling physically sick after an episode of overeating, or from feelings of guilt, remorse, shame, and self-loathing. Food can be viewed as the enemy, but it can also seem like a reliable friend when you need it, creating immediate relief from various painful experiences embedded in daily life. Why is eating, such a natural, pleasurable activity, causing so much pain and disease? Simple exposure to junk food causes us to become somewhat dependent on it. We want more when we are in withdrawal from it. This is in part due to dopamine signaling (D2 receptors). People with obesity have fewer D2 receptors, making them prone to a hypoactive reward system. Thus they need to eat more to get the same sense of pleasure from food. Most people are exposed to high lev-
els of modern stressors and experience excessive levels of perceived stress. The stressed brain needs even more reward activity. Strong subcortical messages drive our behavior: “Go get the donut.” This would be fine if the “brake” on eating were working well. However, our ability to inhibit eating, or any other activity for that matter, is impaired during stress. So we are more likely to seek comfort foods and overeat them when stressed. If our stressed body is thought of as a car, then the gas pedal is on, and our brake is weak. And we are wearing out the car early in life.
We are planting the roots for the future of obesity.
We are creating an obese next generation. Obesity starts in the womb. Obese pregnant women have offspring who are hardwired to become obese earlier in life. We can’t change our genotype, but we can change what proteins we are creating. Gene expression is very sensitive to our mental health and environment. A mother’s stress level, or obesity, can change how genes are expressed. Epigenetic changes are passed on and shaping the next generation in ways that we have only begun to identify.
What can we do?
We need a multipronged approach to the obesity epidemic. The only long-term solutions will be new food policy and economic change. It will require changes in schools, early in life, and it will require extra support for women of childbearing age, the gatekeepers of society’s future health. In the meantime, there are many ways to help individuals. For the individual patient: Identify the role that stress plays in eating. Help your patients recognize that it’s not just energy balance but our internal hormonal milieu that affects our weight. Our perception of stress and our balance of hormones determine the foods we select and where we store fat. High stress and cortisol turn on strong drives for high-fat food. There are stress-reduction programs that help us manage stress better so it
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doesn’t get under the skin, and into our fat cells.
Some helpful discussion points for your patients: • How stressed have you been over the last month? • Are there things going on in your life that have been hard to deal with? • We all eat when we aren’t really hungry. What are triggers to your own eating? You might try making a small list to keep in your wallet or iPhone. • Can you think of ways to avoid or better manage those triggers?
Try a new approach to stress. Stress is part of living, and we can’t usually get rid of all stressful situations. We can, however, change how we respond to them. Trying to get rid of negative feelings usually backfires. Noticing, labeling, and accepting our feelings are powerful ways to ride the waves of experience without triggering the stress response. Mindfulness training focuses on becoming aware of our bodily and emotional experiences, and accepting them with a kind attitude, rather than feeling bad about . . . feeling bad. Try this five-minute “stress buster” exercise, at least once a day. This uses mindfulness and relaxation strategies—present attention, a kind attitude, and imagery. It can activate the control center (in the prefrontal cortex) by increasing awareness of the bodily state and labeling emotions. We can’t become “stress free,” but we can always manage situations better. It helps to start with deep breathing, to give our body a break from stress, to give our brain control over our body, so we can think more clearly and cope better. • Check in. Bring yourself into the present moment. If possible, close your eyes. Notice your breathing and how your body feels. Ask, “What is my experience right now . . . my thoughts . . . my feelings . . . my bodily sensations?” Notice any thoughts that contribute to stress. “What emotions do I feel? How intense are they?” If you’d like, give them a number on a scale of 1 to 10. Allow yourself to acknowledge your feelings www.sfms.org
with kindness, whatever you experience.
• Breathe. Redirect your full attention to your breathing, to each inhale and each exhale, as they follow one after the other. Breathe more slowly and fully when you exhale than inhale.
• Relax. Take several deep, relaxing breaths, letting the air flow all the way into your lower belly, then back out again. Notice any areas of tension or discomfort, and gently release the tension if you can. Notice your breath as it flows naturally like the waves of the ocean, in and out, slowly and fully. With each exhale, you may feel a deeper sense of peacefulness. You might picture ocean waves on a beach, or a sunset, or the word “calm.” How does your body feel now? Do you feel any different than when you started? How would you rate your emotions now? • Try mindful eating. Have you eaten a bowl of popcorn without noticing it? We tend to eat almost unconsciously, and out of habit. We need to both limit exposures to highly palatable food but also enjoy them more fully when we have them. This doesn’t mean we should cut out any food type completely. Making a food group forbidden doesn’t usually work; rather, it usually means that will be the food we binge on. We need our comfort food, but in small quantities. By becoming fully aware and mindful when we are eating, we can better plan and control our food intake. Mindful eating strategies can change our relationship with food to be one that is more healthy and enjoyable. It can allow us to experience the full pleasure of food, taste satiety, and fullness, three factors that we usually ignore. After checking in and focusing on breathing, one can assess level of hunger and distinguish between other emotions that masquerade as hunger. One can plan how much to eat and focus on the experience of smell, taste, pleasure, and increasing fullness while one eats. These strategies are taught by various professionals, as listed on the Center for Mind-
ful Eating website (www.tcme.org). I’ve learned them from Dr. Jean Kristeller, who developed Mindful Based Eating Awareness, or MB-EAT. At UCSF, we integrate MBEAT with stress reduction. Our programs, which are only for research participants at this time, include those listed below. • Try “mindless” eating strategies, too. Add a few strategies that don’t rely solely on mental effort every time you eat. 1) Buy a smaller plate size (this alone can reduce one pound per month). 2) Buy a plate that shows suggested portion sizes for types of food (see “portion plates” at Amazon.com). 3) Try to reduce the amount and variety of highly palatable food you are exposed to at work and home, by planning ahead when you shop or by asking others around you to help you with your new year’s health goals. We all need to change the culture of our workplaces together!
To continue to learn more about both the science of stress eating and the role of stress in weight loss, we are conducting several studies at UCSF, as part of the COAST obesity center (http://chc.ucsf. edu/coast/). We would greatly appreciate your referrals. The MAMAS Study for weight management during pregnancy: Please refer any potential participants who are at twenty weeks or less of gestation, who are overweight, and who do not have diabetes. For more information and to see if a patient qualifies, call the MAMAS Study (Maternal Adiposity and Metabolism Study). Women are compensated $25 per session attended. Call (415) 600-5772 (NINA) or e-mail firstname.lastname@example.org. The SHE Study: This is not a treatment study, but rather a contribution to the basic science to help us understand the relationships between eating, mood, hormones, and opioids. We are looking for overweight premenopausal women. Compensation is $375 to $675. Call the SHE Study (Stress, Hormones, and Eating) at (415) 476-6028. Elissa Epel, PhD, is an associate professor in residence in the Department of
Psychiatry at UCSF. Dr. Epel received her training in psychology from Stanford and Yale University. She is a faculty member of the Health Psychology program, the UCSF Osher Center for Integrative Medicine, and the Robert Wood Johnson Health and Society Scholars fellowship program; the assistant director of the Center for Health and Community; and director of research for the UCSF Center on Obesity (COAST, www. chc.ucsf.edu/coast).
References for Further Reading and for Referrals For scientific information on stress; fun and easy to read: Sapolsky R. Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, StressRelated Diseases, and Coping. 2004; New York: Henry Holt & Co., third edition. Singer T. Stress Less: The New Science That Shows Women How to Rejuvenate the Body and the Mind. 2010; Hudson Street Press.
For self-help and “how to”: www.mindfulnesstapes.com/author. html. (This website sells tapes and has other information to get you started.) Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. 1990; New York: Dell/Bantam Publishing Co. Winner J. Stress Management Made Simple: Effective Ways to Beat Stress for Better Health. 2009. Blonna R. Stress Less, Live More: How Acceptance and Commitment Therapy Can Help You Live a Busy Yet Balanced Life. 2010. For overeating: Adam T. Epel E. Stress, eating, and the reward system. Physiology and Behavior. 2007. Center for Mindful Eating website, www.tcme.org. Wansinck B. Mindless Eating: Why We Eat More Than We Think. 2006; Bantam. (This is a fun read. More informational than “how to,” but understanding why we overeat can help.)
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Psychiatry for the Nonpsychiatric Physician
Recognizing Bipolar Disorder A Description of the Primary Symptoms
William Prey, MD
he diagnosis of bipolar disorders continues to be highly challenging to many primary care clinicians. Time constraints frequently prevent extensive information gathering, and the very concept of mood swings often seems vague, remote, and a bit overwhelming. The suggestions mentioned in the following article are meant to bring focus to several important points. Bipolar conditions are fundamentally mood oscillations that vary greatly in scope and severity. There are multiple aspects of the patient history and clinical findings that can add to a growing suspicion that a bipolar condition is present. Avoiding misapplication of medications may prevent more severe presentations of the disorder. Since a large part of bipolar treatment involves improving sleep, nutrition, and other circadian matters, the primary care setting could be the ideal place for continuity of care. The Diagnostic and Statistical Manual IV – TR differentiates between Bipolar I (periods of mania with or without depression) and Bipolar II (periods of hypomania with or without depression). Bipolar I is found in 1 to 2 percent of the population, but the frequency of Bipolar II and other bipolar spectrum conditions is thought to be much higher. Variations of frequency (normal cycling, rapid cycling, ultra-rapid cycling), symptom states (mania and depression versus mixed states), and severity (full-blown Bipolar I versus cyclothymia) further complicates the diagnosis. The growing realization is that there is a wide variance of presentations within and across individuals. Diagnosing the bipolar conditions correctly can help prevent misapplica-
tion of medications, provide appropriate support, and possibly prevent many of the comorbid illnesses seen in conjunction with this condition. The use of standard antidepressants is not indicated for any of the bipolar conditions, and there is a possibility of triggering a mania in all the antidepressants. Corticosteroids are also known to push patients into their first episode of mania. There is a higher risk of type II diabetes, panic attacks, substance abuse, and injuries from accidents in this population as well. Screening questionnaires are available and include the Mood Disorder Questionnaire, the PRIME-MD Patient Health Questionnaire, the Medical Outcomes Study 12-Item Short Form health survey, and the Sheehan Disability Scale. With the advent of electronic medical records, excess paper causing chartomegly is no longer an issue, making screening devices more practical. Patients often forget how badly they felt once they are no longer in an abnormal mood state. This leads to either underreporting of previous moods swings or no reporting at all. The result is that the diagnosis is either missed or mischaracterized, such as being labeled unipolar depression, personality disorder, or an adjustment disorder. Since the mood often changes spontaneously, false attribution to contextual events and treatments is common. If there is any suspicion of a bipolar issue, it is wise to include a significant other in the interview process. The following factors gain diagnostic meaning the more they cluster together. This list is neither exhaustive nor absolute. Positive family history. The history
20 San Francisco Medicine 21 San Francisco Medicine December December 2010 2010
may include recurrent mood disorders, panic attacks, antisocial behavior, and comorbid substance abuse. The risk is more than additive. If both parents have bipolar disorder, that likelihood of the patient being bipolar is actually greater than just adding together the respective individual heredities. Age of onset. The younger the onset, the higher the suspicion. Conversely, subcortical infarcts in geriatric patients can cause a secondary bipolar syndrome. Cutting behavior. This is common in teenagers as way of reducing overwhelming feelings. It is not the same as suicidal behavior and is often very addictive. Postpartum depression. Depressions that have “atypical features.” Depressions that are high in hypersomnia, carbohydrate cravings, irritability, and rejection sensitivity are more typical for bipolar disorder. There can be wide fluctuations in depressive symptoms from day to day. Patients may not appear depressed but often reveal marked suicidal ideation and lack of joy when asked. Self-described as sensitive to medications. These individuals often have idiosyncratic reactions to antihistamines, caffeine, and other OTC medications. Being “night owls.” Circadian delay is a frequent aspect of all the bipolar conditions. Any major mood oscillations that have a periodicity (with or without mania). Comorbid drug use. Frequent job and relationship changes. Impulsivity is often the underlying theme. History of anger management problems. www.sfms.org www.sfms.org
Periods of motor agitation that the patient may misidentify as anxiety. High lethality of past suicide attempts. The CDC reports that bipolar and unipolar suicide rates are similar but the lethality of the means of suicide (and thus more completed suicides) is higher in the bipolar group. The diagnosis of a bipolar patient often evolves over a period of time spent with the patient. It still takes an average of ten years for most patients’ Bipolar I diagnosis to be established. Keeping the above list in mind will, one hopes, shorten that process. It is also important not to jump to premature conclusions around the bipolar diagnosis. The mention of “bipolar” in a medical chart can markedly reduce a patient’s insurability. This does not prevent the clinician from treating the patient as if they may have a bipolar condition. The current diagnostic system does not acknowledge the wide variance seen in bipolar conditions, so many psychiatrists resort to the label “Mood Disorder NOS (not otherwise specified).” Use of more empirically precise descriptors is better. An example would be “an oscillating depressive disorder with periods of irritability and hyperactivity.” This would at least impart some information that another clinician could use. Bipolar conditions may be an example of excessive or mistimed neuroplasticity. High variance, impulsivity, increased imagination, and the risk of the chaotic manias speaks to a nervous system that is periodically underconstrained. Use of atypical antipsychotics, lithium, and antiepileptics all provide some useful constraint but are often fraught with side effects. Antidepressants may actually reduce neurodynamic constraints; they all lower the threshold for seizures. Their use in bipolar conditions is controversial; they should be used sparingly, with a mood stabilizer, and for only short periods of time. Improving circadian rhythms provides a natural way to reconstrain the nervous system. Regulating bedtime, morning awakening, meal times, and exercise have an enormous benefit in patients with bipolar conditions. Using
this approach also reduces the patient’s risk of health issues such as metabolic syndrome and type II diabetes. To understand the bipolar condition is to see a dynamic interplay of nature and nurture, quick to change but often rapidly responsive to healthier paths. Who could ask for anything more? William Prey, MD, completed his psychiatric training at the Neuropsychiatric Institute at UCLA. After a year-long Psychosomatic Fellowship at St. Mary’s Hospital, he was psychiatric director of the Marshall Hale Eating Disorders Program as well as acting director of the St. Mary’s Sleep Disorders Center. During the 1990s he was medical director of the Adult Psychiatry Inpatient Unit at Ross Hospital in Marin County. Currently he is in private practice in general psychiatry and sleep disorders. He has offices in both San Francisco and Mill Valley. He is also an adjunct faculty member at Argosy University and teaches psychology graduate students on the biologic basis of psychology as well as psychopharmacology.
SFMS Annual Dinner January 27th This year’s annual dinner will take place on January 27, 2011, at the Concordia Argonaut Club in San Francisco. SFMS members: Watch your mailbox for an invitation in December. For more information, or to RSVP, contact Posi Lyon, (415) 561-0850 extension 260, or email@example.com.
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Nurse Practitioners ~ Physician Assistants
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Psychiatry for the Nonpsychiatric Physician
Psychiatry in the Oncology Setting A Practical Guide
Alan Maloney, MD
sychiatry has gone through important conceptual developments in the last ten years, which bear on how physicians might consider psychiatric morbidity in the oncology setting. One illustrative example is a more sophisticated understanding of the interaction between inheritance and development. Contemporary psychiatry has happily moved beyond the invidious dichotomy of nature versus nurture. With this more integrated framework, additional emphasis has been placed on considering psychiatric morbidity in context. This basic insight is every bit as informative of therapeutic approaches to psychiatric symptoms in the oncology setting. A more sophisticated view on the interaction of genes and environment illustrates how context-dependent current psychiatric thought has become. The serotonin transporter gene comes in a wild type and a rarer short allele. Various experimental results suggested that possession of the short allele was or was not associated with psychiatric morbidity. Only when developmental considerations were factored in did a more coherent pattern emerge: The short allele seems to increase an individual’s vulnerability to psychiatric morbidity as an adult only if the individual had less supportive emotional environment during development; but the shorter allele conferred greater psychiatric resilience if the individual had a more supportive than average emotional environment during development. Neither the allele nor the environment solely determines psychiatric diathesis. The short allele of the serotonin transporter gene seems to increase sensitivity to the emotional tone of the environment. Individuals with the
longer, wild type of alleles are less affected by developmental contingencies and are of a typical level of psychiatric resilience. This holistic perspective underscores the value of assessing psychiatric vulnerability in context. By extension, it encourages the commonsense insight that psychiatric vulnerability should be considered in the context of an individual’s life and, by further extension, in regard to their own subjectivity. This more comprehensive framework is often constrained by the rapid pace of medical practice. Interindividual variability is salient in psychiatric evaluation. So while an oncologic diagnosis may seem, at face value, to be a profound existential challenge, it isn’t always. The practical question I want to address here is to identify the sentinel considerations that a medical practitioner might use to identify patients who need psychiatric treatment or referral. The National Cancer Institute estimates that 50 percent of cancer patients suffer with comorbid psychiatric diagnoses. Patients who have multiple risk factors are at highest risk: a history of depression or anxiety, weak social support system (not married, few friends, a solitary work environment), evidence of persistent irrational beliefs or negativistic thinking about their diagnosis, a more serious prognosis, and greater dysfunction related to cancer. Moreover, morbidity may extend beyond the patient and affect the larger family system. For example, in one survey of women with breast cancer, depression was the strongest predictor of emotional and behavioral problems in their children. The most common psychiatric diagnoses in the oncology setting are adjustment disorders, followed by depression
23 San Francisco Medicine December December 2010 2010 22 San Francisco Medicine
(both major depressive disorder and dysthymia) and anxiety disorders. It’s estimated that 30 to 35 percent of oncology patients meet the diagnostic criteria for an adjustment disorder during the course of oncologic diagnosis and treatment. Adjustment disorders typically present as a constellation of mood or anxiety symptoms that begin within three months of the onset of an identifiable stressor (diagnosis, treatment, change in function, or change in prognosis) but that are not severe or pervasive enough to meet criteria for an anxiety or depressive disorder. The sentinel feature indicating a need for treatment is symptoms disrupting a patient’s usual functioning. Treatment of adjustment disorders includes both individual and group psychotherapy. If the patient does not benefit from psychotherapy, adding an appropriate psychotropic medication for a discrete period of time may be appropriate: for example, a two- to three-week course of a benzodiazepine for acute anxiety or a twelve-month course of a serotonergic antidepressant, such as sertraline (25 to 100mg qd). Recall that the term “antidepressant” is a marketing term; selective serotonin reuptake inhibitors, SSRIs, are approved for anxiety, depression, and obsessive compulsive disorder (typically in increasing doses). Trazodone (25 to 100mg qhs) is an effective and non-habitforming hypnotic. While sadness and grief are normal reactions to the crises faced during cancer, and are simply part of life, clinical depression is a distinct diagnosis and is associated with significant morbidity and mortality. Because the term “depression” is a mixed concept, describing both mood (feeling www.sfms.org www.sfms.org
sad, down, or blue) as well as a clinical diagnosis (five or more of: depressed mood, decreased pleasure, unexplained weight loss, sleep disturbance, psychomotor disturbances, fatigue, feelings of worthlessness, and cognitive difficulty), both patient and physician can be easily confused. Clinical depression (major depressive disorder) is a comorbid in approximately 15 to 25 percent of cancer patients. The sentinel feature indicating a need for treatment is the persistence of symptoms for two or more consecutive weeks. Treatment of clinical depression requires psychiatric evaluation for psychotherapy and/or pharmacotherapy with medication such as sertraline (50 to 200mg qd). More severe depression often requires combined therapy, which is best delivered by a single treating psychiatrist. Combined therapy has repeatedly been demonstrated to be superior to monotherapy for moderate to severe depression. For psychotic depression, the addition of an antipsychotic (such as perphenazine 2 to 4mg qhs or bid) to the antidepressant is indicated. Drug-induced mood disorders also occur in the oncologic setting. These often appear as dysthymia (a “milder” atypical variant of clinical depression). Alpha-interferon appears to pose the highest risk of a drug-induced depression. Other common “depressogenic” agents include corticosteroids, interleukin-2, gonadotropin-releasing hormone agonists (leuprolide, goserelin, and histrelin, among others), finasteride, progestin-releasing implanted contraceptives, varenicline, and propranolol, which all may pose a moderately high risk of drug-induced depression. Corticosteroids are associated with so-called “steroid psychosis,” a syndrome that produces irritability; mood disturbances, depressed or manic; or even frank psychosis. The risk of steroid psychosis increases discontinuously above a dose of prednisone 40mg/day or equivalent (~ hydrocortisone 160mg/cortisone 100mg/triamcinolone 32mg/dexamethasone 6.2mg). This can be treated with a dose reduction of the steroid, or if required antipsychotics during higher steroid dose levels (such as perphenazine 2 to 4mg www.sfms.org
bid prn). Antipsychotics carry a dosedependant risk of tardive dyskinesia and, among elderly or demented patients, sudden death (atypical>typical). Alternatively, patients can be treated with lithium carbonate to a blood level of 0.8 to 1.2 mEq/l for a thirty-one-day course. Like depression, anxiety is a mixed term referring to both subjective states and psychiatric diseases. Anxiety disorders are comorbid in approximately 15 to 20 percent of cancer patients. Patients who have problems communicating with their families, friends, and physicians are at greater risk of developing anxiety. Anxiety can take many forms that may be confusing to the nonpsychiatric physician. Patients may present as simply preoccupied or, in severe cases, may appear profoundly compromised. The vernacular “nervous breakdown” is usually severe anxiety that overwhelms an individual’s ability to cope, producing a disorienting experience of raw, primitive emotions that feel “crazy.” Although the individual’s reality testing remains intact, the severity of affective regression can appear psychotic. The sentinel feature that indicates a need for psychiatric evaluation is whether the anxiety is acutely disruptive or whether anxiety symptoms persist for two months. Treatment of anxiety disorders requires psychiatric evaluation for psychotherapy and or pharmacotherapy such as sertraline (25 to 100mg qd). In instances where the anxiety is acute, benzodiazepines may be used for a two- to threeweek course. In general, longer-acting agents are preferred to reduce rebound anxiety. The route of drug metabolism is also an important consideration. When anxiety or agitation is severe, a one- to two-week course of an antipsychotic may be indicated (such as perphenazine 1 to 4mg qhs to bid prn). As with depression, a number of medical considerations may bear on the appearance of anxiety. Certain medications are associated with anxiety, including: corticosteroids, neuroleptics used as antiemetics, thyroxine, bronchodilators, betaadrenergic stimulants, antihistamines, and benzodiazepines (paradoxical reactions are most common in older patients). Anxi-
ety can also be seen with hormone-secreting tumors such as pheochromocytoma, thyroid adenoma or carcinoma, parathyroid adenoma, corticotropin-producing tumors, and insulinoma. In patients with advanced disease, anxiety may be caused by the issues of uncontrolled pain, isolation, abandonment, and dependency. The final practical point to consider in the oncology setting is informed by the discipline social psychology: Roles are consequential. This is relevant to patients’ experience of physicians as professionals with specialized knowledge, powerful advocates, and guides through new dimensions of life. The end of life can be a time of great personal growth for patients. It can also be frightening and evocative of longstanding psychological dysfunction in patients or around them in their families, interfering with well-considered decisions. The topic of death, as well as hospice resources and palliation, should be broached with patients at a time deemed appropriate by their treating physicians. In one study of people with advanced cancer, those patients who reported having endof-life discussions with their physicians subsequently reported a better quality of life. The last loving act we can extend to our patients is a good death. The U.S. Supreme Court decision Vacco v. Quill (1997) prohibits physician-assisted suicide while at the same time recognizing as permissible medical conduct that may foreseeably hasten death (such as terminal sedation) but which is intended for other important purposes (such as the relief of pain or other symptoms). Pain management improves quality of life throughout all stages of cancer care. Patients who ask for physician-assisted suicide can be treated by increasing the patient’s comfort and relieving symptoms. Patients with the desire to die should be evaluated for depression and adequate palliation. Alan Maloney, MD, is a board-certified psychiatrist, analyst member of the C.G. Jung Institute of San Francisco, and an associate professor of psychiatry on the Adjunct Clinical Faculty, Stanford University School of Medicine. He is in private practice with offices in San Francisco and Palo Alto.
December 2010 San Francisco Medicine 23
Psychiatry for the Nonpsychiatric Physician
Helping Grief Along A Road Map for Mourning
Mardi J. Horowitz, MD
s physicians, we are like the “man of sorrows and acquainted with grief” (Isaiah 53:3). As we cope with inevitable losses, we contain our feelings and offer help to our patients and their relatives. Some facts and some resources may be useful. Mourning is the social matrix of helping bereaved persons cope with loss by providing a road map. Rituals of passage, funerals, spiritual tradition, and psychological instructions provide initial support. Then, a long task of grieving becomes more personal. Grief is the mental work a person does to accept finality and give the loss meaning. Those acquainted with grief know they can recover and gradually come to feel less shattered. Those impacted by a first loss have to learn how to grieve. Research in grief has suggested that young widows and widowers are more likely to have symptomatic responses to bereavement than older widows and widowers. Children and adolescents may need even more help. The younger the person, the more identity itself may be impacted and more support may be necessary. Children and adolescents do not grieve in the same phases as their parents. Two parents of the same child can grieve at different rates. A model of phases of grief can be generalized, but in a family, at a given week after a loss, members may be at different stages. One family member may feel numb while another family member is expressing intense emotions and having unbidden images. These general stages are illustrated in the figure “Phases of Grief.” Normal versions of stages of grieving are on the left side, and maladaptive intensifications or prolongations are
shown on the right side. Colleagues and I have worked to enhance psychiatric diagnoses in the arena called bereavement-induced depressions, pathological grief, complicated grief, or prolonged grief. The important theme is to not pathologize sorrow but to recognize when grieving has frozen a river of feelings short of its completion of processing. In the figure, normal completion, which may take years, comes with growth in self-coherence and harmonization within a sense of identity. Because grief work revises cognitive and emotional maps that involve the bereaved person’s own identity, episodic pangs of feeling may erupt at any time. Patience, stamina, courage, and acceptance of a dose-by-dose approach to grief are the relevant virtues. In order to provide information about bereavement processes, I have written a self-help book entitled Grieving as Well as Possible. It is my hope that this book will help mourners, caregivers, and friends understand the grief process. It will also help parents support their children by understanding differences in how people of various ages process emotional information. For adults, I have found it useful to emphasize that reactions to a severe loss (like the death of a child or spouse) often take more than a year to process. I sometimes tell a bereaved person, “your unconscious will be the last to
24 San Francisco Medicine December 2010
know.” That helps them realize that, while they consciously know of the actuality of the death, their deeper mind has not grasped its finality. For that reality to be fully accepted, the person has to reschematize who they are and the fact that the world no longer matches how they understood it, and were attached to it, before the loss occurred. They have to keep their relationship with their deceased loved one going on in their mind while changing from a current attachment to a cherished memory. See biography for Dr. Horowitz with his article on psychoanalysis on page 33.
www.compassionatefriends.org www.griefnet.org Horowitz M. Grieving as Well as Possible. Sausalito: Greyhawk, 2010. Horowitz M. A Course in Happiness. Penguin, 2008. Horowitz M. Stress Response Syndromes, fourth edition. Aronson, 2002. www.sfms.org
Psychiatry for the Nonpsychiatric Physician
Mindfulness-Based Cognitive Therapy Curbing the Tendency to Engage in Negative Thought Patterns
Tracy Peng, MD
ou never came out and said, ‘You’re too critical,’ but I got the sense that softening my perspective might be a good thing,” said Sonia, my dear psychotherapy and psychopharmacology patient, during a recent visit. She sat in the cushioned green armchair in my office looking vulnerable and close to tears, finally open enough to deeply feel the pain of a judgmental worldview. An unseen virtual pandemic in American society is mental negativity—so many of us habitually berate ourselves and others, and fail to appreciate our strengths of character. In our perfectionism we often lose the larger and affectionate perspective that not only holds all of our human foibles, but holds them dear. Is it then so surprising that depression and anxiety are rampant within Western culture? There are many treatments available for depression and anxiety; and an emerging modality that addresses this habitually harsh viewpoint, among other symptoms, is Mindfulness-Based Cognitive Therapy for Depression (MBCT), an eight-week course held in the group setting, targeting patients who have had multiple (three or more) episodes of depression. MBCT has shown usefulness in preventing depressive relapses and in addressing residual depressive symptoms, and it may even allow patients to decrease the amount of antidepressant medication they require. Mindfulness has also begun to show promise in treating anxiety. Mindfulness, defined by Jon KabatZinn, PhD (the “father” of mindfulnessbased interventions in health care) as “paying attention, in the present moment, on purpose, without judgment,” has www.sfms.org
yielded positive effects in a wide range of physical and mental disorders, from hypertension and psoriasis to chronic pain and depression. Mindfulness interventions in health care formally began with his eight-week program in MindfulnessBased Stress Reduction (MBSR), held at the University of Massachusetts Medical Center. It quickly spread to hospitals and clinics across the country and internationally, including UCSF’s Osher Center for Integrative Medicine and California Pacific Medical Center’s Institute for Health and Healing. MBCT for depression was subsequently developed by three psychologists, Zindel Segal, PhD; Mark Williams, PhD; and John Teasdale, PhD; in consultation with Dr. Kabat-Zinn, in an effort to combine elements of Cognitive Behavioral Therapy (CBT) with mindfulness in service of treating depression. What has emerged is a powerful modality that can dissolve the underlying negative “lens” through which depressed persons see the world, leaving only a wider, kinder, and more open awareness. The course uses a variety of experiential mindfulness exercises, including the body scan, yoga, and sitting meditation, to give patients a taste of a way of being that’s simple, alive, loving, and beyond worldviews. It also educates patients about the signs and symptoms of depression and uses CBT strategies to both recognize maladaptive depressive thoughts and encourage behaviors that minimize likelihood of relapse or recurrence of depression. Patients are asked to commit to forty-five minutes per day of various mindfulness practices during the eight-week course. After completing the MBCT program
at UCSF’s Langley Porter Psychiatric Institute, my patient Sonia commented, “I realized that there was no need to do anything with my negative thoughts, that there was no need to latch onto them and go into a downward spiral.” During the course of the eight-week program, I watched with satisfaction as she had gained access to a wiser, more objective, kinder point of view and began to open to the surprising idea that her chronic negative thoughts may actually be mere mental events rather than statements of truth. Many patients learn to befriend their depression without becoming overly identified with it, to recognize “red flags” that signal impending relapse of depression (the so-called “relapse signature” that is unique to each patient but commonly includes symptoms such as sleep changes, increased negative thoughts, social withdrawal, and/or lack of motivation), and begin developing a self-care plan for how to respond when these “red flags” occur. Often during the course of MBCT, patients wake up to the idea that thoughts are not necessarily facts. One common example would be seeing the thought “I’m a failure” as the first symptom of an impending depressive episode rather than believing it to be true, resulting in self-caring actions (such as pushing oneself to engage in activities that one does not feel like doing but that one knows will be beneficial to mood), scheduling extra therapy appointments, inquiring about supplements or increasing antidepressant dose, and regulating the sleep schedule. Although not specifically designed for patients with anxiety disorders, MBCT Continued on the following page . . .
December 2010 San Francisco Medicine 25
Continued from previous page . . . and MBSR have also begun to show early signs of benefit for patients with panic disorder, generalized anxiety disorder, and subsyndromal anxiety symptoms. My own clinical experience has been that motivated patients who have had previous experience with MBCT or MBSR can use the learned mindfulness exercises such as mindfulness of the breath and yoga to calm anxieties and reduce the use of as-needed benzodiazepines. Apart from MBCT, other mindfulness-based mental health modalities include Dialectical Behavioral Therapy (DBT), a system developed for aiding those with borderline personality disorder, and Acceptance and Commitment Therapy (ACT), a mindfulness-based psychotherapy. That said, mindfulness is not a cognitive skill; it is a way of being that requires continued practice and commitment to kind attention and loving awareness in the face of deeply-ingrained habits of criticism and resistance to the flow of life. Although simple and accessible, mindfulness cannot be effectively taught by individuals who don’t regularly practice
mindfulness in their daily lives. In my experience, the most powerful mindfulness teachers are those individuals who have developed a deep and sustained daily personal mindfulness practice most often reinforced by years of regular silent meditation retreats. Like any other effective therapeutic modality, mindfulness-based approaches include maintaining healthy boundaries as an essential foundation of treatment. I have seen in my own outpatient psychiatry practice that mindfulness can be extremely useful in working individually with patients, and many are seeking ongoing mental health treatment with practitioners who can continue to support the awareness and skills that have been learned during a previously-completed MBCT or MBSR program. A taste of one’s own long-forgotten wholeness is a powerful thing, and, once it’s remembered, people tend to naturally want to reconnect with that experience. Mindfulness-based approaches are among many doorways that have the strong potential to encourage that remembering among patients with anxiety and depression. May we
all come to cherish ourselves and others deeply enough to surrender our blaming habits of mind into the vast simplicity of kindness and love. Tracy Peng, MD, is assistant clinical professor of psychiatry at the UCSF Osher Center for Integrative Medicine and at UCSF Langley Porter Psychiatric Institute Consultation-Liaison Service, and she is also in private practice in San Francisco. A longtime meditation and yoga practitioner with Self-Realization Fellowship, she was first exposed to mindfulness while completing the Metta Institute End-of-Life Practitioner Program and volunteering at Zen Hospice Project. She has since co-led Mindfulness-Based Cognitive Therapy (MBCT) for Depression at UCSF Langley Porter Psychiatric Institute with Stuart Eisendrath, MD. She is a graduate of California Pacific Medical Center’s Psychiatry Residency Training Program. She has deep respect for the unity at the core of all true religions, the innate healing capacities of human beings, and the practical applications in treating patients with anxiety and depression.
2010-11 SFMS Directory and Desk Reference Available Now! This important and trusted health care resource contains a comprehensive listing of SFMS members with their specialties and contact information. It is also packed with helpful resources that no medical office should be without! SFMS members receive one copy free as a membership benefit; additional copies are now only $25 each. Nonmembers now pay only $50 per copy. Want to order a copy of inquire about advertising in next year’s Directory? Contact Jonathan Kyle at (415) 561-0850 extension 240 or email@example.com.
26 San Francisco Medicine December 2010
Psychiatry for the Nonpsychiatric Physician
Psychiatric Consultation When Is It Time to Refer?
J. Jewel Shim, MD
sychiatric illness is common in the medical setting, with estimates of up to one-third of patients in primary care offices with a diagnosable (1) psychiatric disorder. The most prevalent illnesses are depression, 10 to 15 (2) percent , with rates up to 20 percent in patients with comorbid medical problems; and anxiety (generalized anxiety disorder), (3) 5 to 7.6 percent. Patients with so-called medically unexplained symptoms— symptoms that cannot be fully explained by diagnostic workup or patients’ whose subjective symptoms exceed what would be expected given the findings—often have comorbid mental health problems. These patients are also common in outpatient settings, with at least one-third of patients (4) having one or more of such symptoms Further, these disorders are associated with increased medical comorbidity, poorer medical outcomes, and subsequent (5) and related higher medical costs. Higher rates of mental disorders are also found among hospitalized medical patients, with (6) estimates between 20 and 40 percent . Additionally, patients with psychiatric illness may be more challenging to treat in terms of adherence to medications and recommended interventions and forming a treatment alliance. Moreover, they may require more time and resources for their care. These factors, in turn, can lead to burnout and decreased job satisfaction for medical providers. It is important then, for medical providers to know when psychiatric consultation and/or referral are appropriate. Overall, a guiding principle is the provider’s comfort level in treating psychiatric disorders. Many clinicians derive a great deal of satisfaction from handling the www.sfms.org
psychosocial issues of their patients and have a degree of expertise in administering treatments ranging from medications to focused therapies. For such practitioners, the threshold for referral or consultation is quite high. In general, however, time and resources limit medical providers’ ability to adequately meet the psychosocial needs of these patients. Clinicians should consider the following in deciding whether to refer a patient to a mental health professional: Degree of experience and expertise in the diagnosis and monitoring of psychiatric disorders Level of knowledge and familiarity with the indications for and prescribing of psychotropic medications, including common and serious side effects, drug interactions, and monitoring guidelines Whether there are questions about the diagnosis Whether the patient is responding to standard treatments Whether the patient is worsening despite treatment Whether the patient’s psychiatric symptoms are interfering with medical condition and care, such as adherence to medications Presence or development of more serious symptoms, such as suicidal ideation, manic, or psychotic symptoms The capacity of the clinician to provide the degree of psychosocial intervention or support that the patient requires For patients who are hospitalized, inpatient psychiatric consultation may be warranted. The degree of availability of such services may be the major determinant of whether psychiatric consultation is pursued. Acuity of the problem
is another important consideration in whether the consultation is requested in the inpatient versus outpatient setting. Inpatient psychiatric consultation can offer immediate intervention for acute issues in the hospital, such as acute anxiety, psychosis, suicidal ideation, altered mental status, and adjustment issues. For longer-term problems such as depression, consultation can provide an evaluation and, if appropriate, recommendations for further treatment, including medications and/or psychotherapy. In addition to the above guidelines, indications for inpatient psychiatric consultations include: Interference with in-hospital treatment due to the patient’s psychiatric symptoms Significant level of distress in the patient from symptoms Questions regarding the patient’s current psychiatric treatment as it is impacted by his/her acute medical issues Diagnostic uncertainty because the patient’s current clinical picture is confusing and she or he has psychiatric and/or behavioral symptoms of unclear etiology Ultimately, referral or consultation to a mental health professional can be helpful in providing comprehensive care for patients. While the medical provider can feel that his or her patients’ psychological and psychosocial problems are being fully addressed, collaboration can also offer the clinician valuable support that’s key in caring for complex patients. J. Jewel Shim, MD, is an assistant professor in the Department of Psychiatry at the University of California, San Francisco, and is the director of the Psychiatry Consultation Service at the UCSF Medical Center. References available at www.sfms.org/archives.
December 2010 San Francisco Medicine 27
Psychiatry for the Nonpsychiatric Physician
Emotional Competence Giving Your Practice a Tune-up
Loma K. Flowers, MD
efore you dismiss the concept of emotional competence1 as irrelevant to your medical or surgical practice, I suggest you check a few of your systems for practical applications of emotional competence issues, as taught by Equilibrium Dynamics.2 Improvements benefit us all, as physicians and patients. Emotional competence includes the skilled management of internal emotions, external situations, and relationships and can promote patient satisfaction and health care outcomes as well as better mental health for practitioners.
Contacting Your Practice
First, call your own practice—or your own doctor’s practice if you don’t have one now—as if you were a new patient dealing with the automated communication system you have in place to handle incoming calls. Imagine some symptoms for yourself (perhaps sudden severe pain in your right heel that precludes walking, significant shortness of breath, or a new lump) and call in now. Don’t cheat and press the number for physicians and pharmacists! Just follow the instructions for patients once or twice and see what happens. Practice self-awareness and note the facts and your feelings. If you decide to make—or recommend—any changes, check in again in a couple of weeks. Is it better? If your experience on the phone is like mine as a patient, all too often you will find yourself steadily more desperate—and irritated—as you try to get through. Most of us who do not use a “boutique” practice have been (re)trained to be grovelingly grateful for anyone live with good judgment who directs our call
to an appropriate response. Even faxing can leave you waiting hopefully for hours, even days, if the fax is overlooked. The crux of the problem is officefriendly phone systems, designed to “protect” the doctor from patients between (infrequent) appointments and to manage inanimate (not live) work flow for the office staff. This efficiency, we hope, offsets managed care’s siphoning-off of income, which is the motivation for the design and doctors’ choice of these systems over earlier answering services. The impact, however, is that (sick) patients get the message (nonverbal communication) loud and clear that they are low priority. But the automated systems physicians choose could be programmed to be patient-friendly also. Inadequate phone systems are common examples of (relationship) emotional incompetence in medical and surgical practices. Feeling bullied by managed care, we do not have to bully in turn (power). Once understood, motivationimpact issues at the root of conflicts can make the conflicts easier to resolve. For example, other awareness, another basic interpersonal emotional competence skill, could fix this situation with a single patient-friendly option in the telephone system. For example, try “if you are feeling unwell or are especially pressed for time, press X to speak to someone immediately.” If someone explains (with a written handout?) to patients when and how to use this option, I expect abuse will be as minimal as it was in my practice, and it can be dealt with straightforwardly in a personal conversation. Some business systems have a “press 0 for immediate assistance” option, which we have all heard, especially when
29 San Francisco Medicine 28 San Francisco Medicine December 2010
we are buying. And patients are buying! Some automated phone systems respond to cursing by immediately connecting to a person. Someone realized their system was so frustrating (emotional competence) that people become enraged enough to curse out loud and so programmed a prompt response. This trains people to use rage to get what they want (emotional incompetence). Such dangerous behavior seems increasingly prevalent. As physicians, we can use our doctor-patient relationship skills to increase emotional competence—not incompetence—in our communities. I like specific written instructions (verbal communication, oral and/or written) on how to contact my doctor between appointments. It helps me avoid the catch-22 of no appointments available for weeks and no access without an appointment. One patient vented to me that she requires the oral medications for periodic yeast infections (because she is allergic to the creams) and has to argue with her doctor’s office staff every time she calls for a prescription. Apparently they follow an office policy that both refuses to supply an anticipatory oral prescription and has no timely capacity to manage her needs. Self-responsibility requires routine self-assessment sessions, done with emotional competence, i.e., kindly and without blame or excuses. Such reviews pick up these small glitches that loom very large to sick patients (conflict resolution). Solutions can be easily devised; for example, “exceptions” are acknowledged and management policies developed. www.sfms.org
Keeping Patients Waiting I am sure that most doctors are as prompt as possible for their patient appointments, but some waiting by patients is inevitable. In my experience, physicians could handle their lateness in more emotionally competent ways. Doctors are often trained in current medical etiquette, meaning they explain why: “I was held up at the hospital,” “There was an emergency.” This is an explanation of motivation, which is helpful but inadequate. It is certainly better than ignoring your tardiness. But it requires patients to be empathetic, rather than validating their feelings: insulted or powerless, neglected or pressured by their own commitments. If neglected, their feelings can play out in noncompliance. Injured parties want acknowledgment of impact. How often do you ask the patients you have kept waiting if the wait inconvenienced them and how? Have you cost them a dollar per minute for a late daycare pick-up? Have you caused them to keep an important client waiting? Is their elderly relative sitting at home hungry because your patient is now late in bringing them lunch? If you do actually apologize and say, “I’m sorry to have kept you waiting,” I suggest you add, “Have I inconvenienced you?” or “Does this wreck your schedule for today?” And listen to the answer. This feels like reparations. It usually takes comparable time to your habitual icebreaker conversations, and you’ll learn more about your patients which may affect your medical/surgical treatment. In addition, with this change in process, your patients will feel immediately cared for, rather than being (unintentionally) manipulated to take care of you. Also, you can develop a system to accommodate those who have serious time restrictions.3 For example, when I was practicing psychiatry with small children at home, I used to schedule my own surgical follow-up appointments at the end of my surgeon’s day and call Roni, his wonderful receptionist—who actually answered the phone—an hour before my appointment to ask how late he was running, to minimize my wasted time. It
worked beautifully for all of us.
The Hope You Give
Hope in the face of a terminal diagnosis sounds simply kind, but it masks extremely complex emotional competence issues. Here’s one example. An elderly widowed friend of my mom’s was dying in the hospital when one of her sons called me, on a Sunday, to let me know. As we talked about the medical details, he mentioned putting in a feeding tube tomorrow. Knowing his mom (other awareness), I was startled. “How did you all decide on that?” I asked. He didn’t know but just assumed his local siblings had dealt with it. This lack of specific communication is common in families and can be crucial in times of crisis. So I asked, “Did you ask your mom if she wanted it?” He assumed so, since she could still nod and shake her head appropriately to communicate, but he wasn’t sure. He agreed to check, recognizing that he might need help, because he was self-aware that he was reluctant to face her preference to die now rather than later. In fact, she had not been asked. The team had just announced it, putting the family in the position of having to oppose it, which none of them were willing to do. Her son requested she be asked—an emotional competence process intervention (vs. content, which would have been to oppose the tube). The team immediately agreed. She was adamantly opposed to any prolongation of her life and conveyed this unequivocally to differently phrased questions, in other words giving clear, specific communication. The entire family was grateful and relieved that they had not inadvertently opposed her wishes. The team had the skills. They had been focused on hope or prolongation of life, possibly to manage their own feelings about her dying (inadequate feeling management), so they failed to continually check with the patient. Self-development of practitioners and the field is constantly needed to avoid this kind of error. For example, we could change the operative principle of “Always Give Hope [of longer life].” I suggest, “Always Tailor the Hope to the Patient.” For some, “hope” may be for quick or comfortable death. This means
you have to ask—and ask again—as the situation evolves. Some patients want the whole truth. Others want part of the truth, or none of it. But the decision is theirs, not the doctor’s. But it is the doctor’s communication skills that elicit their specific needs. Finally, for all patient care, ask and listen to responses. Loma K. Flowers, MD, is a clinical professor of psychiatry at UCSF, a former president of the Northern California Psychiatric Association, and a Distinguished Life Fellow of the American Psychiatric Association. She has awards for both community service and teaching, and she publishes practical aspects of her work, focusing on the relationship between individuality and universality in gender, dreams, diversity, and emotional competence. Her current practice is divided between international consultations in personal and professional development for individuals, families, and organizations and Equilibrium Dynamics, a nonprofit dedicated to teaching the fundamental concepts, principles, and skills of emotional competence for everyday life.
References 1. Flowers LK. The missing curriculum: Experience with emotional competence education and training for premedical and medical students. Journal of the National Medical Association. 2005; 97:1280-1287. 2. www.EQDynamics.org has the complete list of emotional competence curriculum issues. 3. Brown, Flowers LK. Psychotherapy: Black and White. J Nat Med Assoc. 1972; 64:19-22.
December 2010 San Francisco Medicine 29
Psychiatry for the Nonpsychiatric Physician
Coercion and Compassion A View from the Streets
Emily Baldwin, MD
e step around the sleeping homeless, the early drug deals, the panhandlers in the heart of the Tenderloin. In the past two years, I’ve become a part of the neighborhood as well. “Hi, doctor,” people call before returning to their business. We are here to deliver medication, medical care, or a brief conversation to the city’s most severely mentally ill individuals—those who, because of their extreme cost to the city, have been referred to Community Focus, an “Assertive Community Treatment” program run by U.C. San Francisco. Since deinstitutionalization in the 1980s, my patients and others like them are treated in the community. Our program must find ways to engage them and keep them housed, healthy, and out of the hospital and jail. We are highly effective.(1, 2) Yet this morning, as always, I wonder about those we cannot reach—those who refuse any treatment at all. Treatment for the severely mentally ill has undergone a tremendous shift, from a system of lengthy involuntary hospitalizations to one designed to protect individual civil liberties. Currently, Californians are debating “Laura’s Law” (AB 1421), which is closely modeled after New York’s “Kendra’s Law” and would bring mandatory outpatient commitment (MOT) to the state. To understand the terms of the debate, it is crucial to understand the history of MOT—what it can promise, what it cannot achieve, and why, in San Francisco, it has been so difficult to determine a course of action. Our legal system contains safeguards to protect the rights of the individual with mental illness. Even on a “5150” hold, a patient retains the right to refuse medi-
cation unless he is found, in a separate process, to lack capacity to make such decisions. And yet coercion, or “leverage,” remains common in mental health care. Two studies in five different U.S. cities found that 50 to 60 percent of mental health patients reported coercion as a part of their treatment, from “verbal persuasion” to the threat of legal proceedings. (3,4) Although patients reported disliking coercion, “about half retrospectively felt forced treatment was ‘in their best interest.’”(4) Such is the paradox of leveraged treatment: We recognize the importance of protecting the individual, yet it is in the nature of psychiatric illness (and perhaps all illness—what physician has not used verbal persuasion?) that some degree of coercion is, at times, inevitable. One debate over MOT concerns its ability to provide cost-effective care. The highest users of public mental health services consume a disproportionate amount of county resources. One study in Alameda County found that the top 4 percent of patients used 38 percent of publically funded services, generally through a “revolving door” of repeated nonadherence and rehospitalization.(5) As a response to such costs, Laura’s Law states that an individual with diagnosed mental illness, who has a “repeated pattern of poor adherence to treatment that has resulted in multiple hospitalizations” or is “deemed unlikely to maintain safety in community without treatment,” may be court-ordered to adhere to mental health treatment. If the individual fails to comply, he may be returned to a psychiatric facility for a seventy-two-hour evaluation period. Much has been made of the fact that
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the law specifically does not allow the administration of medication without a separate legal process. Opponents, including San Francisco’s director of Public Health, have argued that that this renders the law ineffective and thus worthless. (6) However, the New York Court of Appeals has already ruled on the need to keep medication out of the MOT laws.(7) In the case “In Re: KL,” a patient argued that Kendra’s Law was unconstitutional because a finding of incapacity is required to give forced medication, and because being held for up to seventy-two hours was a violation of due process. However, the New York court upheld Kendra’s Law, stating that the New York law specifically does not allow forcible medication without a separate capacity evaluation and, importantly, “a violation of the court order ultimately carries no sanction,” only triggers heightened scrutiny(7). In other words, the court ruled that the law was constitutional precisely because it has no “teeth”—no severe sanction and no forced medication. This would certainly be the case in California courts as well. Thus, rather than fault Laura’s Law for its failure to provide involuntary medications—a legal necessity if the law is to exist at all—it is more relevant to focus on what the law can accomplish. Again, the case of New York is instructive. In two follow-up reports on Kendra’s Law, patients’ likelihood of psychiatric hospitalization and arrest during the time of MOT was found to be significantly lower compared with their pre-MOT experience.(8,9) Even “without teeth,” the authors declared Kendra’s Law a success. Moreover, despite the fact that the “sanction” of these laws doesn’t www.sfms.org www.sfms.org
provide for nonemergent medication, it is a safe assumption that a nonadherent individual brought involuntarily to a psychiatric facility for up to seventy-two hours is more likely to receive medication than one who is not. However, a second and more meaningful line of debate exists. After all, the New York reports are not a randomized controlled trial, and they do not indicate what factors drove their impressive results. Was it, in fact, the coercive power of the court? Was it simply a result of offering an appropriate treatment where previously none had been available? No study to date has been designed to address which factors in New York’s AOT package are responsible for its remarkable success(10). Moreover, the single study that did offer similar services to patients in and out of AOT found no significant outcome differences,(11) suggesting that it may be treatment, not a judge, that’s the most effective ingredient in such programs. Moreover, New York approved an influx of state money to fund Kendra’s Law, while California has left individual counties to fund MOT. California insists that no money may be shifted from voluntary services to fund involuntary programs— an important safeguard, especially as New York’s data have shown that voluntary service delivery may decrease, at least in the early phases of AOT(12) —but further limiting any counties’ ability to actually enact a program. Before implementing a costly new treatment, we must consider what tools already exist. In particular, the mental health court (MHC), a popular form of treatment nationwide, deserves review in this context. One study of San Francisco’s mental health court showed that twentyfour months after leaving MHC, those who had participated still showed a 39 percent reduction in any new charge and a 54 percent reduction in any new violent charge, compared with similar individuals who did not participate.(13) Other sites have conducted smaller studies on recidivism, with similarly positive results. Of course, only individuals convicted of a crime are eligible to participate in www.sfms.org
MHC, and they are free to decline (in which case they simply serve the remainder of their sentence). A “guilty” or “no contest” plea is often required. A treatment plan is outlined by the judge in concert with a treatment team, and the court monitors progress. Upon successful completion of the plan, there is the possibility that charges may be dismissed— thus providing a “carrot” for the patient, rather than the “stick” of MOT. Another form of treatment that shares features with MOT is Assertive Community Treatment (ACT), a voluntary treatment. In San Francisco, Citywide and Community Focus provides Assertive Community Treatment for 200 patients (and also administers treatment for approximately 80 more individuals enrolled in mental health court). Although we are a voluntary program, our retention is extremely good(2). Many of our patients deny having a mental illness but are willing to come to clinic—and even take medications— because we can offer housing and vocational assistance, library services, free meals, groups, etc. Without the “stick” of involuntary treatment, we have parlayed our services into numerous “carrots” to encourage adherence. And we do have smaller “sticks” at our disposal. Nationwide, it’s estimated that 30 percent of people who receive disability for a mental disorder have a representative payee(14). Mandated payee services, which generally result in more stable housing(15) and money management, have been the subject of surprisingly little academic study. Similarly, psychiatric “conservatorships” (which must be renewed yearly) provide some coercive power for gravely disabled individuals. Despite payees, conservators, and ACT, there are individuals we cannot reach—those who adamantly refuse treatment under any circumstance. Although small in number (at Community Focus, we may “lose” about ten such individuals each year), these tend to be extremely costly individuals whose nonadherence leads to frequent hospitalizations and often ends in jail when their behaviors become too dangerous
to manage in the community. The best way forward for San Francisco would be to take a cautious but innovative approach, perhaps developing a small program for MOT only for those individuals who have “failed” the other treatment options available. Such a program, if rigorously studied, would allow us to answer key questions that remain about MOT. We must not overstate the potential benefits of such a program—it would likely do little to address widespread homelessness, or first-break psychosis, or overall violence rates in the city. But, as New York has shown, we must not minimize the potential benefits either. While our city continues to discuss these issues, those of us who work with the most severely mentally ill continue to step over and around the sleeping figures on the streets by our clinic, wishing there were some way we could bring them into treatment. Emily Baldwin, MD, is an assistant professor of psychiatry at the University of California, San Francisco, and medical director of the Community Focus Clinic, an assertive community treatment program in San Francisco. A full list of references is available online at www.sfms.org/archives.
December 2010 San Francisco Medicine 31
Psychiatry for the Nonpsychiatric Physician
“Get This Patient Out of My ER!” A New, Humane, and Efficient Local Approach to Managing Psychiatric Crises
Keith Loring, MD
n 2006, Emergency Departments (EDs) in San Francisco made a final and abrupt shift from serving as the place of last resort to serving as the place of first and often only resort for patients in acute psychiatric crisis. This was hardly a local phenomenon. It was in line with a two-decades-long unraveling of California’s (and the nation’s) psychiatric safety net. There was little solace at this point in ever knowing that San Francisco held the continuum of care together better and longer than most every other county in the state. All I knew is that the certainty of an appropriate and timely disposition of patients in crisis, which had been the norm ever since I started practice in 1991, had suddenly become a crapshoot at best and a long wait for certain. The safety net unraveled to the point that my emergency medicine colleagues and I were the safety net. For me, the call to action happened when I came in for a shift to find that a patient I had cared for forty-eight hours earlier was still in his bed and still “next” in line for transfer to Psychiatric Emergency Services (PES), the only facility that would accept uninsured patients. No amount of medical school could prepare me for the journey that began that day when, in desperation, I began making calls that took me up the chain of command at my hospital, the Emergency Medical Systems Agency (EMS Agency), the Fire Department, PES, and ultimately the Department of Public Health. The themes became clear: “There are not enough resources for these patients.” “We, this hospital, this system, even Bill Gates can’t afford them.” “Now you know how hard it has been for us to care for them.”
“Good luck in finding a solution, because it’s bigger than you or me.” “It’s the private hospitals’ fault.” “It’s PES’s fault.” “It’s Ronald Reagan’s fault.” I was about to give in to the rampant nihilism when I finally reached Barbara Garcia, the deputy director of health for Community Programs, who sounded a completely different note, one of optimism, a can-do attitude. Here was somebody I could work with. With some thoughtful trouble-shooting, her staff was able to effect a transfer in a matter of a couple of hours. As a result of my contact, Barbara became acutely aware of just how severely the backup at PES was impacting our emergency departments. She gave me the impetus to continue chipping away at this problem from the outside while, unknown to me, she was doing the same from inside the DPH. I raised the issue at the next meeting of San Francisco Emergency Physician’s Association (SFEPA), and it quickly came to dominate our agenda for months to come. We realized that emergency department overcrowding; unnecessary boarding of psych patients; escalating ambulance diversion rates; and competing destination policies of the police, fire, and ambulance services were all part of an intricate nexus for which there were precious little data to allow for rational policy making. So I proposed a simple study: Collect real-time data for a month or two from every willing emergency department in the city on the demographics and wait times for psych patients. The results were eye-opening: Insured patients waited an average of four hours to land in an appropriate bed. Uninsured patients waited an average of
32 San Francisco Medicine December 2010
twenty-two hours. This meant that in San Francisco, a suicidal or gravely disabled patient who made it to an emergency department would likely have to wait an entire day before gaining entrance to a facility where they could undergo a substantive psychiatric evaluation. These data and the urgency of the issue helped galvanize an informal and unsanctioned effort called the 5150 Work Group, facilitated by another can-do visionary, John Brown, MD, director of the EMS Agency. Every public and private stakeholder in the continuum of care for patients in psychiatric crises met in an atmosphere of collaboration and thinking beyond individual interest. The work group came up with a set of recommendations, including the creation of an alternative to PES for the referral of patients in psychiatric crisis, which it forwarded to the health commission and DPH. The needed interests were aligned, which Barbara Garcia was then able to channel into the creation of a freestanding psychiatric urgent care center: the Dore Center. The treatment model was created in coordination between the DPH Community Mental Health Division and Progress Foundation, a nonprofit agency that had a solid track record of successful outpatient management of psychiatric patients in many of San Francisco’s residential treatment facilities. Progress Foundation and the Hospital Council of Northern California funded the purchase and renovation of the building. Despite being born in the middle of budgetary cataclysm, the Dore Center is now in its second year of operation and appears to be serving as a helpful siphon for Continued on page 36 . . . www.sfms.org
Psychiatry for the Nonpsychiatric Physician
Contemporary Psychoanalysis An Update
Mardi J. Horowitz, MD
an Francisco is a hub of updates in psychodynamic theory (Horowitz 2005). At the University of California, San Francisco (UCSF), we teach an integrative approach with psychodynamic understanding employed to formulate cases that may receive a variety of psychotherapies. At the San Francisco Center for Psychoanalysis, we have developed new programs for advanced psychotherapy training, as well as continuing to modify theory in our psychoanalytic training divisions. The other centers in Chicago; New York; Los Angeles; Boston; and Washington, DC, also have modified the psychoanalytic theories of the past. For example, the Boston Change Process Study Group constitutes the authors of a 2010 book entitled Change in Psychotherapy. However, their focus is on contemporary psychoanalytic psychotherapy. They ask how a patient changes for the better in intensive, deep, and exploratory psychotherapy. The focal point of their answers is on learning from new interpersonal experience in the treatment. They changed theory on this topic of the relationship evolving between the patient and clinician from prior theory that they had been taught. What was that earlier psychoanalytic theory? Psychoanalytic theory has always been pluralistic, but in the United States there was a prevalent view called “ego psychology.” Ego psychology, including a focus on defensive operations working as unconscious controls of emotional dangers, prevailed in the last third of the twentieth century. Technical advice focused on romantic drama-conflicts as in Oedipal configurations. Neurotic patients were regarded as www.sfms.org
“most analyzable,” that is, most likely to change unconscious structures of motivation and meaning. Such change was seen as enabled by insight and achieved with the help of the clinician’s interpretations. By modification of unconscious defensive mechanisms, what was relatively unknown could be jointly examined. A key additional ingredient in the earlier theory was intensification of transference in the here and now of therapy. A growing therapeutic alliance led to the resolution of transference expectations in favor of understanding what was really going on. The analyst was trained to become an expert at letting this unfold and then making correct interpretations. How do the authors change this earlier theory? The big changes stem from advanced developmental theory focusing on attachment to maternal type figures. The therapist trains himself and his patient to listen to the co-creating nature of the therapy dyad. Both parties then experience new relationship possibilities and can perhaps verbalize derivatives of prerepresentational infantile views. Both parties learn from an ever-closer empathy and learn a new kind of mutual connection. The authors have the earlier ego psychology theory in their bones. They do not advance in an either-or model. What they do add is more theory about the nature of unconscious fantasy and disturbances in personality. They present enough illustrations to anchor their theory of change to observations of what there was to be changed. The authors clarify a consensus that they achieved within a group. Here is a taste of their unifying paradigm. In
concentrated work on frank disclosure, and their growing and emergent alliance, both clinician and patient learn how to increase their mutual trust and what the authors call a kind of mutual “vitalization.” The authors view the end results of such invigoration as more coherence in the patient’s self-conceptualization. The outcome for a patient is that he becomes more capable of having mutually satisfying experiences outside of therapy. Mardi J. Horowitz, MD, initiated and directed clinical research programs supported by the National Institute of Mental Health and the MacArthur Foundation. The work in these projects, especially his work contributing to the diagnosis and treatment of posttraumatic stress disorder, led to his receiving the Lifetime Achievement Award of the International Society for Traumatic Stress Studies; the American Psychiatric Association’s Foundations Fund Prize for Psychiatric Research; the Hibbs Award, also from the American Psychiatric Association; the Strecker Award; and the Royer Award of the University of California Regents. His most current books are Understanding Psychotherapy Change: A Practical Guide to Configurational Analysis and A Course in Happiness. Professor Horowitz is also president-elect of the San Francisco Center for Psychoanalysis.
Reference Horowitz MJ. Understanding Psychotherapy Change. Washington, DC: American Psychological Association Press, 2005. Portions of this article were published in the Book Forum section of the American Journal of Psychiatry in October 2010.
December 2010 San Francisco Medicine 33
Psychiatry for the Nonpsychiatric Physician
Psychiatry and Ethics A Whirlwind Tour
Steven Reidbord, MD
he practice of psychiatry is rife with ethical issues. Some critics, such as author-psychiatrist Thomas Szasz, attack the legitimacy of psychiatry itself, claiming it’s unethical to treat mental distress as though it were a medical disease. Psychiatric diagnosis has been challenged on ethical grounds when used to punish political dissidents in other countries, and here in the U.S. when a criminal defendant is found not guilty by reason of insanity. Involuntary psychiatric hospitalization and treatment looms large as a matter of ethical concern. The “5150” became California law in the 1960s and authorizes civil commitment for up to seventy-two hours when a patient is “dangerous to self or others” due to a psychiatric disorder. It soon became the model for such laws nationally, yet revisions and reformulations are constantly put forward. While each of these issues is profoundly important, they are not the ethical challenges that most psychiatrists face on a day-to-day basis. Most of us don’t spend our time questioning whether the field is legitimate in general, nor whether making a diagnosis is an ethical act. Most psychiatrists have outpatient practices and rarely contend with involuntary hospitalization or treatment (although it happens). What are the more common ethical challenges in psychiatry? Clear and professional boundary keeping is the cornerstone of psychiatric practice, especially for those psychiatrists who conduct psychotherapy. Just as a surgeon drapes the surgical field to assure a clean and well-demarcated work space, the psychiatrist establishes a “frame” of time, place, and purpose with each patient to assure a psychologically clean and well-
demarcated space to do psychological work. The best known and probably most important ethical rule in psychiatry is not to exploit patients sexually. (Unlike in other specialties, this also extends to former patients.) Less understood is that this attention to psychological boundaries precludes many other social interactions that seem more innocuous. Unlike other physicians, psychiatrists who use psychotherapy cannot attend sporting, dining, or other events, public or private, with patients. Since we use the doctor-patient relationship as the very instrument of care, it cannot be put to other purposes. This illustrates something unique about psychiatry: Ethical and clinical issues often overlap. Clear professional boundaries are both an ethical matter and a clinical matter. Here is another example. Psychiatrists deal with confidentiality dilemmas all the time. For example, young adult patients often have parents who both pay for the treatment and want to know about it. Yet such patients have ethical and legal rights to confidentiality. Other specialties deal with this as well, although in psychiatric practice the presenting problem may be the parental relationship. Thus, what to tell family members—or what to advise the patient to tell—is a matter of both ethical and clinical significance. The same is true of reporting confidential details to thirdparty payers, magnified here by the social stigma attached to psychiatric disorders. Many psychiatric problems do not cause immediate distress in the patient, but only in those around him. Typical examples include mania, paranoia, narcissism, sociopathy (antisocial behavior), some eating disorders, and so forth. Since subjective distress does not motivate
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treatment in such conditions, a large part of psychiatric practice is helping patients appreciate the need for treatment and choose it for themselves. While the ethical issues here are not as stark as plainly forcing treatment, there are still several matters to consider. It may be ethically problematic to try to change a patient for the benefit of others, even if the patient would also benefit in the long run. Most physicians would feel qualms about trying to change anything in a patient without that patient’s conscious assent, yet in psychiatry we often have no option but to proceed when the patient lacks the insight and judgment to assent. As a result, there are ethically problematic pressures to persuade the patient, using emotional appeals and slanted arguments—anything to gain cooperation. Such situations place the psychiatrist, at least temporarily, in an adversarial position with respect to the patient’s subjective desires and constitute a conflict of interest between the patient’s wishes and the psychiatrist’s. A special case of divided loyalties occurs when a patient seeks psychiatric treatment for a reportable behavior. The state mandates the reporting of suspected child or elder abuse, and certain other behaviors. While there is obvious value in such reporting, unfortunately it can also prevent patients from receiving the very treatment than could curtail such behavior in the future. In some such cases, legal reporting requirements may conflict with ethical practice. Another common set of ethical issues surrounds the placebo effect. Among the various medical specialties, psychiatry stands out in allying with the placebo efContinued on page 36 . . . www.sfms.org
Psychiatry for the Nonpsychiatric Physician
Everyday Dream Work Using Dreams to Identify Stress Factors in Medical Practice
Gayle Delaney, PhD
t’s generally accepted that stress can play an important role in triggering, complicating, or perpetuating pain, fatigue, anxiety, insomnia, and addiction. Identifying the stressors in a patient’s life is not always easy. Patients can lack insight or be in denial about their stress. They often prefer to hide it from their physician, and often the doctor has too little time to tease the relevant information out of the patient. Helping a patient to briefly explore a presented dream or nightmare can result in a stunning clarification of sources of stress while enhancing your collaborative alliance with the patient. True, some dreams are too long and too complicated to work with in five or ten minutes. Some patients are too resistant or too verbose to work quickly with a dream. But if you have a few effective skills in asking well-targeted dream interview questions and know how to corral your patient so that he keeps on topic, most dreams can be surprisingly efficient tools that engender insight, openness, and responsibility for dealing with one’s symptoms. The key to quick dream work is to resist the temptation to make quick interpretations, and rather to ask the dreamer to summarize the theme of the dream rather than tell the whole story. One can help the dreamer get the idea of themes by listing a few. Is your dream about being chased? About being smothered, or frustrated, or killed? Get the headline or outline version of the dream story if possible. What are the dominant feelings you have in the dream? Help the dreamer describe the theme and then help him describe the main actor in the dream. Was it a stranger www.sfms.org
or a thief, a mafia or a family member, a politician or a celebrity? Ask the patient to describe the person in the dream as if you had never heard of him or her before by using three or four adjectives. Now that you have a minimum of descriptive material, recapitulate it for the patient and ask if there’s a metaphor in the theme of the dream that parallels a situation or feeling in his current life. Then consider if this metaphor sheds light on the stresses or symptoms in the dreamer’s life. A forty-five-year-old man who was in his fifth year of recovery from heroin told me this dream outline: “I was with my old buddies, white-water rafting, and I fell out, hit my head, and was dying. I awoke terrified.” Asked to describe the main feeling in the dream, he said, “Losing consciousness, and fear only upon awakening.” Asked if he saw any parallels in his life to this feeling, he said, “I fear dying from heroin. I’ve been hanging around my old drinking buddies for the last week. I know that’s stupid, like white-water rafting without a helmet. When I drink, I do heroin next. And if I do heroin again, I think I’ll never come back.” The patient ceased drinking and did not relapse. Loma Flowers, MD, and Joan Zweben, PhD, have written several articles on the use of dreams in addiction recovery that are important reading on this topic (Flowers and Zweben, 1996, 1997). Furthermore, in a couple of minutes, patients can be instructed in incubating dreams or asking for dreams that deal with possible psychological aspects of specific symptoms (Flowers, 1995). Success in eliciting a dream on a particular topic has an empowering effect on the dreamer and
heightens her motivation to understand and act on the insight offered by her dreaming mind (Delaney, 1998). For example, “Suzanne” suffered from extreme back pain from an old lifting injury. After making an appointment with her physician, she went to sleep worried that she might need unwanted medication. Before sleep, she posed herself the question: Are there any psychological/ emotional triggers for this current pain? She dreamed a transparent dream of hearing an authoritative male voice saying that she was looking for excuses to put off finishing her dissertation. She woke, arranged her seat with several pillows, and in one week finished her paper. Her pain had subsided by the third day, and when she visited her doctor, it was decided she did not need any medication. Directions for incubating a dream can be found at www.gdelaney.com. The same questions can be posed for nightmares and recurring dreams. It’s most efficient and least confusing to ask for only one example of a recurring dream. Even the most common dream has specific relevance to a given dreamer at the time he dreams it (Delaney, 1997). A dream of calling out for or dialing for help and being unable to make a noise or get the right number may remind the dreamer of her difficulty in asking help with a major life issue. Dreaming of being chased begs the question: Can you describe who or what is chasing you? And is there anything or anyone in your life from which you are running that’s like the chaser in your dream? A dream of being smothered: Is there any way you feel smothered in your life? A dream of Continued on the following page . . .
December 2010 San Francisco Medicine 35
Everyday Dream Work Continued from the previous page . . . harming yourself (with a gun, knife, etc.) and feeling no pain at all: Is there any way you are hurting yourself, but you don’t feel the pain yet? In most cases, just asking about the dream experience will increase the patient’s sense of being heard. If you don’t find a connecting metaphor, better to send the patient home with a few backup questions than with an interpretation that may be off the mark, or that, at any rate, has not allowed the dreamer to discover her own interpretation and thus take greater responsibility for the insight. You can suggest further reflection (as time often allows connections to pop up), reading on dreams, or a consultation with a specialist. Gayle Delaney, PhD, is codirector with Loma K. Flowers, MD, of the Delaney & Psychiatry and Ethics Continued from page 34 . . . fect. In internal medicine, a treatment that makes the patient feel better but leaves the infection or tumor unchanged is a failure, and a dangerously misleading one at that. In contrast, a psychiatric treatment that relieves a patient’s depressed mood or anxiety is a success, regardless of whether it changes the patient biologically. Usually the patient’s subjective experience is the endpoint. Ethical dilemmas arise when honesty falls prey to the need to instill hope. For example, a depressed patient who has failed five medication trials of adequate dosage and duration presents for a sixth. The patient hopes the sixth medication, possibly a heavily promoted new product, will be the longawaited miracle cure. The psychiatrist knows this track record bodes poorly but doesn’t want to be pessimistic in front of the patient, as success or failure often hinges on the patient’s expectations. So the sixth medication trial proceeds despite the psychiatrist’s better judgment, and it typically fails. Putting aside the placebo effect, the psychiatrist would advise a different approach—psychotherapy maybe, or perhaps a fresh look at the patient’s work history, coping skills, nutrition, exercise,
Flowers Dream Center, founding president of the International Association for the Study of Dreams, and author of All About Dreams. Her website is www.gdelaney.com.
References Delaney, G. All About Dreams. San Francisco: HarperSanFrancisco, 1998. Delaney, G. In Your Dreams. San Francisco: HarperSanFrancisco, 1997. Flowers, LK. The use of presleep instructions and dreams in psychosomatic disorders. Psychotherapy and Psychosomatics. 1995; 64:173-177. Flowers, LK, Zweben JE. The dream interview method in addiction recovery. Journal of Substance Abuse Treatment. 1996; vol. 13, no.2: 99-105. Flowers, LK, Zweben JE. The changing role of “using” dreams in addiction recovery. Journal of Substance Abuse Treatment. 1998; vol.15, no.3:193-200. and social support. None of these, however, are what the patient believes in or wants to hear, and thus potentially effective alternatives aren’t even tried. Speaking of heavily promoted products, psychiatry has the dubious distinction of prescribing the most expensive drugs in the whole medical armamentarium. According to a recent New York Times article, antipsychotics are the top-selling class of pharmaceuticals in America, with annual revenue of about $14.6 billion. Antipsychotics were formerly a niche product, but recently manufacturers have gained FDA approval for a much wider range of indications. Moreover, most antipsychotic prescriptions are now written off-label (not always, or even primarily, by psychiatrists). The burgeoning use of expensive and potentially hazardous antipsychotic medications for relatively minor indications—insomnia, anxiety, nonpsychotic depression, and so forth—has both clinical and ethical implications. Psychiatrists, and all physicians, should recommend treatments based on risk/benefit considerations, and not on extraneous factors such as lavish marketing, financial ties with industry, and so forth. Such conflicts of interest remain endemic in medicine despite
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“Get This Patient Out of My ER!” Continued from page 32 . . . patients who would otherwise languish in my emergency department. It has become a useful tool in managing psychiatric crisis in San Francisco. How it serves moving forward remains to be seen. Much will depend on the willingness of every stakeholder in the process to look beyond self-interest, seek useful data, and act upon it. Much will depend on continued dedicated leadership and dedicated participation by everyone across the private/nonprofit/public spectrum of interests, including those least likely to care about the broader care of psych patients: ER docs like me, who just want to get them out of my ER! Keith Loring, MD, is an emergency physician on staff at Saint Mary’s and Saint Francis Hospitals, immediate past-president of the San Francisco Emergency Physicians Association, and Treasurer of the SFMS.
recent voluntary restrictions by the pharmaceutical industry and some professional organizations. Psychiatrists in particular should be acutely aware that such influences can, and do, operate unconsciously and despite one’s best intentions. Yet again and again, prominent psychiatrists appear in news headlines about improper funding by industry and failure to disclose financial conflicts of interest. The field risks trading away its most valuable commodity—trust. This whirlwind tour of psychiatry and ethics has barely scratched the surface. These are only some of the most common ethical issues in clinical practice; there are many other equally worthy contenders. Nonetheless, it illustrates some of the range of issues faced in the field, the many commonalities with other medical specialties, the great overlap with purely clinical decision making, and the way psychiatry, more than any other medical specialty, is defined and shaped by the social context in which it is practiced. Dr. Reidbord is a psychiatrist in private practice in San Francisco. He blogs about psychiatry at http://blog. stevenreidbordmd.com. He teaches at CPMC, chairs the CPMC CME Committee, and serves on its Ethics Committee. www.sfms.org
Psychiatry for the Nonpsychiatric Physician
A New Approach to Mental Health Care Coming This Winter to the Presidio
Amy Berlin, MD
t’s a Tuesday after a winter holiday weekend. Your pediatric practice’s waiting room is full of sniffly kids and sleep-deprived parents. Behind schedule, you enter Exam Room #3, quickly scan your medical assistant’s note (“ear pain, URI”), register the vitals (no fever), and breathe an internal sigh of relief as you recognize your two-year-old patient and her mother, a “veteran” of your practice. A reliable historian with two older children, she has been around the otitis media block before. This should be quick. A peek in the ears, nose, and throat and an amoxicillin prescription later, as you reach for the door, Mom stops you. “Doctor, as long as I’m here, I was hoping to ask you about David, my twelve-yearold. I’m really worried about him. There is something different about him—he seems sad, distracted, more angry lately. His grades are dropping, and he wants to spend less time with his friends. Some of my friends say it’s a phase, but I’m not so sure. I myself remember being quite depressed at his age, so I worry. I called our insurance for some names of child psychiatrists, but only a few returned my calls, and the ones who did aren’t accepting new patients. My husband just had a pay cut, so our budget is tighter than ever. I’m not quite sure what to do.” You understand this mother’s sense of helplessness and frustration. Fifteen years in practice, and you still haven’t figured out how to help your patients locate quality, affordable, and comprehensive mental health care. At the same time, you’re relieved your patient’s mother has reached out. You have at times worried that she herself seems sad and withdrawn, and you know that in the bestwww.sfms.org
case scenarios, children entering mental health treatment can lead their parents to help as well. But you are still at a loss for referrals. The few child psychiatrists with whom you have collaborated over the years don’t accept insurance in their practice, and you’re sure this family would be stretched to pay out of pocket. You take a deep breath, preparing to give your patients’ mother your well-worn “how to get your insurance company to help you find mental health treatment” pep talk, when you suddenly remember reading about a new center opening up in the Presidio in December. “I’ll be right back with some information,” you call over your shoulder as you sprint from the exam room and down the hall to your office, to find the article in San Francisco Medicine that you read last week about the Masonic Center for Youth and Families.
About the Masonic Center for Youth and Families
Opening its doors in December 2010, the Masonic Center for Youth and Families (MCYAF) will be a dream come true for many Bay Area children and the doctors who care for them. Treatment at MCYAF begins with an extensive evaluation of the child, including comprehensive psychological testing and history gathering from family members and other important figures in the patient’s life. Following this evaluation, an integrated treatment plan, ranging from individual treatment for a child alone to treatment for her whole family, is offered on a sliding scale. Clinicians at the Center participate in regular case conferences to ensure coordination and supervision of care. Families receive
case management and education about the treatment process. Response to treatment is closely and thoughtfully tracked so that children and their families receive care that’s personalized and effective.
A New Model for Care Independent of Financial Constraints A not-for-profit service of the Masonic Homes of California, MCYAF intends not only to set an example as a new model of care for youth and their families (made possible by its independence from thirdparty reimbursement) but also to contribute to the evidence base on psychological treatment of children. MCYAF hopes to tell the story, says clinical director and child psychoanalyst Terrence Owens, PhD, of “what real [treatment] progress looks like.” An exaggerated emphasis on diagnostic categories, he explains, leaves children and their families with labels but little more to help them understand their actual needs. The clinicians, administrators, and researchers at MCYAF plan to give the children and the families they serve much, much more. More information about MCYAF’s services and staff can be found at www. mcyaf.org. Amy Berlin, MD, has a diverse background as both a practicing psychiatrist and as an informatics consultant. In addition helping health care organizations and private practices break free from I.T. twilight zones, Dr. Berlin has also supervised and taught psychiatry residents at UCSF. Dr. Berlin remains on the volunteer faculty in the UCSF Department of Psychiatry.
December 2010 San Francisco Medicine 37
Book Review Steve Heilig, MPH
A “Messy” Specialty Danger to Self: On the Front Line with an ER Psychiatrist Paul R. Linde, MD University of California Press, 2010
ere’s a writer/physician with a good opening line: “I love my job when I’m not there.” And it’s hard to fault him for that, as “there” is the psych emergency room at San Francisco General, where “the afflictions I see are some of humanity’s most tragic: AIDS, homelessness, poverty, alcoholism, addiction, major depression, chronic pain, bipolar disorder, schizophrenia, the emotional effects of torture, social isolation, the aftermath of fresh and major losses, and the experience of being terminally ill.” Throw in suicide and violence, both domestic and street, and it’s a heavy caseload. In such a setting, Paul Linde notes, “emergency psychiatry is messy.” But he relates how, after training at UCSF, he was drawn to the specialty “as an antidote to my own perfectionism” and that he “liked the nearly impossible challenges, which gave me a chance to feel like I was working against all odds, with a chance to figuratively pull a rabbit out of a hat.” Judging from his worthy and frank book, he does so at times but also often has to contend with the fact that the rabbit stays hidden, or may not even exist. Linde writes clearly and candidly about the many conflicts he encounters in his line of duty, some with colleagues who have differing views on the role of psychiatry in dealing with some of society’s most difficult members. He outlines the history and tensions within his specialty between medication-based
approaches and more psychoanalytical ones, over forced treatment and 5150s versus patient autonomy, and he explores the sad legacy of the “dehospitalization” of the mentally ill and the trend that “psychiatry is more highly influenced today by health care policy makers, insurance, and pharmaceutical companies, regulators, activists, and lawyers than it is by those who actually provide the care.” Much of the book consists of case studies Linde uses to illustrate and humanize the problems encountered, and they do tend to be tragic. But not always, and often it becomes clear that the services Linde and his colleagues provide are the “thin white line” between complete tragedy and self-destruction and some semblance of dignity and health. Linde is also unafraid to relate his failures, such as a suicidal patient he misjudged, and what he learns from such events. “Welcome to San Francisco! It’s not Mayberry,” Linde quips at one point, while dealing with a crack-smoking patient. A friend of mine who trained in family practice at UCSF once told me that, after his brief rotation through the psychiatric emergency service at SFGH, he vowed never to return there again. Understandable, and he’s gone on to do great other work elsewhere, but we
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are lucky there are also physicians like Paul Linde who choose to stay on these particular front lines, to “put a human face on the system,” as he sees it—and to write so eloquently about what he does and how it feels. “My real strength as a physician comes from the heart,” he concludes.
Hospital News Kaiser
Robert Mithun, MD
A visit to a primary care provider typically involves several tests that measure such vital signs as blood pressure, weight, and pulse. These tests are measured using diagnostic instruments and lab results. The patient isn’t asked, “How high does your cholesterol feel?” or “Do you think your blood pressure is high or low?” It’s ludicrous to imagine these questions being asked of a patient. But, in fact, in typical clinical practice, we have assessed mental health this way for the last 150 years. In order to truly manage conditions such as depression, one of the highest causes of morbidity and suffering worldwide, we must assess at baseline using standardized instruments, establish ranges that require treatment, and, above all, adjust our interventions to a particular outcome target that indicates remission or substantial relief. Patient selfreport, while important, is no more likely to lead to positive mental health outcomes than relying on someone to tell you how high his glucose is or whether or not her kidney function is intact. At Kaiser Permanente, we have begun to do just that. We know that in order to understand the severity of psychological distress, we must measure it. And to establish true mental health, we must not only ask if symptoms have improved but we must also use standardized instruments to determine if our treatments are reaching the desired outcome, adjusting our approach when they are not. In the next few years, outcomes-driven mental health treatment will become the new standard of care, and we all must learn how we truly measure psychological distress and determine when our healing interventions have ameliorated that distress.
Patricia Galamba, MD
Michael Rokeach, MD
On the cutting edge at Saint Francis, we are proud to announce that the hospital has almost completed the fourth phase of its complete renovation and upgrade of the Surgical Department (no pun intended). We now have nine new operating suites, five of which have state-of-the-art technology, including boom-mounted lights, monitors, gases, and equipment that reduces practically all the obstructions on the floor and allows for easy customization of space for surgeon preferences. LED lights provide superior illumination and accurate color rendition over the operating field. The custom integrated OR system offers seamless video routing of sources such as endoscopic camera, C-Arm, microscope, PACS, etc. In addition to providing these cuttingedge technologies and tools for complex cases, the new Surgery Department reinforces patient safety with its utility infrastructure upgrades. A new HVAC system provides optimal air circulation plus temperature and infection control. The universal design of each of the OR suites facilitates scheduling and monitoring of services, allowing cases and rooms to be rotated in a way that enables the surgeon to finish one case and begin the next without delay. Also important to the success of the new Surgery Department is its proximity to support services. A sterile processing department has been built adjacent to the Surgery Department, offering more efficient processing of instruments and supplies. The overall workflow has been improved, resulting in reduced staff travel time and fatigue associated with transporting materials. Low-resolution presence cameras in each operating suite allow nurses at the control desk to monitor the progress of each case and shorten turnaround times. In closing, I want to wish the entire San Francisco Medical Community a very happy and healthy holiday season. Here’s to a fantastic 2011.
Genetic counseling for hereditary cancer syndromes is now available at the newly opened Bryan Hemming Cancer Care Center. Comprehensive genetic counseling includes a thorough evaluation of the patient’s medical and family history as well as a detailed risk assessment and genetic education. If necessary, the Center helps the patient get genetic testing. A board-certified genetic counselor provides counseling and assessment, helping identify patients at higher risk for developing cancers due to an inherited predisposition. Assistance is available for determining insurance coverage and possible financial assistance for those patients in need. Referrals and inquiries can be made by calling the Cancer Genetic Risk Assessment Program at (415) 600-3073. Referral forms and additional information are available at www.cpmc.org/ services/cancer-genetesting. Congratulations to the 131 CPMC participants who raised $15,244 in the recent American Heart Association’s annual Heart Walk. The top two fund-raisers were Merle Norman, Cardiac Rehab manager, who raised $2,550; and Alice Louie, Acute/Sub-Acute/SNF Services manager, who raised $1,645. Merle and Alice will both receive a free massage and facial from the Institute for Health & Healing for their hard work. The CPMC-St. Luke’s Diabetes Center and Health First raised more than $2,000 for the STOP Diabetes campaign. Stop Diabetes is the movement to end the devastating toll that diabetes takes on millions of individuals and families across our nation. Diabetes Center Team Captain Ana Mayorga enthusiastically led the Walkie Talkies and Luis Iglesias from Health First fired up his Step Out team on the two-mile walk down the Embarcadero to Pier 39 and back to Justin Herman Plaza. Donations will be accepted until November 1 and can be made at the ADA website.
December 2010 San Francisco Medicine 39
Hospital News VA
C. Diana Nicoll, MD, PhD, MPA
Richard Podolin, MD
Adolescence can be a hazardous time. Between ages 15 and 24, the three leading causes of death are accidents, homicide, and suicide, in that order. For adolescents with psychiatric illness, the emotional turmoil of this period is more extreme. These years are often when chronic mental illnesses such as bipolar disorder and schizophrenia first emerge. The Adolescent Inpatient Psychiatric Unit of the McAuley Neuropsychiatric Institute at St. Mary’s Medical Center (SMMC) is the only inpatient psychiatric facility for adolescents in San Francisco. Each year this 12-bed unit, established in 1954, serves about 600 patients aged 11 to 17 from all over the state. The McAuley program offers a full psychiatric diagnostic evaluation, psychopharmacological management, routine medical workup and management, more specialized medical care as indicated using hospital resources, psychological testing, twenty-fourhour monitoring, individual and group therapy, school, thorough psychosocial assessment, and discharge planning. Usually, McAuley patients are hospitalized until their behavior is stable enough to predict that they will remain safe upon discharge. During that brief time, the staff teaches patients basic skills to help them cope with situations that may put them at risk for harming themselves or others. For psychiatric treatment to succeed, the patient’s family or caregivers must be engaged in the process. Family meetings are an essential part of a patient’s treatment at McAuley. A productive family meeting is usually a prerequisite for discharge. When adolescents are hospitalized, they and their families often get their first exposure to mental health treatment. For many, the experience can be frightening and bewildering. These patients will often require some form of psychiatric care for years to come. With this in mind, the McAuley treatment team does everything it can to provide a positive experience that will motivate patients to keep getting the help they need in the future.
The National Institutes of Health’s Alzheimer’s Disease Neuroimaging Initiative (ADNI)—the largest public-private partnership in Alzheimer’s disease research—has been renewed for an additional five years. Some $69 million is expected to support ADNI2 over five years. The aim of the study expansion, called ADNI2, is to gain new insights into the onset and progression of Alzheimer’s disease, with the goal of improving clinical trial design and aiding drug development. “The study’s chief goal is to identify biomarkers that recognize Alzheimer’s disease at an early stage and monitor progression and response to treatment,” said Dr. Michael Weiner, ADNI principal investigator and director, Center for Imaging of Neurodegenerative Disease, San Francisco V.A. Medical Center. “This grant renewal will fund enrollment
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and continued measurement of more than 1,000 subjects, including healthy elders, people with mild cognitive impairment, and patients with dementia due to Alzheimer’s disease. The continuation of ADNI will accelerate the development of diagnostic methods and clinical treatment trials, helping to develop effective therapies to prevent Alzheimer’s disease,” concluded Weiner. This expansion of ADNI allows for the recruitment of 550 new study participants to join those already participating in the study. The innovative partnership and collaborative scientific vision of ADNI and ADNI2 will generate new knowledge of how Alzheimer’s develops and progresses, as well as what can be done to intervene to stop it. Since ADNI’s launch in 2004, data have been posted to a publicly accessible database available to qualified researchers worldwide. More than 1,700 researchers have signed up for access to the ADNI database. The public sharing of data is fostering unprecedented collaborations among academics, government, and industry researchers, resulting in more than 170 published papers. Dr. Weiner and the ADNI project were featured on a recent edition of PBS NewsHour.
SFMS Would Like to Thank This Year’s Delegates for Their Participation in the CMA House of Delegates!
Stephen E. Follansbee Steven H. Fugaro Gordon L. Fung E. Ann Myers Michael Rokeach Shannon Udovic-Constant H. Hugh Vincent Gary L. Chan George A. Fouras George P. Susens
Lawrence Cheung (pictured above) Peter J. Curran Roger Eng George A. Fouras Robert I. Liner Leslie M. Lopato Rodman S. Rogers Judy Lynn Silverman Peter W. Sullivan John I. Umekubo
2010 CMA House of Delegates Report Stephen Follansbee, MD, and Steve Heilig, MPH
Policy Making in the Belly of the Beast
hat do you want most from your professional associations? A recent survey of physician members of the CMA confirmed what we all know: The most important role of “organized medicine” is advocacy. In the broadest sense, that can mean a wide variety of functions, from bare-knuckles political lobbying to gentler advocacy for patient protections, from specific clinical details to tough reimbursement allocations to arcane ethical dilemmas to broad public health topics. Newcomers to the table are often surprised at the breadth of topics CMA addresses. But how are the topics chosen and priorities set? As much or more than virtually any other organization, this is done democratically, via elected representatives—delegates—from each county medical association, at an annual meeting of more than 1,000 such physicians. Here, new proposals from any CMA member are debated, revised, and adopted or rejected; legislative priorities are presented and refined; political representatives come to brief us and pay respect; and much more is crammed into the seventytwo-hour agenda. This year, all this took place in Sacramento itself. This was the 139th such meeting—there was a nice story of physicians in the 1800s riding their horses for days to attend— and nearly 1,000 physicians from around the state gathered to debate more than 100 resolutions relating to medical ethics, public health, science, insurance, and public policy. Dr. James Hinsdale accepted the presidency of the 35,000-member organization, and Dr. James Hay of San Diego County became president-elect. Dr. Hinsdale, 61, is the director of trauma at Marin General Hospital and executive director of trauma at Regional Medical Center in San Jose. Our own SFMS delegation met three times prior to the annual meeting, primarily to craft some of our own proposals and debate those brought by others. This can get contentious, in a (mostly) professionally polite manner. Our proposal to have CMA take a neutral stance on the topic of physician-assisted dying (original author: Robert Liner, MD) was one example of this—it was not adopted, but the vote was close. Likewise our proposal to change the default for organ donation (Follansbee) to one of “presumed consent”—a policy adopted in some other nations, which has significantly decreased waiting lists for organs. Some ideas take time to be widely supported, and we will likely continue with those, as our experience with others in the past has taught us to not easily accept defeat. We were successful on a few other fronts: improving the
medical aspects of foster care (George Fouras, MD), calling for better evaluation of “alternative” medications (George Susens, MD), developing standards for clinical ethicists practicing in hospitals (William Andereck, MD), and calling for more independent analysis of drug trials conducted by pharma (Susens). Other notable new policies would mandate coverage of tobacco cessation by insurers, mandating that schools post warnings about vaccine-preventable illness in schools where the personal-belief exception rate exceeds 5 percent, and safety of youth in sports. There were important resolutions focusing on environmental safety, including bisphenol A in consumer products, mercury emissions, and air quality. Of course, there was much debate about health care “reform” as well, with at least one resolution calling for wholesale repeal of the national effort but, on the whole, much more nuanced discussion. Some of the points made will no doubt appear in resolutions made to the AMA for national advocacy, and some perhaps in state legislation as well. Constructive suggestions regarding form and function of Accountable Care Organizations (ACOs) will be relayed to the AMA, especially the desire that ACOs be physician-directed. And that might be said to be the primary point of the whole process: to influence elected officials, who so often make policy decisions that influence and impact the practice and delivery of, and access to, medical care. CMA has a very good legislative scorecard on health care issues. The House of Delegates is where their marching orders are formulated. It’s a messy process, and it doesn’t always result in the positions we would hope for; but as Winston Churchill famously opined, “Democracy is the worst form of government, except for all those other forms that have been tried from time to time.” Beyond the hard work, the camaraderie we enjoy while at the HOD is frequently noted as an inspiring element of the meeting. One particularly rewarding event was the annual CMA Foundation dinner; the CMAF does great work on numerous fronts and this is always a fun event. This year SFMS was prominent, with CMAF Chairman Dexter Louie, MD, and SFMS staffer Steve Heilig having the honor of presenting the CMAF’s prestigious Sparks Award for community service to our own David Smith, MD, founder of the Haight-Ashbury Free Clinics and a longtime SFMS member. Standing ovations ensued, and CMA members from around the state approached “Dr. Dave” to tell him what an inspiration he had been to them at some point in their careers. It was a wonderful moment. A list of SFMS Delegates appears on the opposite page. December 2010 San Francisco Medicine 41
In Memoriam Nancy Thomson, MD
Henry L. Cuniberti, MD Dr. Henry L. Cuniberti was born August 17, 1916, in his immigrant parents’ apartment above their market on Haight and Divisadero in San Francisco. A preemie, he was kept in a shoe box on the oven door, but he survived to live a full ninety-three years. He passed away in his sleep on June 21, 2010, in the home he built in the Sunset district fifty-five years ago. He graduated from Lowell High School in 1933 and worked his way through Stanford picking oranges, waiting on sorority tables, and slaughtering sheep. He graduated in 1938 and attended Creighton Medical School, graduating in 1942. He had enlisted in the Naval Reserves in July 1941. After returning to the Bay Area to work as a physician and surgeon for just one year, he was called to active duty in World War II. He headed to the South Pacific in July 1943 and served as a medic and medical officer in Acorn Fourteen Unit. He left the Navy in 1946 and set up practice in San Francisco as a surgeon/general practitioner who also delivered babies at St. Mary’s Hospital. He also worked at Little Sisters of the Poor nursing facility and had an office on Geary Boulevard, where patients could come without an appointment. He also made house calls. He had met Vivian Rymerson, a fetching nursing student, when they were both at Creighton, and they were married in 1941. Over the years they traveled to many places around the world, but never during football season. They were avid Forty-Niner fans, holding season tickets for many years before they got to see them beat the Bengals in Super Bowl XVI (1986) in Detroit. Most of Dr. Cuniberti’s leisure hours, when not with his family, were spent at the Olympic Club, where he enjoyed a round of golf, followed by dominos and a cigar and sometimes what he called “the best martini in the world.” With his family he enjoyed ping-pong and cards. What most people will recall about him is his unrelenting sense of humor. He made up jokes, poems, and songs and always kept everyone laughing. He is survived by his wife of sixty-nine years, his children, six grandchildren, five great-grandchildren, and hundreds of other people he would count as family: his patients.
E. Trent Andrews, MD, FACS
Dr. E. Trent Andrews was born in Philadelphia on December 14, 1936, to his Afro-American parents, Enos and Gertrude Andrews. After a long, valiant battle with Parkinson’s disease, he passed away at home on October 12, 2010, aged 73. He graduated from Central High School in Philadelphia, Lincoln University, and Hahnemann Medical College, and he interned at St. Joseph’s Hospital in Syracuse, New York. From 1963 to 1967, he served in the U.S. Navy as a battalion surgeon with the Marines. Afterward he completed a residency in orthopedic surgery at the University of Pennsylvania Medical Center, then moved to San Francisco, where he set up private practice. He was on staff, serving on multiple commit-
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tees, at most of the hospitals around the Bay Area. He loved teaching and lecturing and became an associate clinical professor at UCSF. He was always looking for ways to improve surgical techniques, and this resulted in many patents for equipment related to his field. His best known are the Andrews Spinal Surgery Table and the Andrews Frame, used worldwide for more than twenty-five years. Dr. Andrews had a trademark zest for life and enjoyed everything it had to offer. He called himself a “sampler.” He was member of the Flying Physicians’ Association; Aircraft Owners and Pilots Association; Kappa Alpha Psi and Sigma Pi Phi Fraternities; Grand Boule Olympic Club; and the St. Francis Yacht Club. Outdoor activities were his passion, including running, tennis, skiing, scuba diving, and especially sailing. He was able to combine work and hobby when he served as medical director for the Golden Gate Challenge with the twelve-meter yacht USA in the 1987 America’s Cup in Australia. Music, both jazz and classical, was another pleasure. He was also an insatiable reader and world traveler, his most memorable trip being a monthlong dog-sledding expedition to the High Arctic, N.W. Greenland, with his Danish wife, Kaethe. He had a lively sense of humor and a hearty laugh. He loved good food, great wines, and especially conversations with his friends and family. He is survived by his son, Eric Trent Andrews (Joyce) from his marriage to Adrienne East, whom he had met in Philadelphia; second wife, Kaethe, a retired ER nurse; sister Gertrude Baker; niece Terri; twin grandsons, Trent and Marcus; stepson Thomas Carter; lifelong friend Irad; and a host of faithful friends and colleagues.
Victor Gerald Fellows, Jr., MD Dr. Victor Fellows was born in 1923 in Iowa to Victor and Edythe Fellows and passed away October 18, 2010, aged 87, in Hillsborough, California. He was raised in New York, attended Wesleyan University, and graduated from Columbia University Medical School. He did his residency in ophthalmology at Stanford University Hospital and, at the time of his retirement after more than fifty years, was the oldest practicing ophthalmologist in the city of San Francisco. An active yet gentle man, he balanced his love for medicine with his passion for physical fitness, travel, fine wines, Shakespeare, and the opera. His sweet spirit, wry humor, strong personal ethics, and devotion to his family were recognized by all who met him. He is survived by his wife, Audrey; his three children, Susan, William and Robert; seven grandchildren; and his two sisters, Lois Blasseti and Ruth Saunders.
It’s Open Enrollment time for the San Francisco Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees.
• Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings.
Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on January 1, 2011. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.
Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.
46809 (11/10) © Seabury & Smith Insurance Program Management 2010 • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC Companies, including Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).
When was the last time a doctor came to YOU?
At California Pacific Medical Center’s Robotic Surgery Program we are committed to working with referring physicians to provide comprehensive care for complex benign gynecologic surgeries. We are Drs.
Heidi Wittenberg, Leslie Kardos, Pearl Yee and Katherine Hsiao—all extensively trained and experienced using the DaVinci Robot Si, the most advanced technology for treating: • • • •
Endometriosis Excessive menstrual bleeding Hysterectomy Myomectomy
• • • •
Ovarian cystectomy Pelvic prolapse Uterine fibroids Uterine prolapse
The Robotic Surgery Program offers: •
Board certified gynecologists, extensively trained in minimally invasive surgery and advanced laparoscopy
Surgeons specially trained on the DaVinci Robot; as members of the Clinical Robotic Surgery Association, they are both simulation and cadaveric trained and receive extensive proctoring on equipment
With robotics, the conversion rate to open procedures is extremely low. And the advantages to your patient are many:
• Easier and faster recovery • Less pain • Fewer and smaller scars • Shorter hospital stay • Less need for medication after surgery • Less blood loss
We would like to make an appointment to see you in your office. Why? We’d like the opportunity to acquaint you with our facilities, staff and with this amazing technology. We want to explain how it can help your patients, particularly those women with extremely large or multiple fibroids, those who need extensive reconstructive pelvic surgery for incontinence and women who have had difficulty with conception.
Let’s schedule an appointment for a visit to your office: 888-637-2762
San Francisco Medicine, December 2010. Psychiatry for the Nonpsychiatric.