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Sounds perfect Wahhhh, I don’t wanna

There’s a court case called Tarasoff where a psychiatrist’s patient killed someone, and they found the psychiatrist liable for failing to warn the victim. The case established a “duty to warn” - psychiatrists need to warn anyone threatened by any of their patients that there’s a guy out there trying to kill them. This makes sense and has basically been universally accepted.

The other day I went to a lecture on so-called “Tarasoff expansions”. The guy giving the lecture basically admitted they made no sense. The principle seems to be that if anyone ever does anything bad, people can sue their psychiatrist and and win.

So for example, suppose you treat a psychotic person in the hospital, and after they’re better, you let them out. There are no signs of any problems and they are exactly like all your other successfully-recovered psychotic patients. Then a few months or years later they stop taking their medicine, snap, and attack someone. Can the victim sue you? You bet they can. Can they win? If the judge and jury really want someone to blame, absolutely. The specific charge will be that you failed in your “duty to warn”. To warn who, exactly? Uh, the general public. About what? Uh, that somebody might become a threat a few years down the line.

None of these cases specify what it means to warn the general public. Also, you can’t actually tell the general public about any specific patients of yours, or you could be sued for violating confidentiality. Also also, you have only the faintest idea which of your patients might become violent in the long-term future.

(also, it doesn’t have to be violence. One person got successfully sued under a Tarasoff expansion case because their patient drove under the influence and killed someone in a car crash)

One of my colleagues suggested some kind of non-specific warning. We came up with the idea of hiring one of those skywriter planes to write the message “PSYCHOTIC PEOPLE MIGHT BE TRYING TO KILL YOU” in the air above major cities. Sounds like this can’t possibly go wrong.

psychiatry

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I’ve been thinking a lot about that deFOO cult today.

Families are terrible. I say this as someone with a really great family who have always gone above and beyond to help me and whom I love a lot. I thought families were generally great until I went into psychiatry. But there are so many people screwed up in every way by their family that I’m starting to think I’m just a weird outlier.

I remember a case where I got a call from a distressed father. He wanted to know if he could have his son committed to the psychiatric hospital, because the son was constantly trying to beat and assault and murder people, including the father and other family members. The only problem was that as far as we could tell, this didn’t have anything to do with psychiatric illness. He was just a murderous kind of guy.

The boss said we wouldn’t take him, and told me to call the father back and advise him to press charges and have the son sent to prison. I felt kind of dumped on, because this was going to be an absolutely miserable phone call. Tell a father to have his son sent to prison? I prepared myself to get either yelled at, cried at, or both.

Actually, he was super-receptive and thanked me for excellent advice that he had apparently never thought of before. Press charges against someone just because they tried to murder you? You can DO that? I guess he had just internalized that this wasn’t the way the father-son relationship worked, and resigned himself to probably getting murdered one of these days.

One of the really common AskReddit thread topics is “If you could send one short message to everyone in the world that they had to read, what would it be?” And usually I think of kind of joke answers like “DON’T TRUST SOCIAL SCIENCE HYPOTHESES WITHOUT CHECKING IF THERE IS A TWIN STUDY THAT CONTRADICTS THEM FIRST”, but maybe my real answer, if I were ever in this situation, would be something like “CONSIDER THE POSSIBILITY THAT YOUR FAMILY MEMBERS ARE HORRIBLE, AND IF THEY ARE, TAKE THE SAME SORT OF ACTION THAT YOU WOULD AGAINST A HORRIBLE PERSON WHO IS NOT YOUR FAMILY MEMBER.”

work psychiatry

Anonymous asked:

I'm the guy who failed to specify if he was asking for psychiatry specifically, or in general: it was the first. (If they forced you to learn something that is'nt psychiatry, yet you found deeply worth the effort, of course that I would love to know, too)

I don’t know any amazing psychiatry textbooks. Kaplan and Saddock are the standard, and are much like standard textbooks anywhere - a combination of “pretty complete” and “really boring”. Stahl’s books are the classics for psychopharmacology - I find his actual textbook really boring, but his Prescriber’s Guide is a great resource for learning just the core practically important facts about different drugs. In terms of less-complete and less-well-known sites, I find that The Last Psychiatrist’s actually-psychiatry-related posts are really good and say things really clearly I wasn’t able to understand in more official sources, like the tiered-fountain model of receptor saturation. Also, this guy is fascinating and really knows his stuff despite ticking a couple of points on the crackpot index and being of very variable quality.

I have to give a short presentation on some episode from the history of psychiatry next month, topic is my choice. Any of you know any really weird, really interesting history-of-psychiatry episodes?

(right now the best I can think of all the psychedelic psychiatry experiments of the 60s, especially if I can work in the part where John Lilly’s assistant had sex with dolphins for important science-related reasons)

My experience of the various psychiatric sub-fields thus far:

ADULT PSYCHIATRY
Doctor: What seems to be the problem?
Patient: [says whatever]
Doctor: *prescribes Abilify*

CHILD PSYCHIATRY
Doctor: What seems to be the problem?
Patient: [describes perfectly normal childhood behavior]
Doctor: *prescribes Adderall*

GERIATRIC PSYCHIATRY
Doctor: What seems to be the problem?
Patient: [drools wordlessly]
Doctor: *prescribes Risperdal*

FORENSIC PSYCHIATRY
Doctor: What seems to be the problem?
Patient: [spouts BLATANT LIES]
Doctor: *prescribes Depakote*

ADDICTION PSYCHIATRY
Doctor: What seems to be the problem?
Patient: [spouts BLATANT LIES]
Doctor: *prescribes Suboxone*

LONG-TERM STATE HOSPITALS
Doctor: What seems to be the problem?
Patient: [tries to kill you]
Doctor: *prescribes Haldol*

theunitofcaring

‘laziness’

theunitofcaring

I’m a lazy person.

What I mean by this is that I do not do my homework; I miss deadlines at work because I’d rather play games than do the work; I have projects I’m excited about but instead of starting them I scroll aimlessly through tumblr. I have occasionally failed to turn in important assignments because I didn’t do them because I didn’t feel like it.

Out of sheer curiosity I recently started tracking the amount of time I spend productively, and it was 17%. (This is during the school year). 

My whole life I’ve thought of this like a personality trait. I can’t do things unless they’re interesting because I’m lazy. I tend to get in trouble with jobs and at school because I’m lazy. I hated the personality trait, I wanted to change it, I aspired rather desperately to be a hard-working person and caused myself a great deal of pain trying to imitate one, but I was still thinking of it as some sort of fundamental tendency, some sort of fact about me.

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psychiatry - it works bitches at least one drug does and others have small but statistically significant effects

(patient stories changed slightly to obfuscate identities as usual; please don’t reblog)

I have a patient who suddenly started hallucinating this giant face floating in front of her. She doesn’t know whose face it is but she worries it’s some kind of angel or demon there to judge her. It’s a weird case, I’ve been trying a lot of different things, so far nothing has helped, I’m starting to suspect some really weird organic pathology involving the facial processing region of the brain, and so I sent her to the hospital the other day for some further tests.

Well, I stop off at the hospital this afternoon to check up on her and some other people, and I see they’ve changed their Inspirational Wall to this:

image

YOU ARE TRYING TO INSPIRE PATIENTS USING THE SAME ISSUE THAT I AM SENDING THEM TO YOU TO CURE.

psychiatry

Opinions I heard voiced in a class full of Freudians this week:

1. The patient who developed a new anxiety disorder after being in New York on 9-11 did so because the contrast between the beautiful day and the twin towers falling reminded her of how her mother was sometimes nice and sometimes mean.

2. Women are less moral than men, because the fear of castration keeps men in line, but women have nothing left to lose.

3. Temple Grandin was successful, therefore she must not have really been autistic.

tw dumb opinions tw psychiatry

safer-jug-omens asked:

A while ago, it was decided that anticholinergic drugs increase the already-pretty-high risk of developing dementia. When I go on the internet and try to figure out if bupropion is an anticholinergic drug, I get very conflicting results. It didn't seem to be doing much for me so I stopped taking it as a precaution, but is bupropion "really anticholinergic"?

Yes, there’s a lot of conflicting stuff on this.

image

As you can see here, bupropion has the (5) mark representing anticholinergic activity almost all the way to the right, which means it has very little of it - less, in fact, than most other antidepressants. The Beers Criteria List for anticholinergic drugs to avoid in the elderly doesn’t list bupropion

However, the Anticholinergic Burden Scale gives it a score of +1, for “possible anticholinergic”.

Two things seem to be creating this confusion. First, bupropion is a “pseudoanticholinergic”, which means that it increases dopamine, which has some downstream effect on the acetylcholine system I don’t really understand that causes it to be less active. So it’s downregulating the cholinergic system (SLIGHTLY) without actually blocking any receptors. Second, most drug effects on the cholinergic system are via muscarinic receptors and these are the ones we usually mean when we say “anticholinergic”, and bupropion doesn’t touch these, but it does affect a different kind of receptor called nicotinic receptors which are also cholinergic.

(by the way, all of the news articles that list bupropion as an anticholinergic drug that should be avoided if you want to avoid dementia are just getting their information by going to the Wikipedia article on “Anticholinergic Drugs,” listing the best-known ones on that page, and assuming the study’s conclusion applies to them - I know this because they all use about the same language, and one of them admitted that was what they were doing. But that doesn’t necessarily mean they’re wrong.)

Do antinicotinic drugs contribute to dementia in the same way as antimuscarinic drugs? God only knows. The studies that have shown a link don’t include any antinicotinic drugs, and certainly not bupropion, but there does seem to be some nicotinic reception dysregulation in Alzheimers, and smoking (which obviously agonizes nicotinic receptors) does have some evidence for preventing Alzheimers (true story!) so based on total conjecture about the mechanisms involved it seems vaguely possible, maybe, although without any direct evidential support.

A more interesting question might be - do you, as a person presumably below 65 years old, need to worry about this? I can’t answer that question. All the studies showing a link between AC drugs and dementia have been on people taking the drugs in their 50s, 60s, and 70s. Whether an AC drug taken in your 20s will come back to bite you later is a totally different question. My guess is no, but I have no evidence for this.

None of this matters for you, because you said bupropion didn’t work for you anyway. If you’re depressed and bupropion doesn’t work for you, just switch to an SSRI or something. And good news! SSRIs probably decrease your risk of Alzheimers!

psychiatry
slatestarscratchpad

Anonymous asked:

SS guy again, it looks like the interaction between trazodone and venlafaxine is known to cause seratonin syndrome in some patients: drugs com/drug-interactions/effexor-with-trazodone-2296-1524-2228-0 html

slatestarscratchpad answered:

See, this is why I said that serotonin syndrome was complicated.

Yes, every source will tell you that combining pretty much anything with anything else can cause serotonin syndrome. Heck, just taking one SSRI alone can cause serotonin syndrome in theory if you’re incredibly unlucky. The question is whether the risk is worth worrying about.

Once again, this is the old Science vs. Rationality question. It’s unethical to do a big experiment where we take the top 20 serotonergic drugs, match them with one another in a big 20 x 20 table, and for each cell, give that combination to 1000 people and see how many of them develop the syndrome. So instead, all we have to go off are a couple of irrelevant experiments (this guy got SS on a drug sort of like trazodone, maybe it generalizes!) and our own theories.

Websites like drugs.com solve this problem by just taking anything that has even the slightest chance of doing it and saying “Yup, it does it, avoid this combo”

I think that based on a rational understanding of drug design principles we can do slightly better.

(and if you don’t like rational understandings of drug design, here’s an n = 50 study of the two drugs together that doesn’t encounter any serious problems)

slatestarscratchpad

Also, someone’s going to bring up that there are a few case studies of this (although AFAIK most involve other drugs more likely to be the culprit) so let me tell you about case studies.

A lot of people think case studies mean “Wow, somebody took the time to highlight this, this means it must be pretty important.”

This is sometimes true. Other times it means “This is so rare and completely contrary to the way things usually work that somebody decided to write a case study about it.”

To put it another way, nobody writes a case study on “my patient got a cold”. But if your patient got a cold, and they had some kind of super rare embryological issue that caused there to be nose tissue in their sternum and so mucus started running out of their chest, that is definitely a case study.

But this makes searching the literature for case studies a really bad way of determining whether something is likely to happen or not.

I’ll just tell one story: I had a patient who suddenly developed a mysterious psychosis with no apparent precipitating factors. We gave them an MRI and found an Arnold-Chiari malformation, which is totally irrelevant and doesn’t cause any psychiatric problems and for various reasons there was no way this could possibly be linked to the psychosis.

My colleague said this had to be significant, and after an epic search found a case study from Croatia in 1980 about a patient with an Arnold-Chiari malformation developing a psychosis.

I just glared at him and asked “What percent of people have Arnold-Chiari malformations and what percent of people develop psychosis?” Well, we looked it up, and 0.1% of people have the malformation, and about 2% of people become psychotic at some point in their lives. So about 1/50,000 people should have the conjunction, which means the conjunction should occur in about 100,000 people worldwide by chance, and apparently in one of those 100,000 people, somebody wrote a case study on it. So what?

(later, he suggested that we should write a case study on our patient. I got angry and said we would just be making the problem worse!)

psychiatry
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