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.”

Safety contracts are a tool in psychiatry where you get patients to formally promise to take certain actions if they start feeling suicidal. The research doesn’t really support them, but they’re pretty common anyway.

I just learned that my boss writes really formal safety contracts in Olde English and seals them by making his patients swear a formal oath with their hand on a copy of the DSM-V.

A psychiatrist I work with recently learned through the obituaries that one of her former patients had died. She was upset, both because it’s always sad when someone you know dies, and because she didn’t know what he died of and hoped that it wasn’t because of anything she did or didn’t do (he was really young, like 45, so something must have gone wrong, and he was on a lot of medications, and all medications have potential side effects).

I suggested she look at his medical chart, since whatever killed him probably landed him in the hospital first, and since as his doctor it is 100% her right to view his chart (much of which she has written herself).

She said she’d asked about this, and the hospital lawyer had said she should not look in his chart, since our electronic chart system logs whenever anyone looks in somebody’s chart, and if his family sued over his death then looking in his chart might hurt the hospital’s case. The exact argument would be something like “This doctor was obviously curious about what killed Mr. A, which could have been because she wanted to know if it was her fault, which means it was something she considered a strong possibility.”

I guess this might be something a lawyer could argue. But we’re a teaching hospital. The whole point of our being at this hospital is to learn how to treat patients well. If we’re not even allowed to check whether something killed a patient or not, that makes it kind of hard to get any feedback and learn not to do patient-killing things.

If you come to a psych ER saying “Help, I have no money and no friends and I want to die,” the first time we will just hear the “I want to die” part and admit you for depression + suicidal ideation. We will give you some antidepressants, one to two group therapy sessions, and if you are lucky also a piece of paper with the names and phone numbers of helpful social services.

If you come back a month later saying “Help, I still have no money and no friends and want to die,” we will look at each other awkwardly, then admit you for “treatment-resistant depression,” because we feel bad and we don’t want to just do nothing. We will switch your antidepressant to a different antidepressant. We can also give you another sheet of social service phone numbers again, but it will just have the same ones as last time.

If you come back a third time a month or two after that saying “Help, I still have no money and no friends and want to die,” we will politely inform you that the psychiatric hospital might not be the right place for you, and wish you luck finding other means of support. If you ask us where else you can go, we will tell you that we are very busy and we have lots of other patients to see, and maybe give you the same list of social service phone numbers again.

I wish there was a social services ER that I could transfer people to.

It’s only 12:00 on my call night, and I am already just one more depressed person’s life story away from becoming one of those supervillains whose origin story is that there is so much suffering and evil in humanity that it would be better off destroyed.

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)

Tonight an Armenian man was admitted to the psychiatric hospital on an emergency basis with some kind of really serious psychotic break, but we couldn’t figure out what was going on with him because he didn’t speak English.

So we called the hospital administration for an Armenian translator, which is apparently complicated at the best of times but practically impossible on Christmas Eve. Finally somebody agreed to come in from far away, but he seemed pretty confused and angry by the whole thing and didn’t actually speak English that well. My boss tried to explain the situation to him, but he wasn’t interested and might not have even really understood. He just demanded “Take me to man, I will translate.” So we did.

So the translator goes into the patient’s room, and the patient gets really excited and starts talking in Armenian in this very animated way. The translator gets more and more upset, and finally he takes my boss into the corridor outside the room and shouts,

“THIS MAN IS A FUCKING LUNATIC!”

Online continuing medical education courses are notorious for being easy. Doctors are required to take some, but there’s no rules about which ones they have to take, and they all cost money and are for-profit enterprises. The companies have figured out that if they fail people, those people probably won’t be return customers, so they make it hard to fail.

The course I’m taking now has a pre-test which is word-for-word the same as the post-test. This is fine. It helps me figure out what to watch for when I’m taking the course.

But they seriously just copy-pasted the post-test. So much so that one of the questions on the pre-test is “how did you like this course?” You’re not allowed to begin the course until you tell them whether you liked it or not.

I said it was okay.

Lots of people seem to agree with me about making FDA approval easier, but every so often I flirt with a much crazier position - I think we need to overhaul the prescription system, with less of an emphasis on making people get constant prescriptions from doctors every time they want to take drugs. Let me give an example.

Yesterday I was called in to evaluate a patient who had attempted suicide. He’d attempted suicide because his pain was so bad. His pain was so bad because he “couldn’t afford” the one medication that could control his pain.

(I’m being deliberately vague for confidentiality reasons, sorry)

I looked up the medication that could control his pain on GoodRx.com. It costs $5 per month in our area. This guy was poor, but not so poor he couldn’t pay $5/month to prevent pain so bad it made him want to die.

Turned out the problem was: he’d been receiving the medication happily for a couple of years, getting new prescriptions from his doctor each month. Then he lost his house. Somehow his Medicare (Medicaid? I can’t remember) was tied to his home address, such that by missing some stuff they sent to his home address he lost the insurance and had to re-apply for it. This took however long it takes to re-apply for things with government agencies. During the interim, he had no insurance. When he had no insurance, he couldn’t afford to see a doctor. Without a doctor, he couldn’t get his monthly refill on the prescription that he’d been receiving without any problem for years. So he couldn’t get the $5 medication he needed to control his pain. So he decided to commit suicide.

This is an interesting case because it cuts through a lot of the pat solutions that people have for these kinds of things. “Oh, just regulate the price of everything!” Wouldn’t help. I guess making applying for government insurance less bureaucratic would help, but good luck with that.

I know this isn’t the most consequentialist way to think about things, but imagining that I’m in terrible pain, and there’s a medication which I *know* works, and which I’ve used safely for years, and which only costs $5, but nobody will let me buy it because I don’t have an Official Piece Of Paper from a suitably credentialled rich person, would make me…well, it’d make me want to kill myself.

Sometimes we have to transfer psychiatric patients from our hospital to a different hospital. Usually it’s because they came in for a medical problem, somebody realized during their stay that they also had a psychiatric problem, but our psych unit is either full or doesn’t take their insurance.

Regulations say that every transfer from one hospital to another has to be done by ambulance. It doesn’t matter if the patient is in the hospital for depression, or obsessive-compulsive disorder, or something else where it’s hard to see why an ambulance would be necessary. If we send them by some kind of transportation method other than ambulance, maybe they’ll have a heart attack, or decide to commit suicide mid-taxi-ride despite never having been suicidal before, or whatever, and then someone will sue us. So those are the rules. Every transfer has to be done by ambulance (this adds a few thousand dollars onto their final bill, but whatever, that’s the insurance companies’ or the taxpayers’ problem, right?)

Ambulance companies refuse to transport psychiatric patients without a petition. A petition (technically a clinical certificate; to real lawyers the petition is something else) is an official legal paper signed by psychiatrists saying that somebody is a danger to themselves or others and needs to be hospitalized against their will. The ambulance companies say that if they don’t have that, then the patient can just ask them to get off the ambulance at any point, and they could get sued if this caused problems down the line. Or something. I don’t really know what the ambulance companies are thinking.

The problem is, a lot of the time we want to transfer patients who aren’t dangerous or in need of involuntary commitment. A lot of times there’s a depressed person at our hospital, and they’re not suicidal or homicidal or anything, and they’re asking for psychiatric help, and we want to give it to them, but our hospital is full and we need to send them somewhere else.

So the first thing I tried was just to tell the ambulance companies “Yes, we’re sending this patient to another hospital. No, they’re not dangerous.” The ambulance companies said they didn’t care. No petition, no ambulance.

The second thing I tried was explaining this to the patient. “I know you’re requesting to come into the hospital voluntarily, and I know you’re not suicidal and you’re just looking for help, but for bureaucratic reasons I just have to sign this paper that says you’re a grave danger and takes away all of your rights. It doesn’t actually mean anything and it will probably get thrown away after the ambulance ride, although really that’s the other hospital’s call and if they want they can just keep it and then you’ll continue not to have any rights.” This was not popular among patients. Also, it turns out that the legal document says “THIS IS AN OFFICIAL LEGAL DOCUMENT AND YOU HAVE TO SWEAR EVERYTHING ON IT IS TRUE AND IF IT ISN’T THEN YOU ARE GUILTY OF PERJURY AND CAN GO TO JAIL”, so I’m kind of wary about falsifying it.

Now what I do is give the ambulance companies a petition, but instead of actually filling it out I just write in the comments field that the patient is fine and no legal action is required. Whoever is on the receiving side apparently just confirms that they received a petition-looking piece of paper, nobody reads any of it, and the patient gets sent where they need to be without me risking a jail sentence. Although I guess if the patient ever decides to just stop the ambulance and get out halfway, and then gets hit by a car or something, I’m going to get in a lot of trouble.

Everything in medicine is like this.