Shirah Vollmer MD

The Musings of Dr. Vollmer

Transcranial Magnetic Stimulation

Posted by Dr. Vollmer on April 15, 2015

TMS, transcranial magnetic stimulation, is an FDA approved treatment for Major Depression, but insurance does not pay, and fees are in the 5 digits. As the rate in which new psychotropics appears diminishes, the rate of neuromodulation treatment increases, in a similar way that technology is on such a rapid rate of change, that treating psychiatric diseases with drugs could become a “so yesterday” phenomena. Of course, this could be another tool in the box, an additive treatment, rather than a substitute, but my fear continues to be that newly minted psychiatrists will trust devices more than they trust their ability to use their words, their feelings, and their imagination to help people. Is this large sum of money better spent on intensive psychotherapy? I wonder. Psychotherapy takes longer, a lot longer, and hence one could argue that this is a “quick fix” in that it is usually administered over a period of one month, instead of many years. Like with the promise of the SSRIs, the hope is that we will find some external treatment to fix the complexities of mood and motivation. My bet, as my readers could predict, is that TMS may significantly help a lot of people, but it will very rarely be a substitute for a deeply analytic experience of understanding oneself. Most people restrict themselves from having a richer experience in life, usually due to unconscious forces which lie deep in the psyche. TMS may provide temporary relief to the human suffering of misery, but it will not substitute for the long road of building self-esteem and self-empowerment. There, I have said it again.

See also…https://shirahvollmermd.wordpress.com/2013/04/25/brain-stimulation-literally-speaking/

Posted in neuromodulation | 8 Comments »

Giving “The Gift of Therapy” and “In Treatment” To Psychiatrists! Yay!

Posted by Dr. Vollmer on April 9, 2015

 

The trainees, those committed to a career in Psychiatry , at UCLA, have organized themselves to learn more about psychotherapy. Yes, I am clicking my heels with joy and excitement. Finally! The pendulum of biological psychiatry dominating my field is pushing back to regain the mind, the human kindness involved in healing. At least, that is my hope, as evidenced by this year’s intern class, the class that graduated medical school in 2014, coming together to ask the UCLA Psychiatry Faculty for a Spring retreat in which they have protected time (no on-call duties) in which to get to know each other, and to be introduced to the concepts of psychotherapy. First, in preparation we will read this book, “The Gift of Therapy” and discuss what it meant to them. This book focuses on how psychotherapy provides the unique experience of listening, a gift that few people ever receive in their lives. Learning to listen and valuing listening are essential components that contribute to emotional growth.  Then, we will watch together a few episodes of  “In Treatment” and we will discuss how this fictional psychotherapy show illustrates the complexities of listening. Together, we will free associate to the book and to the episodes in ways in which we will come to appreciate that thinking about thinking is a stimulating and curative endeavor. I am glad I am around to see this change. The hope is that as very young psychiatrists they will “grow up” appreciating the value of the personal narrative, and in so doing, they will resist being pill mills. There is a smile on my face, with a certain guardedness at the same time. This is a positive baby step and we will see if it grows into a new world, which, of course, would be the old world of psychiatry.

Posted in Teaching, Teaching Psychoanalysis | 4 Comments »

Work Ethic

Posted by Dr. Vollmer on April 8, 2015

Another rant about how the world of medicine has changed. In my era, we saw inpatients, which meant that we saw the same patient every day. That patient expected Shirah to show up, and not the “doctor.” Some patients would track when I was on call (sleeping in the hospital, resulting in a 36 hour shift) and they would have the nurses page me in the wee hours, because they wanted to talk to ME, not the doctor on call. I would have seen that patient hours early, during “business hours” but as we developed a bond, he began to see how talking to me relieved his anxiety, as we developed a trust which grew out of spending many daylight and nighttime hours together. Seeing these patients was more than my job, it felt crucial to the well-being of these hospitalized patients. I, like my colleagues at the time, would never think of “leaving early” or “coming late” as we understood that specific patients were counting on us to be there. It was as much my personal integrity, as it was my professional duty to show up and work my grueling hours. Fast forward thirty years and inpatient psychiatry has dwindled, making the Resident’s experience, mostly outpatient. As a result, the Psychiatry Resident never sees the same patient every day, nor does he/she see them every week. Patients are shuffled like cards and they may or may not see the same doctor, at a frequency of once a month or longer. Consequently, Psychiatry Residents do not have the same work ethic, as it is not as critical that they be on time, or show up for a particular patient. The environment changed, and so did the working style. I do not blame the Residents, as I would be just like them, if I were working in today’s environment. Patients depending on you is different than a clinic depending on you. The problem is not that millennials were raised with entitlement, although that may also be at play. Rather, the problem is that the work is no longer personal. If you change the game, then you change both the people who want to play, and how the players approach the interaction. Duh?

Posted in Psychiatry in Transition | 9 Comments »

Belsomra

Posted by Dr. Vollmer on April 7, 2015

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm409950.htm

 

We have a new sleeper on the market which antagonizes a chemical called Orexin. Orexin is a wake promoting chemical which is stimulated by the drugs Provigil and Nuvigil. Nope. I have not used it yet. Yep. I am excited to have a new tool for those sometimes stubborn symptoms of initial, middle and late insomnia, meaning the type of sleeplessness which could be trouble initiating or maintaining sleep. Provigil and Nuvigil I do use and really appreciate. Those two drugs increase wakefulness which is handy for those with chronic fatigue from a variety of sources. It is exciting to prescribe medication and watch people get better. It is even more exciting to bear witness to a new generation of medication which helps people who could never be helped before. Prozac did that for some individuals with irritable dysthymia and severe OCD. Belsomra could also be revolutionary. We will see.

Posted in Psychopharmacology | 2 Comments »

Lab Rant

Posted by Dr. Vollmer on April 6, 2015

Ordering laboratory tests is an important part of my work as a physician. I prescribe drugs which require laboratory monitoring and as such, blood work is important for some of my patients. I write an order. The patient takes it to their lab of choice and results are sent to me. When it is urgent, I tell the lab, and results are given to me promptly. Sounds simple? Well, not so much. As the wheels of payment changes, as patients and physicians are being forced into specific ecosystems, the flexibility is lacking if a patient or a physician is not part of a larger group. Like a PC user who feels foreign in an IOS environment, so a patient that gets most of his healthcare at UCLA will have trouble integrating his medical record if he also goes to Cedars. Example. A patient needed a stat or urgent lab. I called the lab and they said that since I did not have a physician member number, they could do the lab, but they could not do it stat. “Isn’t that unethical?” I asked, wondering how the laboratory has the right to refuse a physician’s order. I got the repetitive answer that I had to sign up with that lab in order to get the blood result quickly. There are politics here, and payment streams and consumer manipulation, all of which I am not clear about, but a laboratory telling me that they refuse to do a stat lab because I am not a frequent flier, just seems wrong. Rant complete.

Posted in Psychiatry in Transition | 2 Comments »

Andreas Lubitz

Posted by Dr. Vollmer on April 3, 2015

27 years old. Premeditated murder/suicide. 149 innocent victims. h/o depression with suicidal ideation. What of it? How do we make sense of these facts? As a psychiatrist, what are my thoughts on the matter? For a week I have thought about my perspective, wondering how I reconstruct this story which has no answers and only questions. As this is also the eve of holidays in which many family and friends get together, Mr. Lubitz might make it into dinner table conversations. For the families of the victims, there are simply no words. For the world, there is fascination and quick answers, hoping that the next plane we step on, or the plane our loved ones step on, does not suffer this tragic fate. My first point is that I want to rid the world of the shock value of these tragedies. Like school shootings, or suicide bombers in the middle east, there is a  small group of people, who will take harmless victims with them to the next world. This will always happen, and there is no way for psychiatrists, or anyone else to fully prevent these tragedies. For a variety of reasons the perpetrator of these crimes believes that this murder-suicide is justified, and as the human brain can convince oneself of almost anything, once the brain is convinced, the behavior follows and terrible consequences ensue. To be shocked by this behavior is to be naive to human nature. Most humans want to help others, but a minority of humans do terrible destruction. This is our landscape. To pretend that is not true, is denial. The shock of Andreas Lubitz behavior is evidence of this denial. My second point is more difficult to articulate. Mr. Lubitz has a history of depression with suicidal ideation and he sought medical care immediately prior to this event. Does this mean he was mentally ill? Probably, but we will never know, unless the physicians who evaluated him can disclose their findings. Assuming he was depressed and a danger to others, then he should not have been allowed on that plane. However, it is rarely that clear. He may have been vague in his description of his mental state, and he may not have mentioned that in his suicidal ideation he was contemplating taking down innocent people. A psychiatric assessment includes asking about homicidal ideation, but his answer could range from “sometimes I hate people” to “I can understand the man who did Sandy Hook.” The privacy laws in Germany are not clear to me, and so I can only imagine if Mr. Lubitz walked into my office in California. If he specifically stated that he was going to take the plane down, then I would call Lufthansa immediately. However, the likelihood is that he hinted at his plan without being explicit, leaving, I imagine,  the five doctors he saw prior to the plane crash in terrible despair, desperately trying to remember exactly what he said. Unfortunately, the relationship of mental illness to violence is not clear. Our most clear understanding of behavior comes from the past and from family  history. The adage that past behavior predicts future behavior holds true. I do not know what is in Mr. Lubitz’s past, but I suspect he had no violent history, making this event even more difficult to predict. My final point is that as awful as this tragedy is, we need to acknowledge that we are terribly inadequate at predicting these events, and hence having two people in the cockpit at all times is a good intervention. Trusting passengers to one pilot will ensure that this tragedy will repeat.

Posted in current events, depression, Media Coverage | 1 Comment »

Where Have I Been?

Posted by Dr. Vollmer on April 1, 2015

 

I went dark there for a bit, compelling me to talk about my professional transitions. First, I am slowly working on making my office an electronic, moving into our digital world, with all the associated fears and excitement. My first goal is to e-prescribe, giving my patients the freedom to go directly to the pharmacy without the hassle of dropping off a prescription. My hesitation thus far has been that scheduled drugs, meaning stimulants and sleeping medications, require more sophisticated software to e-prescribe and so that limits me considerably. Still, I am going to take the baby step of e-prescribing to those who do not take regulated medications. This will give me mobile access to more information and it will make information management simpler. On the other hand, privacy concerns are huge, as is the dependence on connectivity. I can still write prescriptions, but with each baby step, I get more and more dependent on the internet.

Second, I am expanding my clinical practice to include an emphasis on “recovery” patients, meaning those people who find themselves wanting (and usually needing) to clean themselves from dangerous substances. This is an exciting expansion for me, as I am curious to drill down into the psychological underpinnings of self-harm. Self-harm, in big ways and small ways, has always been a major emphasis of my practice, but adding a focus of substance abuse expands my understanding of the human mind. My inquiry, my passion, for hearing a person’s narrative fits well with helping those who are seeking to start a new chapter. My understanding of psychotropic drugs both helps me understand some of the consequences of their addiction as well as helping me use prescription drugs to decrease their suffering while they transition from substance dependence to sober living.

These two areas of expansion have consumed the part of my brain which allows me to post often. As I settle into my new routines, while maintaining my previous focus on private practice and teaching, I hope to resume frequent postings. Thank you, readers, for your patience.

Posted in Musings, Psychiatry in Transition, Substance Abuse | 2 Comments »

NYer Cartoon

Posted by Dr. Vollmer on March 23, 2015

I knew I would be replaced by a robot, but I did not know I would be picking up a robot.

Posted in Cartoons | Leave a Comment »

Teaching Child Psychiatric Assessment

Posted by Dr. Vollmer on March 11, 2015

A child comes into the Emergency Room because the parents are worried about their behavior. The adult psychiatry resident, not schooled in child development, is called to make an assessment, to triage this patient. Send them home, admit them, call for help, these are the choices. My task today, in one hour, so nearly an impossible task, is to teach psychiatry residents how to begin to triage these children and adolescents. Given that I do a three-hour assessment, and the reality for these residents is that they have, at most, one hour to make this decision, I need to help them pare down my three hours, such that they distill the most important clinical issues. Clearly, this is an inverse situation, in that I, with more experience, could do one-hour assessments, and these residents, in order to learn, should be given three hours, but alas, that is not the current reality.

I will begin by helping them think about where the presenting problem lies?

Emotional?

Cognitive?

Physical?

Behavioral?

Behavioral disorders are the most acute, since those issues can lead to immediate self-destruction or harm to others. We all worry, I will tell them, about seeing the next school shooter, and somehow, tragically, missing the acuity of the situation. At the same time, we know that we will let children and adolescents out of the emergency room, only to find out later, that violence ensued. Our tools are flawed. Our ability to predict, hopelessly fallible.

Next, I will talk about how to get a history, by thinking about the child in four domains.

Family Situation

School Functioning

Community Functioning

Cultural Issues

Returning to the reason for landing in the Emergency Room, the major questions are “why now” and “says who?’ Pre-pubertal children can usually, but of course, not always, return to the care of their parents, but post-pubertal adolescents are much more challenging because they have the means to independently cause destruction. On the other hand, if the parents are part of the problem, or if there is any suspicion of abuse, then the Psychiatry Resident is charged with contacting the authorities, with the possible outcome that the child will land in an emergency foster care situation. The dance between being sympathetic and suspicious of the parents begins. Likewise, this same dance with the child begins as well. Is the child a victim of his circumstances or are the parents victimized by this child, or is it some combination? Eventually, after the data is obtained, both by direct interview and record review, the resident is charged with making a diagnostic formulation and treatment recommendations. Finally, these ideas need to be conveyed to the parents in a way which minimizes defensiveness, as talking to a parent about psychiatric issues in their child is a very delicate conversation. As complicated as all this is, the most challenging issue will be finding outpatient referrals. Child psychiatrists are in short supply, and as such, most families have tremendous difficulties finding good care. Further, the good care that is available is not always well-known to those that work in emergency rooms.

At the conclusion of my lecture, as most of my teaching goes, there is usually a heavy feeling associated with the uncertainties in our field, which is tied together with huge responsibilities, leading to an uncomfortable sense of fear and uneasiness in the provider. I will joke about how this uneasiness might be correlated with the shortage of child psychiatrists. Maybe though, this is no joke.

 

Posted in Child Psychiatry, Teaching | 2 Comments »

Sonia Nazario

Posted by Dr. Vollmer on March 9, 2015

soniaheadshot2

http://www.enriquesjourney.com/about-sonia/bio-2/

 

The best talk I have ever heard. She presented her investigative reporting about a boy named Enrique who fought incredible odds to find his mother in the United States. He traveled through five countries, as a twelve-year old, in search of his mother. As Ms. Nazario says, storytelling is the best way to help people understand, and indeed, she told an amazing story. What was gripping and sad about her tale was that she mirrored his journey, herself, so that she could convey the determination and the tenacity that these children, these young people, who cross multiple borders in search of a parent. Her emphasis on wanting to tell Enrique’s story, mirrors my daily attempt to understand my patient’s story. It is through understanding the narrative, the tale, that we connect as human beings, and we reach out to each other. If we do not take the time to understand the story, then we miss out on understanding the common humanity. I cried and cried as she illustrated the danger that Enrique faced, day after day, and yet he persevered, and yet she persevered in parallel. Sonia first told her own immigrant story, and then told Enrique’s story, and at the end she tied them together, as if they were one tale, as if there were more commonalities than differences. She was right. The deeper you dig, the more the differences drift apart. Rarely, am I that moved by one speaker. Sonia Nazario did that for me.

Posted in child abuse, Child Psychiatry, Child Psychotherapy, child safety | Leave a Comment »

 
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