My Doctor in Singapore!

My other blog ‘ informed me that a site called “Doctor World” had started following me. I try to always look at such sites or blogs that follow my amateurish offerings, so I followed the notification’s link and found to my surprise that the Doctor World entity is located in Singapore.

Furthermore, it is an Internet-based medical doctor telemedicine site for service to patients. This surprised me greatly. Reading through the site showed that even I here in the USA could download an iOS or Android phone app and then start to receive services for non-serious medical maladies.

And the rates started at $15 per 15 minutes of consultation. Right inexpensive compared to American rates known for our high cost of medical services. There were other services listed such as come to your home doctor visit which was a little confusing as I inferred that this was likely restricted to just in Singapore and not to my home in North Carolina.

In any case on a humorous note, I can just see me from now on, stating on medical intake information forms that my physician is “Dr. So-and-So in Singapore. I can just imagine the stir that would cause in front office window medical secretaries’ world. “How do we get records from all the way across the Pacific Ocean? etc. “Can we call them on YOUR cell phone?” [to save their phone bills, for which I would not blame them. I am known at my various physicians’ offices for my wacky sense of humor, but I think this would be going too far and perhaps cost me future cheery hellos in my physicians’ offices and maybe lots of other informal courtesies. I can imagine being subtly shoved off the weight scale, the blood pressure being inflated incredibly tightly, the phlebotomist drawing my blood twice because “they all clotted in the first tubes.” Yeah, it could be BAD. Or my digital rectal exam having to be done twice, because “I couldn’t feel your prostate the first time and I know it is still in there.”

On a final note, I cannot for the life of me why this Singapore site is following my mental health reform blog. But I welcome all who do!

Advice to Young Psychiatrists, But Not From Me…

In a recent opinion piece published October 4, 2019, in the freebie psychiatric periodical that most psychiatrists in the USA receive monthly, Psychiatric Times and its column “Couch in Crisis,” Dr. Allen Francis MD, penned a piece, “Advice to Young Psychiatrists From a Very Old One.”

I have chosen to include the entire column that he wrote because of its great advice in the form of 50 tips/recommendations to young psychiatrists. However, I think that its value goes beyond psychiatrists and is of similar value to all mental health professionals who see patients if one leaves out the tips that focus on entirely psychiatrist specific forms of practice and expertise such as prescribing medicines. These tips are very well thought out and of supreme value to promote good practice and ethics. So here goes including the blurb introduction of Dr. Frances. Enjoy and ponder.

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Twitter: @AllenFrancesMD.

I recently came across this compelling tweet: “An open question on mental health as a junior psychiatrist. What do you think I should learn and focus on to be a better doctor and advocate for my patients?

Could there possibly be a better question for all people starting out in any field to ask themselves, and others, as they embark on their careers?

The 140-character limit imposed by Twitter forced me to offer only a brief reply containing five scant snippets of advice. This troubled me—his serious request deserves a more serious response.

Here it is—the 50 most important things I have learned in my 50 years studying psychiatry:

1. Your patients will be your best teachers.

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

3. Focus on establishing a strong therapeutic alliance and healing relationship—the most important goal of any first session is the patient’s returning for a second.

4. Helping serious mental illness is very much harder, but also much more gratifying, than treating mild illness or the worried well.

5. Validate that your patients are currently trying to do their best, but also set a tone of future expectations they will find ways to change themselves, and their world, for the better.

6. Always inspire realistic hope and always reverse unrealistic demoralization.

7. Follow your patient, not your preconceived notions, a supervisor, or a manual.

8. There are no bad or boring patients, but there are some bad and boring doctors.

9. Be as empathic, as caring, as involved, and as alert for the tenth patient each day as for the first.

10.Never lose sight of the practical struggles the patient faces in the real world and try to help them find practical solutions.

11. Don’t be shy about giving advice when advice is needed.

12. Don’t give advice when the patient can find their own way.

13. Include family, friends, other informants, and potential co-therapists whenever possible.

14. Be open ended enough in your questions to let patients tell their life stories; structured enough in your questions to get the specific information you need.

15. Try to create rare magic moments—things you say to patients that they will remember always and use in changing their lives.

16. Take your time and be careful—small mistakes can have major consequences.

17. Know the patient, not just the diagnosis.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don’t worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

20. Educate patients about their symptoms, diagnosis, course, the risks and benefits of plausible treatments.

21. Negotiate, don’t dictate, the treatment plan: allow the patient to pick whichever plausible treatment most suits them—with awareness that no one size fits all.

22. Do not join the bandwagon of diagnostic fads. Whenever everyone seems to suddenly have a diagnosis, it is surely being way overdone (eg ADHD, autism, bipolar disorder).

23. Watchful waiting is the best treatment whenever there is doubt or the symptoms are mild.

24. Placebo is best medicine ever invented and responsible for most of what appears to be “drug effect” when milder symptoms improve.

25. Severe illness is usually easy to diagnose reliably and always requires urgent intervention.

26. Always rule out the real possibility that symptoms are caused by medications, alcohol, street drugs, or medical illness.

27. Don’t be a careless “pill-pusher,” but do understand the great value of medications used wisely for proper indications.

28.  Know the risks, not just the benefits, of medications

29. Educate your patients on adverse effects, complications, and withdrawal symptoms.

30. Be alert to, and try to avoid, drug-drug interactions and include in your consideration all the many non-psychiatric medications the patient is likely to be taking.

31. Start low and go slow especially with young and old patients.

32. De-prescribing requires much more skill than prescribing—learn it well and apply it often to reduce the harms caused by over-medication.

33. Avoid the current tendency toward irrational poly-polypharmacy

34. Learn and use three treatments that are very effective, but relatively harder to use and thus very underutilized: lithium, clozapine, and ECT.

35. Never meet with drug sales people; ignore all drug company marketing; do not believe any study that was funded by a drug company; and educate patients to be skeptical of direct-to-consumer drug ads that misleadingly promote disease mongering.

36. Read the scientific literature with great skepticism and awareness that most studies do not replicate, positive results are always exaggerated, and negative results are usually buried. Do not be wowed by genetic findings—so far, they have flopped in finding causes and have no place in planning treatments.

37. Uncertainty sure beats false certainty. Accept its inevitability;’ dont jump to conclusions; and help your patients deal with the anxiety it provokes.

38. Learn statistics, especially as it applies to medical decision making, and think probabalistically, not in rigid yes/no categories.

39. Have a rich, varied, and satisfying personal life.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

41. Learn from your supervisors, but don’t follow them slavishly.

42. Read widely, especially the great classic novels, and see psychologically astute movies and plays.

43. Read history and try to deduce its recurring patterns.

44. Travel the world to understand the wide diversity of human experience.

45. Do not impose your cultural biases, your religious beliefs (or non-beliefs., or your personal values on your patients).

46. For every complex question, there is a simple, reductionistic answer—and it’s wrong. Don’t expect or believe simple answers to complex questions, such as “What causes mental illness and how best to treat it?”

47. Instead, do have a well-rounded, four-dimensional bio/psycho/social/spiritual approach to understanding mental disorders and selecting treatments for them.

48. Be a vocal advocate for our patients. We must do all in our power to reverse the shameless neglect of the severely ill that has relegated 600,000 of them to jail or homelessness.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.


Is Fortnite Addicting?

WGN in Chicago had a news piece over the weekend that I heartily and snickeringly commend to the reader, “‘‘Addictive as cocaine’: Parents sue Fortnite creators.” Now we have the old saw and trope of a video game being addictive. Some parents in the Montreal Canada area, are now suing Epic Games with that assignation of guild in mind. (And I thought all Canadians were really polite!

I remember as the oldster in me likes to say, when very early games were judged addicting by the moralilsts, including Pong of all things. But back then in the early 1970’s that was basically all that was to be had and played with.

Pong one of the earliest video games

I supppose if you define gaming addiction by the amount of time its sucks out of the player, and how many real life tasks and roles it causes failure in, they can be addicting.

One of the comical things coming out of this story is that the law firm driving the suit, noted in a press release that the game released dopamine like cocaine does in the brains of players. As my son and all his friends, would say in mocking sarcasm, “Well YEAH!”So does watching pro football on tv, would say my spokesperson son of 19 years age and wisdom based on years of gaming. He noted that he does not gamble, do compulsive things, ignore his role in life, fall behind in his studies, waste away, etc.

He did have the final say on this latest tempest in a teacup. He and his friends over the weekend, decided the only way the game could be truly addictive like cocaine, was “if they sprinkled cocaine on the controller.”

Nuff’ said.


Fears of The Joker Movie

The movie “The Joker” starring actor Joaquin Phoenix opened actually last night at the time of this writing (Friday, Oct. 4, 2019). It opened nationally for regular time movie-goers today. And before it opened there was a national flap arising among the nervous types and realistic worriers about the potential effects of this movie.

I want to just reproduce, I hope with appropriate credits for a presentative piece that is and has been appearing in the media nationally warning about this movie. It is of course as referenced in the below article that I have included a URL link for, prompted by the fears that this could set off copycat to the Aurora CO movie shooting by James Holmes at the showing of the Batman movie with a Joker character, “Batman: A Dark Night Arising.” So please read, use the URL link if you wish to go the original article then continue below:

The Joker’ raises concerns about mass shootings; Hosted by Madeleine Brand Oct. 03, 2019 HOLLYWOOD of the KCRW website:

A scene from “The Joker.”

A scene from “The Joker.”Photo credit: Warner Bros

“The Joker,” starring Joaquin Phoenix, opens on Friday. It’s been hailed as one of the best movies of the year, and there’s Oscar buzz around it. 

But in an era of frequent mass shootings, critics (including families who’ve lost loved ones to gun violence) say the sympathetic Joker fits the profile of many mass shooters. He’s lonely, he feels rejected by society, and he picks up a gun to make a public point. 

The film isn’t showing in a theater in Aurora, Colorado, where in 2012 a gunman killed 12 people during a screening of another Batman-related movie, “The Dark Knight Rises.” The Joker isn’t in that movie. 

Law enforcement and the FBI say they were tipped off to a threat of a copycat shooter at an unspecified theater. Some theaters, including in LA, are also beefing security and telling fans they can’t wear any costumes.

At the start of my psychiatric career way back after I finished general psychiatry training and two fellowships, video games started to come out and well as Dungeons and Dragons board game. After full-blown computer graphics hit at the introduction of Windows 95, the new iMac computers in the mid-1990’s, as the video games became more colorful and had decent graphics far beyond the incredibly crude games like Pong and text-based games, the more violent games came out to satisfy the aggressive impulses of teenage boys.

And “lament was heard across the land” to paraphrase some Old Testament warning. The media went nuts over the supposed harmful effects of the early and later (i.e., ever since) shoot’em up games, gory monster and zombie games and all the other genres and game franchises that had non stop violence, dismemberment, blood, gore, splatter bones and dissected spinal cords to name a few. And I cannot get into this subject without mentioning the greatly reviled game franchise, “Grand Theft Auto.” Without which my teenage son now 19, would go ballistic if it were taken off the market…

Back to many years ago. As the video game craze took over and played into a massive market, teenage boys, it became clear this was NOT going to disappear like the overly liberal hair on fire types, AND the right-leaning conservative and especially fundamentalist moralist types wished so fervently. I remember back then when the liberal enclaves thought that such video games would spawn waves of mass murderers as the early Arkansas school shootings had happened by them. Teen boys would be getting guns, pistols and long rifles from devious sources and shooting anybody in sight they were mad at, teachers, parents, their bullies at school, and the guy who had stolen their girlfriend. The fundamentalist right-wingers thought surely the souls of American teenage boys were at risk especially if any of the games had The Devil, Mr. Satan himself in them enchanting players to go out and kill and claim souls for him or whatever.

Like any therapist in mental health, I saw lots of boy gamers. Nobody I emphasize, none of them ever transferred their gaming entertainment reality from the gaming machine and controller at home to shooting somebody in the real world. And that is the nubbin of the issue. The hair on fire types of any political or moral-religious persuasion tends to forget that almost all gamers in my view, are able to keep a solid perceptual and experiential boundary between what is real and what is not real. Games are not real, they are fictional entertainment. Even my patients ranging from neurotics to very troubled kids did not fail to be able to exercise this essential function of the ego, a concept and capability we in psychiatry and mental health call, “reality testing.” That is the ability to distinguish between what is real and what is not real.

This function tends to be diminished or lost in the state of psychosis. When one is hallucinating, one often cannot tell for instance if a voice coming out of the tv, or on the street somewhere, is real or not. Some teens who are psychotic also lose this ability. There are a few cases, but a very minuscule number, of teens who have gotten “lost,” in graphic violent video games in the past 30 or so years that they have been with us. They have taken the stories, legends, narratives, and themes too much to heart, make them a reigning guidance system (if I can coin a term/concept) and committed crimes. They are very very few in truth. Perhaps at most, a few dozen since the phenomenon of mass crimes and shootings have started to be a feature of our national life since Charles Whitman in 1966? at the University of Texas at Austin Bell Tower. I always use that as the start of all this since it was the first one on national tv and for me the first event of its kind in my memory.

I have only seen forensically one teen/young adult who committed a crime that was even peripherally to his involvement with his loner immersion into video games. Forensic psychiatrists with fellowships in that subspecialty which I do not have, and who see such mass crime patients as part of their practices very likely have seen somewhat more, but they are still very rare birds.

So years ago, for the local paper where I had trained and practiced for 20 years. I went out on a limb, or so it seemed in those days with the mass media hysteria starting for the first time about the dangers of violent video games. I had only daughters back then. The main complaint they had back then was that their boyfriends were starting to spend too much time playing video games with their male friends and not dating the daughters enough! But none of their boyfriends committed any crimes. And in chatting with them before or after the dates as I always did, the boys did not show any proclivities toward such and viewed video games with great enthusiasm as they described their games, their point scores, their “winning,” and newfound prowess. And they all talked of a growing telltale marketing and economic phenomenon. They were all saving up their part-time job earnings to buy MORE video games. I realized then that this new entertainment form was going to be a massive moneymaker, even more than it was back then.

My article on video games back then tried to reassure the worriers of all stripes. I talked of teen boys seeing it all as just entertainment. I expressed faith in their abilities to keep the unreality of gaming separate from the reality of everyday life. I talked of my own sampling experiences back then of gaming, trying out a daughter’s boyfriend’s game machine he brought over for me to try out. My daughters and wife were aghast…I later bought one of the earliest machines and proceeded up through the Playstation 3, PSP3 machine. I learned that as an adult, the games quickly became “old,” to me and I habituated to them fairly soon, tired of them and did not show the teen boy continuing interest and some would say, “addiction.” (I grant that some can become overinvolved in gaming but that is another discussion for another post.)

I remember that I received in the local newspaper a number of irate letters castigating my opinion paper. I was a bad or naive psychiatrist. My training program had erred in letting me out to practice. My soul was in danger. One writer wondered if I had been “saved.” A couple of my daughters’ boyfriends followed all this out of curiosity as I had quoted them with permission and notice in the article and they were greatly tickled over the letters to the editor. They also had many teen sarcastic jokes and takes on the whole affair. It was great.

On another note, my 19-year-old son, long a gamer, has not shown any bad proclivities from his gaming except one. He has learned it can make him procrastinate and be late in approaching school homework in past years. He almost had a few academic disasters in high school. That was useful as he learned to master all that mess and now has the science of “time management” in hand, a benefit in my mind resulting from “gaming.” And yes he spends a bit too much money on new games, but it is better than spending it on drugs. And he and his many friends who congregate in our basement gaming and huge computer networking lab, are not secretive or hiding Dark Net exploits. They are forever dragging down there to game with them, and listen to sophomoric humor shows on YouTube that leaves me gasping for breath after my laughter subsides.

The final sentiment-observation in all this. My son and his gang went last night to see the early screening of The Joker movie at some ungodly hour, perhaps midnight. It was a special occasion on two accounts. First, they are all diehard Batman and Joker aficionados. So they went decked out in the best Batman and Joker clothing, Tee-shirts, some had masks (which they had to take off before the theater would let them in; they understood why but were stilled insulted, affronted and miffed since all their masks were very “cool.” Second, the oldest in this gang of friends who have known each other going on 9 years was celebrating his 21st birthday on that very night! They all thought this was the very best way to celebrate, not going out for his first beer, etc. The movie was IT. They had a great time and came right home after it was over, to wake me up to regale me with the details of the movie from start to finish. That took an hour. I was blotto but now I don’t have to see the movie, since I know it for the most part, from start to finish. Eight guys worth of spoilers after 2 a. m. But I will see it with my son for his safe and wishes for Batman-Joker father-son bonding time.

Then they all adjourned to the kitchen so they could raid the refrigerator, eat all our leftovers and massive snacks my wife had cooked for them and relive the movie once again in between or with full mouths of food.

Naloxone for Chronic Pain

My trusty Google search bot fleet turned up this recent article highlighting a recent piece on NPR (radio) that I had not heard or heard tell of as we say in the South since I work and cannot listen to it as much as I would wish. It concerned a trend in utilizing naloxone in treating chronic pain.

This is somewhat significant as naloxone is about as far away from using opioids to treat pain as you can get. Naloxone is used to treat addictions and simply cannot be viewed at all in the same pejorative light as opioids.

Naloxone, without boring the reader with a brainy, academic, overly pharmacologic explanation of the in’s and out’s of this area of “medication-assisted treatment” (MAT in the new parlance of addictionology), is a blocker of effects of opioids and helps to blunt the effects by which opioids and even alcohol induce and sustain addiction. It is both a generic (not a brand name, i.e., not expensive) drug and a brand name form drug, Vivitrol (super expensive and highly promoted by its parent manufacturer.

Naloxone has been around for decades. It has a well-established place in the pantheon of tools to treat addictions, along with, of course, the cognitive therapies and my sentimental favorite the 12 Step programs that I view as all-important in the journey of anyone in recovery.

As an aside, I will never forget my first patient with alcohol addiction as a naive, dumb, unschooled psychiatry resident over 45 years ago at Duke. He was not my then biased stereotype of a problem drinker, someone who had lost almost everything, came into the hospital inpatient service in alcohol withdrawal, etc. On the contrary, he was a professional, respected in his circles, accomplished, educated and showing almost none of the physical issues or stigmata of the ravages of alcoholism. He had relapsed. His treating Duke psychiatrist, my instructing attending was wise enough to ask this man to educate me about his disease. And this was in the days when moral opprobrium still reigned supreme toward alcoholism and addictions. the concept of addiction as a disease was just making headway into the lingua franca of our world then as the new enlightened way to view and approach addictions courtesy of two of then past giants in addictions, the recently late Dr. Herbert Kleber MD then of Columbia University Dept. of Psychiatry and UNC-Chapel Hill School of Medicine’s Dr. John Ewing, a giant in alcoholism research and treatment, founder of the Center for Alcohol Studies.

My patient above told me his ‘story.’ I had the sense to listen to him for as long as he wished to talk. He took me through his life account for well over an hour. I was astonished at how open he was with me about his failings, drinking, failures, and relapses. When I intimated that I would have to digest all that he had told me, he surprised me further. He asked me if I knew about A.A., Alcoholics Anonymous. I answered honestly that I knew very little. I recounted that I remembered my parents taking in geologists and mining engineers from my father’s international mining teams when I was a kid, who had been alcoholics and helping them get back on their feet. I said I only knew that my father had helped them go to AA and that it helped them but that was about the sum total of my knowledge.

My attending’s patient then proceeded to tell me of his years’ involvement with AA and gave me an introduction I would not forget. He helped me to see it as one of the most accepting, supportive organizations ever. I kept thinking to myself while he told me of AA, why weren’t most of our social organizations more like AA? Churches, fraternal orders, etc. I marveled at the trust he felt he was able to place in persons in AA.

However, what blew me away was one of the final points he left me with. He was a traveling professional, who worked in other professional centers somewhat regularly. He told me of how AA saved him from his core internal loneliness and depression that he struggled with. He spoke of his long past pattern of drinking to salve his loneliness in hotels away from home and family in the evenings after he had completed his consultations.

AA helped him to break that many year pattern by going after supper in hotels or restaurants to local AA meetings. He told me that he knew wherever he found himself, there would be an AA fellowship of persons in which he could find acceptance, support and positive booster inoculation against drinking. He described as the western world’s largest support community. I was flabbergasted as I grasped what he was conveying. And I never lost that sense of AA.

Back to naloxone. The article that set off all this in me, “In Tiny Doses, An Addiction Medication Moonlights As A Treatment For Chronic Pain,” from just days ago (Sept. 23, 2019) is well worth the reader’s attention.

One of the issues that might not strike the reader right off is that this long generic, out of patented brand name status, money-making status, has only modest research behind it to explain its now anecdotally reported effectiveness in unrelated pain syndromes. But reports are continuing to surface in some number and frequency that this medication is making perhaps a more and more solid case for more clinical investigation of it in pain control.

But, and it is a BIG but, it has not much potential as a MONEY MAKER. No drug company appears likely to pick it up and develop it as a pain modifying medication. The company marketing Vivitrol is not going to do so as documented in this NPR article.

So this possible more desirable medicine will be left to the backbench of interventions. It is not addictive in and of itself at all, like buprenorphine can be which is also used as an “MAT” medication in the treatment of opioid addiction.

This medication has little support for its use and ‘development.’ By development, I mean good clinical, nationally coordinated research that would establish its “place” in pain control clinical practice.

I think that generic medications such as this with a clearly very valuable social medical potential should be ‘adopted’ by the national research and clinical research arms that be. Monies to support and drive the clinical research that should be devoted to a medication such as this, ought to be easily devoted to its cause. A new mechanism of initiating, driving, funding and sustaining the R&D of such a lowly generic medication ought to exist. I would even propose a policy of supporting monetarily pharmaceutical companies to jointly share somehow monetarily in the sale of a naloxone category of medicine so that the use of naloxone or medicines like it, would not be a marginal effort but part of mainstream medical practice to benefit the huge cohort of pain patients who need an effective non-addicting medication intervention.

Just because a medication would never make BILLIONS for companies as the Oxycontins of this world have done, does not mean it should not be developed in a way that paves the way for its mainstream use and establishes its scientifically based modes of action in the mysterious world of pain.