Shrink Population is Shrinking

In a not so surprising but still distressing article in Health Affairs, Jul 2016, Vol. 35, No. 7, pp. 1271-1277 entitled: “Population Of US Practicing Psychiatrists Declined, 2003–13, Which May Help Explain Poor Access To Mental Health Care,” discussed the long-standing decrease in the population of psychiatrists in the USA. This has been one of those long predicted results of issues that started in the 1980’s that were decried by legions of psychiatrists at all levels of psychiatric “guild” organizations from the American Psychiatric Association to the Amercian Academy of Psychiatrists, the Academy of Child and Adolescent Psychiatry and others. This all fell on deaf ears and in the Reagan era of deregulation, and prejudicial cutting off funding especially for the “social” professions [read the professions such as college professors, and mental health types, all viewed with varying degrees of suspicion, after all, “social” is close to “socialism” “right here in River City” to utilize the wholesome hysteria of the movie “The Music Man,” of decades ago].

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Modern Deadly Ambiguity: Mass Shootings, Guns and the Mentally Ill

The media is now filled with various statistics quoting the factoid that in over 200 days we have had over 200 mass shootings in the United States. Mass shootings are variously defined as a shooting incident in which three, or now more commonly the definition requires four victims by a perpetrator. The victims may be all in one site like the James Holmes Colorado theater shooting, or in more than one location where a shooter will shoot usually first members of his (recalling that most mass shooters are male), a spouse or estranges spouse or intimate partner, and then shoot members of the public at another location.

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National Psychiatrist and Child Psychiatrist Shortage

In my previous life some two decades ago as a young Turk clinical teaching and supervising faculty of psychiatric and child psychiatric residents and fellows in training at Duke Medical Center, I became interested in “manpower” (the vernacular then) or more properly speaking practitioner distribution and training issues of psychiatrists. This was in the so called Golden Age of mental health practice, even though the service delivery system in all disciplines, had serious issues, I and many many others could see the troublesome issue of maldistribution of mental health care professionals that was emerging three decades ago and worsening  year by year. Basically what was evolving was a situation in which desirable places to live, urban areas with urban amenities such as the symphonies, ballet and performing arts companies, university centers, and above all many colleagues around for support and lively continuing education meetings of regional psychology, social work and psychiatry societies, kept graduates of advanced training programs in the regions in which they trained. So over time, it evolved that areas like Boston/Cambridge MA, Raleigh-Durham-Chapel Hill NC (the Triangle Area), Ann Arbor MI, Dartmouth, New York City especially Manhattan, Stony Brooke, Long Island, Houston, Los Angeles, San Francisco, Seattle, Eugene OR, San Diego, Davis CA, Charleston SC, Atlanta GA, Birmingham AL, Albuquerque, Tucson AZ, and many other urban areas became the landing places where psychiatrists trained and often stayed to practice, in the university medical center cities. A good friend and colleague, now passed on Bruce Neeley MD of Duke and Emery, used to give lectures to residents nearing the penultimate stages of their training careers and were a year away from the decision of where to settle to practice. By then the 1980’s the trend had become set in concrete, only a minority of graduating psychiatrists left the training centers and set up practice in under-served areas.

Bruce Neeley and I separately in turn would give almost off the records seminars to the ‘senior residents,’ telling them in so many words, almost like the famous newspaper editor of the 1800’s, “Go West Young Psychiatrist,” In North Carolina we first meant go literally to western North Carolina which I knew very well because of my wife’s origin from Cherokee NC. But we also meant “get out of the urban centers, there are too many of us here already.”

WNC then and sadly still is vastly under-served by psychiatry with a chronic shortage that is almost criminal. I can count on the fingers of one hand the number of child psychiatrists in practice west of Asheville and that is a lot of territory. I used to tell senior residents to “Get out of the RTP [Research Triangle Park, another term used to denote the entire Raleigh-Durham-Chapel Hill area since each of those cities incredibly are only 8 to 15 miles from each other!

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Josh Duggar reportedly enters “treamtnet”

Yesterday I posted painfully after much professional self deliberation on one segment about the evolving soap opera of “America’s Family,” the Duggars, the TLC channel tv family with “19 and Counting,” children. This show had been on for years and as it turned out was too  good to be true. It emerged earlier this year that the eldest son who molested young girls outside the family and as a teen had incested reportedly two of his own sisters. The family concealed all this from the TLC folks and just about everyone else. They referred the lad for “treatment” {and truly I use that term very loosely and with the greatest of reservations] to a friend of the family, a law enforcement person who put him to work for three months, had no mental health experience and as far as is known this lad received no real counseling, and was not reported as sex offender which the media seems to have forgotten would have been the legally mandated duty of this officer. The family waited until the statute of limitations was expired for such a crime of an adolescent, then the story started to emerge when the son was the front man for a Christian morals advocacy organization and his escapes even as an adult were emerging.

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The Treatment of Multiple Sclerosis as a Metaphor for Schizophrenia

Multiple sclerosis, or M.S., is a devastating, chronic, debilitating illness, that has defied until recently most treatment approaches. It hits the young adult in the prime of life typically, more young women than men. It is like ALS though much slower, and not quite as destructive neurologically as ALS but well bad enough. Only in the last two decades or so, have treatments started to be even minimally effective. I have followed M.S. patients in my decades of psychiatric practice since I started in the neurosciences, brain science as a collegian, then aspired to go into neurosurgery before I decided on psychiatry as a medical student. I have long enjoyed practicing medical centers and general hospitals on the “psychiatry consult liaison services,” almost specializing in seeing neurology patients and M.S. patients most of all.

M.S. is like many other chronic illnesses. For decades we had only paltry symptomatic treatments. That is to say, our treatment only treated symptoms, or brought episodes to a close and did not treat the etiological, causative basis of M.S. When one had a flare of M.S. with “shorting out,” loss of a sense, use of a limb, sight, balance, etc., then one was given intravenous treatments with whatever immunosuppressant was in vogue at the time. These over the last 40 years or more have included ACTH, prednisone, methotrexate, bee venom (which like many other briefly popular treatments, did NOT work) and other agents de jure.

Then the advent of more scientifically based, more specific anti-immune system based medications came out in the 1990’s, the family of the interferons. These were much better for many M.S. patients at stopping an episode in its tracks than the previous agents. But they had like so many modern medicines in all branches of medical practice, enormous side and adverse effects. Betaseron based medicines tended to be given by injection shallowly into the subcutaneous tissues every other day and would cause in the vast majority of persons, a day of in-the-bed-flu like syndrome. “Flu without the flu” as many called it. And on an every other day schedule, you got the shot, had the flu and then the next day when the flu like aches and low grade fever and fatigue passed, you got your next shot and braced yourself for starting to feel bad physically that evening…it was awful and many many patients tolerated this for years and then en masse stopped the interferon based therapies. A newer, slightly different family of agents came out nearly a decade ago but were no better.

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