Sunday, August 22, 2010

The Author's Show- Tuesday August 24th all day

I will be on the Author's Show This Tuesday August 24th.
Interview with Don McCauly

Click on The Link Below to Listen:

The Author's Show Internet Radio Program

Sorry link works now.

Friday, August 20, 2010

Is Alzheimer's a mental illness ????

This seems to be such a common question and issue. Everyone wants to know the answer. I have blogged about this in the past, but the question still comes up all the time. If it is not a mental illness does that make it better? If it is a mental illness, well does that somehow make it worse? Does it make AD less real if it is a mental illness.

When my mother developed AD, it was so shocking, so furious, so heart-breaking, I don't remember ever really pondering that question, because I was so overwhelmed, so bewildered, my head was spinning. Being seventeen at the time, it felt like I had a million things on my mind already. The whole process was like a waking dream.

My book "When Can I Go Home?" speaks to that waking dream. It also speaks to the process of me becoming a doctor and a psychiatrist- much of that process happened while she was dying from the disease.
For me a related question is, did I ultimately choose psychiatry as a specialty, because my mother had AD, and she had it long before I was anywhere near going to medical school.

I mean I could have entered and specialty right? God knows my life would have been a lot different if I had. Life would have been a lot less of a financial struggle, I would not have faced so much disdain and prejudice, because of the horrible stigma we place on mental illness. That stigma is why the question of AD being a mental illness is so important and why we place so much emphasis on it.

People with mental illness face it every day. It is parallel in my world. Let me explain what it is like. For so many people there is something uncomfortable, disquieting, "icky" about being a psychiatrist and mental illness in general. When someone learns a person is a physician, it immediately conjures up biases, stereotypes, preconceived notions. People might think you are smart, hard working, or a weasel, that your are no better than them, and all the usual chip-on-the-shoulder things and biases we have about physicians. Some still respect you as a person more than if you were not a physician.

But as soon as you advise your are a psychiatrist, my God, do peoples' expressions change. Many people get that "icky" disquieting feeling. They are also let down in some fashion. The ideal of a physician and all the underpinnings is gone. "Not the same as a real doctor"

Why do we consider the whole concept of mental illness as something subhuman, something more related to morality than a clinical manifestation? In our prejudicial minds the leap between someone having mental illness and their questionable integrity and questionable character is not a leap, but a thin blurred line.

So if you are a good person with good character from a family of good and decent character and someone gets AD, does that mean somewhere along the lines there was a breech of character, someone did something wrong? If it is NOT a mental illness then no intergrity or character issues right? Sort of off the hook. Moreover if it is a mental illness, then on some level would that not mean it is less than real- at least in the sense that if the person tries harder, than maybe it will go away. If we just figure out what that character flaw is.
If you have mental illness you know what it is like to be treated a little bit less than human, to have your character called into question, that prejudice, that bias, that icky feeling and manner other people present to you because you have mental illness. If you don't have mental illness, imagine what it would be like to have to live with that bias. I mean real imagine it for a second.

So AD is not a mental illness or a "functional" illness in this way: You can see it, you can find the amyloid plaques, we are moving closer to being able to test for it- checking spinal fluid, biomarkers. Therefore it is legitimate. It is real. We have tests and we can tangibly SEE it. But here is the problem, this is why we want to know if it a mental illness. We as family members are in the twilight zone. A gray area:

The everyday CLINICAL world lags behind the RESEARCH world, by 10 or 15 years.
Right now you can't routinely see it on a blood test, or a really good MRI or CT, you can see non-specific atrophy of the brain consistent with it, but you can't really definitively see it, unless you look at brain tissue on an autopsy, after the person has died from it. At least in 2010, thats the everyday reality we are all faced with.

Here's how Alzheimer's is a mental illness is 2010. We can't really see it on an x-ray or any blood test that you or I or most Americans may have access to. Nor with the deterioration and reduction of health care delivery, non of us are going to have much access to the evolving sophisticated research anytime soon, the same research that politically helps legitimize Alzheimer's disease.

-Alzheimer's disease affects behavior, actions, thoughts feelings personality, cognition, a persons manner of relatedness to others, all those things we conventionally equate with "MENTAL ILLNESS.

My mother had changes in her personality, and behaviors, sometimes it was odd, sometimes bizarre, sometimes not, but there were changes. Most AD victims do have these at some point.  AD makes your brain deteriorate. You brain regulates behavior, personality, something has to do this and it is the brain. behavior and personality are not random or coincidental happenings.

A neurological disorder is so legitimate, a psychiatric disorder is not legitimized in our society.
The best answer to the question is "Alzheimer's disease is a progressive neurological disorder with overlapping psychiatric symptoms. Alzheimer's disease is a progressive deterioration of the brain. The brain regulates behavior and personality. In our society we have severe bias and prejudice toward mental illness and pass judgment harshly on psychiatric disorders but not neurological disorders."  That's how I would answer that right now. There just is not a perfect yes or no answer. The correct answer is both, the more correct answer is, it does not matter, If you say yes it is a mental illness, you would not be incorrect but it immediately changes our views of the disease, based on our biases. If you say NO it is not a mental illness, we all breath a sigh of relief. We feel a bit better in that disease is legitimate. 

In the end the question does become irrelevant as you or your family member struggles with the diabolical process. It does not really make the process easier to know it is not a mental illness. 

Remember people with mental illness are just people, they have feelings too, hopes, dreams, just like everyone else. People with mental illness can develop Alzheimer's disease, just like people who never had mental illness can also get Alzheimer's. The behavior and personality changes associated with Alzheimer's can be at times crazy, bizarre, strange weird, it is upsetting and disquieting. The person is not doing it on purpose, It is not a sign of character, or something we have done right or wrong in our lives. The same can be said for mental illness.

The health care world incidentally and ironically has some of the strongest and worst biases about mental illness. As a psychiatrist, I face it from other doctors, maybe not as much as from other non-physicians that work in the health care field, but it is there. There are also so many people in the Alzheimer's world- caregivers, health care workers, bureaucrats, that have this bias, it is so Hypocritical, two-faced and not very humane, but it is where we are at as a society. Something we don't like to talk about or admit, Alzheimer's=neurological, mental illness= uncomfortable, "icky".  Let's admit that prejudice and start growing up and working past it.

Until we start getting over ourselves and becoming truly humane towards all disease states, and people suffering from them, including mental illness, you are not going to see much true progress. towards treating the aging population with respect, dignity and honor. After all if it is easy to secretly judge people with mental illness, it is not easy for the fascist, intellectual, politically superior to exploit this?- to  place less value on the aging and the elderly and those with Alzheimer's disease?  Get it? We are talking out of both sides of our mouth when we distinguish Alzheimer's as not a mental illness.  It is easy to exploit that paradox, that is part of the reason why we have not advanced much in our society in our understanding of Alzheimer's, and we ponder the question of AD being a mental illness. It is a vicious circle. Throw in the health care debacle and limited resources, and you are one step away from the E word, euthanasia.
Hence cost savings- euthanasia. free thinking atheist, cool people with certain correct, political views= forward thinking know- it-alls? utilitarian,- grow up.- most people will get old some day, and all that youth driven narcissism won't really matter will it? "How many people under thirty years old, say "well if I ever get like that just shoot me!"
It's all our faults, it's how we are raising up our kids, generation after generation.

Here is an a paradoxical,  optimistic point, I believe the legitimacy of AD will be hammered in stone  (in other words the clinical world will catch up to the research world, and we will have everyday access to the legitimizing tests that unequivocally convince us that AD is a clinical disease) this will happen long before the stigma and prejudice toward mental illness is obsolete.

If I was a policy maker, or if I worked for a nice big non-profit and could lobby for AD all day, I would lobby that the question of Alzheimer's disease being a mental illness is irrelevant. I wouldn't spend all day working to draw that line ion the sand, that distinction for society. It Exacerbates the stigma, to argue the point.

So my mother's Alzheimer's disease was a factor probably in me going into psychiatry, but not THE factor. There was no one main factor. It certainly taught me about empathy, and emotional pain and loneliness, ands societal prejudice, something most psych patients deal with on a day to day basis. (and family members of an Ad victim.)  Yes its true I saw the emotional anguish the disease causes, I lived it. I thought psychiatry was the most humane of all medical specialties, some days I still think that, other days not. After all, a psychiatrist talks to their patients, understands there patients from a human aspect, not a disease aspect, or so most of us thought. That is why most went into it. It seemed to bridge the gap between the art and the science of medicine in so many ways, in ways that nobody cares about much anymore, in ways society places little value on- IE. humanity.  Cost-effectiveness supersedes humanity. that's the reality, throw in some power-drive economics and political correctness and well you have more bias and prejudice but yet we still convince ourselves everything is okay.

Friday, August 13, 2010


hmmmm call me old fashioned, call me a heretic. But will this really improve care? If I was one of those slick high tech cool medical bloggers, I would tell you how wonderful it is and how the art and the science of medicine will be so greatly advanced and how much this is going to help patients. Lots of people would read and retweet, the news media loves it and it will help patients.
Now lets talk about the realities nobody wants to blog about except me it seems.
First of all, how will it help patients. LESS ERRORS. This is good. How so? Handwriting errors, handwriting errors HANDWRITING ERRORS. Fantastic. Hmm is that an N or an H? I can't read the handwriting. EXCELLENT. No more of that ever. IT will probably save a few lives every year.
Think about it there are only so many ways for a prescription to get from your doctor to the Walgreen's in your neighborhood. 3 ways actually. The doctor phones it in to the pharmacy, the doctor faxes it to the pharmacy, or the doctor hands you a handwritten prescription to take down and hand to Kristen or Eli your ever pleasant pharmacy technician at the drugstore.
That's it that's how it works. No More. Electronic prescribing will be the law in the great progressive State of Minnesota at the end of 2010.
It will cut down on other errors too. Maybe. Theoretically You can have a more thorough list off all the meds you have ever been on. This should help on missed drug-drug interactions. Right. Sounds good.
Hows it work?
Well first off all most people that work in medicine are not doctors, they could never see electronic prescribing as being anything but good. These non medical people actually write most of the templates for the software for electronic prescribing. Big money to be made for these non medical- medical consultant experts. Licking their chops so to speak.
So you doctors office or somebody spends a lot of money to get the templates and then they can electronically prescribe. It gets sent to the pharmacy electronically, sort of to a clearing house over the Internet, I guess you could call it sort of an intranet, and it is about as secure as secure can be with lots of firewalls and things. I mean think about how secure your stored information is when you purchase something over the Internet. nice and secure, nobody could ever get in with all those firewalls.  
The software really is great, lots of drop down menus invented by non-physicians telling you exactly when where how much how often you get to prescribe something. Since these templates are generally written by non-medical people the art of medicine really shines. You doctor can't really personalize the treatment to you.It is rigidly standardized. Sure there is a little place at the end where you can attempt to put in specific instructions, often hard for the [pharmacist to find and extremely user UNfriendly for the doctor, to actually individualize the treatment to the patient. I mean we all fit into nice pigeon holes, right?
Then there is the issue of the fact that many non-physicians are going to be entering the prescription into the computer and hitting "send". Boy I hope they are not having a bad day or pissed off or something or having a bad home life that week and  don't make an error on the drop down menus. Its ok though because it will still be the doctors fault in the end.
Then there is the beauty of the fact that depending on the software and the clearing house, something you took for a week will still be showing up years later, like you broke you toe and went to the ER and got three lortabbs. That just will keep coming up or or you took amoxicillan for a strep throat five years ago for am week. Right there in your face, the dates and quantity may be a little less harder to find. Sort of got to look. Hopefully someone will mark it as not active but expired stuff still follows you around, thank you rich thoughtful computer software companies medical non-doctor consultants.
But here's the best part. Formulary restrictions, all a patients data is out there including insurance, behind lots of firewall encrypted safety devices of course.
In other words when a doctor tries to prescribe something and a patients insurance won't cover the med-BAM the clearing house will reject it. Nice hunh? You are not allowed to have that med. It is like that now, but at least we still have the old prior authorization,- that's where you doctor spends all day usually several, fighting with some private sector company employee of a corporation contracted with the federal government, sitting in some cubical in Solon or somewhere telling the doctor they are not allowed to prescribe the appropriate med and to use something else.
It will be a lot easy to avoid this, with e-prescribing and to really really start limiting and putting the clamps down on what meds you are allowed to have based on your payer.
And this part is even better than best-now we can truly monitor physicians prescribing habits and make lots of inferences and punitive actions against physicians who prescribe too many expensive meds. Way to really reign em in. Bout time right? Unless its your husband or wife. then shouldn't they have the best medication even if it is expensive? Nope and NOPE.
Anyways I guess it will cut down on forgery and prescription drug abuse too right? Maybe. Luckily criminals are not smart with computers and all that stored information on you and dangerous drugs out there in the electronic password encrypted firewall protected cyber world.
Call me old fashioned, I will get used to it. I must be getting old and set in my ways, I just don't think human beings and their treatment fit into drop down boxes and templates. It will be OK though, in all fairness a majority of hospitals have been using electronic entry of orders and meds for inpatient units for years. Why look how often we don;t have errors in those hospitals anymore.
Pretty soon we can have a robot hold your hand or talk to you instead of a human, technology-nice and healing but a human will still have to program and turn on the robot, chances are it won;t be a physician.
In more all fairness the Government Medicine Programs the VA and the DOJ (Federal Prisons) have excellent electronic prescribing and electronic records, that are prototypes and lead the way. I'm sure we can find lots of data on how errors have been decreased and patients helped and the care improved over at those venues. Right?
I know I got to do it. It just feels sort of bad to have something imposed on you, when you had a pretty good system and checks and balances set up to avoid errors, and now you have to change, you had something that worked and maybe the system you had actually helped patients and not hurt them, and now that system will be illegal in a few months. Sad Sad Sad.
By the way do you know how often I hear- "the doctor (half the time it is a nurse practitioner) never looked at me they just kept staring at the computer screen"
and  here's a good one "the doctor could not do anything, the server was down, they were having trouble with the computer"
I hear those quotes a lot more and more every year, I pray those are not said about me someday.
A final thought, I think we should be more cognizant of the CEO' salaries of these medical software companies and start scanning the benevolence factor of these companies- kind of like we do the drug companies, God knows there first priority is helping the patient.

Saturday, August 7, 2010

On medical blogging

I read so many blogs from doctors, the psychiatry ones like to discuss how psychiatry has been reduced to simply writing prescriptions. It is old news. Most psychiatrists did not go into psych to write scripts all day to see patients every ten minutes. Generally speaking most start out with the ideal of wanting to understand and help their fellow human being. Old news.
Then their are the usual blogs about bashing the pharmaceutical industry, nothing new, usual stuff, politically correct. Meds are bad, pharmaceutical companies sinister etc etc. Lots of bad doctors pandering to the drug companies. People love these blogs, safe politically correct targets to bash.
There seems to be more physicians blogging than ever before, but they may reflect more the fact that there are more people blogging than ever. Some are a bit more pithy than others, some walk a political line, hoping to stay ahead of things with electronic media preserving their place in the cosmos, as the current physician-patient relationship, the therapeutic alliance, what medicine was created on since the beginning of human-kind, continues to erode. It erodes because of economics and politics.
I hate it when some of these blogs stay on the right side of the line, stopping short of speaking what is really on their mind. You can feel it and smell it. They don't always speak with candor, they may be honest, but they don't say what people don't want to hear, because nobody would read them. Fortunately for the blogger it is a world where most people are on the outside looking in, so most would not know if they are candid or not.
The blogger feels good because they are honest, but generally there is a pervasive fear and a general need for self-preservation, that behooves the medical blogger to stop short of telling the whole story.
Some actually open up about their human side of things, but one must be very careful with that. It is a very ultra thin line as we still hold the medical profession in some sort of bizarre precarious inflated esteem.
We want and assume our doctors to be smart and flawless and the greatest healers, but we know and expect them to be money-grubbing, selfish crooks, who don't care about their patient. We almost expect it, and the system reinforces our negative perceptions.  We look and wait for any clue to reinforce it. Is it any wonder the most prolific medical bloggers stay on the safe side? What option to physicians have?
I always assumed that the physician was the primo patient advocate, but nowadays we must be wise consumers who bring people to advocate for the patient against the physician. Who truly made the system adversarial? FDR? LBJ? Managed Care? HMO's? the AMA?
Perhaps I idealize the past, maybe the system was always adversarial, maybe the old physician-patient alliance was always challenged and precarious. I have to admit though since I have been working for 17 or 18 years now, it seems that their is less and less opportunity to take care of your patient and much more paperwork, defensive work, fighting with insurance companies and so many things in the way of letting you care for your patient. That part I can see. The doctor is just not free to practice medicine anymore. Yet on some level in the end, we still want our doctor to be the best and do everything right.

Sunday, August 1, 2010


I have found a rather odd way to connect with my dad over the last month or so, I have started trimming his fingernails. And man, they do grow fast. At first he was really apprehensive about me doing it but has become OK with the idea. Today I trimmed his fingernails and toenails. It's really good for me and I think for him because when I am concentrating on it, it is something tangible I can do for him. It also distracts him and seems to calm him down. So instead of a manicure, I'm gonna call it a "Man-Cure."

His dementia is getting worse by my estimation though Dr. Sivak says these things ebb and flow and progress slowly over time. I get that but he's beginning to check out on us a little more. Ironically, his "worsening" has made it easier for me to visit him because he has forgotten, for the most part, that he was angry at me (for moving him out of his home). I have had 4 or 5 consecutive visits without him getting ugly or aggressive. It is such a huge relief. My 3 year old daughter and I visited today. We also visited last Sunday. Dad still knows me and her and we are thankful for that. He cannot read anymore and there are many words and things I mention that confuse him and I am having an increasingly hard time understanding what he is trying to say. Today I mentioned I had driven one of his classic cars, his 57' Chevy. He had no clue what it was, at all. The week before I showed him a picture of the Chevy, that he could connect with that but not the uttered words. When it comes to an emotional connection, that is still 100% there. He laughs and smiles and has a superb time with my daughter.

I have finished reading Dr. Sivak's book. It was wonderful, I plan to write a full review sometime soon. Thanks be to God. JP

Elder Rage Review

Here is a review I posted on Amazon for Elder Rage, Jacqueline Marcell's book about her struggle with her father's Alzheimer's:

-"As a Physician and a Caregiver for my mother diagnosed with Alzheimer's when I was a teen, I recommend this book to caregivers. Not only do I advise this book to be read by caregivers but by the general public at large. Alzheimer's is something we don't want to know about or hear about till it touches our own family. It's time we open our eyes. The book is thorough, gripping, and filled with insights that offer utility to caregivers of AD victims. No matter what age you are when a parent or loved one is affected, AD is a coming of age process. It makes people grow up, and dig down inside ones' spirit to find the courage to persevere. Jacqueline did something with this courage and fortitude and offers it to others in similar circumstance. I had the pleasure of appearing on the Author's Radio Show "Coping With Caregiving", and found her to be gracious and a Caregiver Advocate, filled with passion and zeal toward bringing this disease out of the darkness. It is a passion and insight that I rarely see in regard to this devastating"-
Joseph J. Sivak MD

Talking about the book with the Lake Superior wind....... a calm day