Shrink Rap News

Psychiatry is a wonderful medical specialty; as a career, it is both diverse and flexible. Psychiatric careers can encompass the entire spectrum of clinical practice where the doctor sees many patients infrequently and focuses on symptoms and medications, or they can include psychodynamic and psychoanalytic treatments where the psychiatrist sees fewer patients but gets to know the details of their psyches and their lives. Psychiatrists can work in settings where they concentrate on administration, research, teaching, writing, or public policy and never go near a patient. It’s an easy specialty to mix-and-match any of the above components, and it’s feasible to have a fulfilling career while working part-time, and most psychiatrists get uninterrupted nights to sleep.

Still, psychiatry has trouble attracting enough doctors to fill the need. According to Stephanie Steinberg in a July 2010 article in USA Today titled “Of Medical Specialties, Demand for Psychiatrists Growing Fast":

Though demand is growing, fewer medical students are entering careers in psychiatry. Health officials say the field garners little interest because psychiatrists earn less than other specialties, even though they spend the same amount of time in medical training.

This is not surprising, and I’d venture to guess that the stigma associated with all-things-psychiatric does not help the recruiting process. The myth on the street continues to be that psychiatric patients are difficult to work with, that psychiatric disorders are not “real” diseases, that no one gets better, and that psychiatrists live in the pockets of the pharmaceutical companies. Lousy pay for lousy work, why would anyone go in to this field?  Perhaps because it’s not true.

In Maryland, we conducted an informal e-mail survey of the members of the Maryland Psychiatric Society. We asked, “Overall, are you satisfied with your career as a clinical psychiatrist?” Ninety percent of respondents answered, “Yes, I find my work rewarding and would choose this career again.” You may want to read that last sentence one more time. Four percent answered, “No, I don’t find my work rewarding and would not choose this career again.” Of those who chose to comment, the remarks centered on frustration with reimbursements and insurance and 22% of respondents qualified their response by checking “Other” as well as “Yes.”

Physicians in other specialties get paid better. Do 90% of surgeons find their work to be rewarding? The American College of Surgeons did its own survey. The surgeons’ survey population was a bit larger, with 7,905 respondents (compared to our 245 psychiatrists), and they found that 40% of their sample suffered from burnout, while 30% had symptoms of depression. One might conclude that more psychiatrists are needed to treat the depressed surgeons.

Psychiatry really is a wonderful career and the word on the street is wrong. Somehow, we allow ourselves to be sold short, and we need to do a better job of conveying what we do, and how rewarding it is, to the medical students.

-- Dinah Miller, M.D.

If you are a physician and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the July 27th post titled Happy Shrinks.  Comments on Shrink Rap are open to all readers. Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Psychiatry is a wonderful medical specialty; as a career, it is both diverse and flexible. Psychiatric careers can encompass the entire spectrum of clinical practice where the doctor sees many patients infrequently and focuses on symptoms and medications, or they can include psychodynamic and psychoanalytic treatments where the psychiatrist sees fewer patients but gets to know the details of their psyches and their lives. Psychiatrists can work in settings where they concentrate on administration, research, teaching, writing, or public policy and never go near a patient. It’s an easy specialty to mix-and-match any of the above components, and it’s feasible to have a fulfilling career while working part-time, and most psychiatrists get uninterrupted nights to sleep.

Still, psychiatry has trouble attracting enough doctors to fill the need. According to Stephanie Steinberg in a July 2010 article in USA Today titled “Of Medical Specialties, Demand for Psychiatrists Growing Fast":

Though demand is growing, fewer medical students are entering careers in psychiatry. Health officials say the field garners little interest because psychiatrists earn less than other specialties, even though they spend the same amount of time in medical training.

This is not surprising, and I’d venture to guess that the stigma associated with all-things-psychiatric does not help the recruiting process. The myth on the street continues to be that psychiatric patients are difficult to work with, that psychiatric disorders are not “real” diseases, that no one gets better, and that psychiatrists live in the pockets of the pharmaceutical companies. Lousy pay for lousy work, why would anyone go in to this field?  Perhaps because it’s not true.

In Maryland, we conducted an informal e-mail survey of the members of the Maryland Psychiatric Society. We asked, “Overall, are you satisfied with your career as a clinical psychiatrist?” Ninety percent of respondents answered, “Yes, I find my work rewarding and would choose this career again.” You may want to read that last sentence one more time. Four percent answered, “No, I don’t find my work rewarding and would not choose this career again.” Of those who chose to comment, the remarks centered on frustration with reimbursements and insurance and 22% of respondents qualified their response by checking “Other” as well as “Yes.”

Physicians in other specialties get paid better. Do 90% of surgeons find their work to be rewarding? The American College of Surgeons did its own survey. The surgeons’ survey population was a bit larger, with 7,905 respondents (compared to our 245 psychiatrists), and they found that 40% of their sample suffered from burnout, while 30% had symptoms of depression. One might conclude that more psychiatrists are needed to treat the depressed surgeons.

Psychiatry really is a wonderful career and the word on the street is wrong. Somehow, we allow ourselves to be sold short, and we need to do a better job of conveying what we do, and how rewarding it is, to the medical students.

-- Dinah Miller, M.D.

If you are a physician and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the July 27th post titled Happy Shrinks.  Comments on Shrink Rap are open to all readers. Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Psychiatry is a wonderful medical specialty; as a career, it is both diverse and flexible. Psychiatric careers can encompass the entire spectrum of clinical practice where the doctor sees many patients infrequently and focuses on symptoms and medications, or they can include psychodynamic and psychoanalytic treatments where the psychiatrist sees fewer patients but gets to know the details of their psyches and their lives. Psychiatrists can work in settings where they concentrate on administration, research, teaching, writing, or public policy and never go near a patient. It’s an easy specialty to mix-and-match any of the above components, and it’s feasible to have a fulfilling career while working part-time, and most psychiatrists get uninterrupted nights to sleep.

Still, psychiatry has trouble attracting enough doctors to fill the need. According to Stephanie Steinberg in a July 2010 article in USA Today titled “Of Medical Specialties, Demand for Psychiatrists Growing Fast":

Though demand is growing, fewer medical students are entering careers in psychiatry. Health officials say the field garners little interest because psychiatrists earn less than other specialties, even though they spend the same amount of time in medical training.

This is not surprising, and I’d venture to guess that the stigma associated with all-things-psychiatric does not help the recruiting process. The myth on the street continues to be that psychiatric patients are difficult to work with, that psychiatric disorders are not “real” diseases, that no one gets better, and that psychiatrists live in the pockets of the pharmaceutical companies. Lousy pay for lousy work, why would anyone go in to this field?  Perhaps because it’s not true.

In Maryland, we conducted an informal e-mail survey of the members of the Maryland Psychiatric Society. We asked, “Overall, are you satisfied with your career as a clinical psychiatrist?” Ninety percent of respondents answered, “Yes, I find my work rewarding and would choose this career again.” You may want to read that last sentence one more time. Four percent answered, “No, I don’t find my work rewarding and would not choose this career again.” Of those who chose to comment, the remarks centered on frustration with reimbursements and insurance and 22% of respondents qualified their response by checking “Other” as well as “Yes.”

Physicians in other specialties get paid better. Do 90% of surgeons find their work to be rewarding? The American College of Surgeons did its own survey. The surgeons’ survey population was a bit larger, with 7,905 respondents (compared to our 245 psychiatrists), and they found that 40% of their sample suffered from burnout, while 30% had symptoms of depression. One might conclude that more psychiatrists are needed to treat the depressed surgeons.

Psychiatry really is a wonderful career and the word on the street is wrong. Somehow, we allow ourselves to be sold short, and we need to do a better job of conveying what we do, and how rewarding it is, to the medical students.

-- Dinah Miller, M.D.

If you are a physician and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the July 27th post titled Happy Shrinks.  Comments on Shrink Rap are open to all readers. Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

The Affordable Care Act (ACA) included legislation that created a market of health insurance exchanges that each state would develop (because health insurance products are regulated by state insurance commissions). The idea was that insurance products would be marketed that have equivalent benefits, so that consumers could easily comparison shop, thus fostering competition based on customer service, benefits above the minimum required, and price.

The ACA set the idea of exchanges in motion, and the Department of Health and Human Services came out with the new exchange regulations on July 15. The regulations, known as “45 CFR Part 155,” outline how the states would establish the Exchanges and describe the minimum set of functions of an Exchange. Part 156 outlines the proposed standards for health insurance issuers with respect to participation in an exchange, including the minimum certification requirements for Qualified Health Plans. These regulations are described in the Notice of Proposed Rule Making (NPRM), which can be found at http://bit.ly/cpnexchanges.

Later regulations will be developed that address (1) standards for individual eligibility for participation in the exchange, cost-sharing reductions, and related health programs and appeals of eligibility determinations; (2) defining essential health benefits, actuarial value and other benefit design standards; and (3) standards for exchanges and QHP issuers related to quality.

So, why do we care about this? Because we have seen what has happened in the past when managed care established discriminatory practices that added barriers to receiving psychiatric and substance abuse treatment, resulting in a dramatic shrinkage of behavioral health care expenditures along with excessive growth in complicated and time-consuming administrative procedures that resulted in unnecessary barriers to access to care and psychiatrists voting with their feet to escape the red tape. Armed with the Mental Health Parity Act of 2008, we are committed to not repeating the same mistakes again. Educating ourselves about these proposed regulations – and submitting public comments (by Sept. 30) that seek to improve the process -- becomes necessary in order to have final regulations that are acceptable to psychiatrists and our patients.

The proposed regulations require exchanges to consult with certain stakeholders as they develop and maintain their programs, including “[a]dvocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder,” and to educate and reach out to these hard-to-reach populations. They are required to consult with these stakeholders on an ongoing basis, meaning that psychiatrists and other mental health advocates will need to be alert to opportunities for input into these state-level decisions.

Section 155.205(b) requires that an exchange must maintain an up-to-date website that contains enrollee satisfaction survey results, levels of benefits, quality ratings, the medical loss ratio (what proportion of premium income is spent on medical care), and an online provider directory.

The rules surrounding the provider directory is where I will focus the rest of this column. The Network Adequacy Standards (section 156.230) require that insurance issuers must make their online provider directories available to the exchange so that current and potential enrollees can access them. It also requires them to note providers in the directory that are no longer accepting new patients. The NPRM specifically “seek[s] comment on standards we might set to ensure that QHP issuers maintain up-to-date provider directories” [page 126]. It also requires issuers to be compliant with “network adequacy standards” as defined by the exchanges. “We solicit comment on additional minimum qualitative or quantitative standards for the Exchange to use in evaluating whether the QHP provider networks provide sufficient access to care.”

There are many accounts of health plans that have robust-looking mental health provider networks in their directories, but when patients try to get an appointment with one of these providers, they discover that only a handful are now accepting patients, because the provider is retired or deceased, the practice is full, they have moved, or they are no longer accepting new patients from that health plan. If the provider is accepting new patients, the waiting time may be weeks or months in the future. A 2009 study found that research assistants posing as patients trying to access an outpatient appointment for depression in the next 2 weeks were able to obtain an appointment only 22% (private insurance) and 12% (Medicaid) of the time (Annals Emerg. Med. 2009;54:272-8.

The term “phantom network” has been used to describe the actual provider network, which differs from the apparent provider network listed in the directory. This discrepancy in network adequacy can sometimes border on fraud. Potential plan enrollees rely on the directory to determine if it has sufficient specialty providers convenient to them. The bait and switch occurs after they have committed to that plan and later find that they need a service that is much more limited in availability than initially implied.

The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.

A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.

I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at http://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at [email protected].

The Affordable Care Act (ACA) included legislation that created a market of health insurance exchanges that each state would develop (because health insurance products are regulated by state insurance commissions). The idea was that insurance products would be marketed that have equivalent benefits, so that consumers could easily comparison shop, thus fostering competition based on customer service, benefits above the minimum required, and price.

The ACA set the idea of exchanges in motion, and the Department of Health and Human Services came out with the new exchange regulations on July 15. The regulations, known as “45 CFR Part 155,” outline how the states would establish the Exchanges and describe the minimum set of functions of an Exchange. Part 156 outlines the proposed standards for health insurance issuers with respect to participation in an exchange, including the minimum certification requirements for Qualified Health Plans. These regulations are described in the Notice of Proposed Rule Making (NPRM), which can be found at http://bit.ly/cpnexchanges.

Later regulations will be developed that address (1) standards for individual eligibility for participation in the exchange, cost-sharing reductions, and related health programs and appeals of eligibility determinations; (2) defining essential health benefits, actuarial value and other benefit design standards; and (3) standards for exchanges and QHP issuers related to quality.

So, why do we care about this? Because we have seen what has happened in the past when managed care established discriminatory practices that added barriers to receiving psychiatric and substance abuse treatment, resulting in a dramatic shrinkage of behavioral health care expenditures along with excessive growth in complicated and time-consuming administrative procedures that resulted in unnecessary barriers to access to care and psychiatrists voting with their feet to escape the red tape. Armed with the Mental Health Parity Act of 2008, we are committed to not repeating the same mistakes again. Educating ourselves about these proposed regulations – and submitting public comments (by Sept. 30) that seek to improve the process -- becomes necessary in order to have final regulations that are acceptable to psychiatrists and our patients.

The proposed regulations require exchanges to consult with certain stakeholders as they develop and maintain their programs, including “[a]dvocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder,” and to educate and reach out to these hard-to-reach populations. They are required to consult with these stakeholders on an ongoing basis, meaning that psychiatrists and other mental health advocates will need to be alert to opportunities for input into these state-level decisions.

Section 155.205(b) requires that an exchange must maintain an up-to-date website that contains enrollee satisfaction survey results, levels of benefits, quality ratings, the medical loss ratio (what proportion of premium income is spent on medical care), and an online provider directory.

The rules surrounding the provider directory is where I will focus the rest of this column. The Network Adequacy Standards (section 156.230) require that insurance issuers must make their online provider directories available to the exchange so that current and potential enrollees can access them. It also requires them to note providers in the directory that are no longer accepting new patients. The NPRM specifically “seek[s] comment on standards we might set to ensure that QHP issuers maintain up-to-date provider directories” [page 126]. It also requires issuers to be compliant with “network adequacy standards” as defined by the exchanges. “We solicit comment on additional minimum qualitative or quantitative standards for the Exchange to use in evaluating whether the QHP provider networks provide sufficient access to care.”

There are many accounts of health plans that have robust-looking mental health provider networks in their directories, but when patients try to get an appointment with one of these providers, they discover that only a handful are now accepting patients, because the provider is retired or deceased, the practice is full, they have moved, or they are no longer accepting new patients from that health plan. If the provider is accepting new patients, the waiting time may be weeks or months in the future. A 2009 study found that research assistants posing as patients trying to access an outpatient appointment for depression in the next 2 weeks were able to obtain an appointment only 22% (private insurance) and 12% (Medicaid) of the time (Annals Emerg. Med. 2009;54:272-8.

The term “phantom network” has been used to describe the actual provider network, which differs from the apparent provider network listed in the directory. This discrepancy in network adequacy can sometimes border on fraud. Potential plan enrollees rely on the directory to determine if it has sufficient specialty providers convenient to them. The bait and switch occurs after they have committed to that plan and later find that they need a service that is much more limited in availability than initially implied.

The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.

A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.

I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at http://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at [email protected].

The Affordable Care Act (ACA) included legislation that created a market of health insurance exchanges that each state would develop (because health insurance products are regulated by state insurance commissions). The idea was that insurance products would be marketed that have equivalent benefits, so that consumers could easily comparison shop, thus fostering competition based on customer service, benefits above the minimum required, and price.

The ACA set the idea of exchanges in motion, and the Department of Health and Human Services came out with the new exchange regulations on July 15. The regulations, known as “45 CFR Part 155,” outline how the states would establish the Exchanges and describe the minimum set of functions of an Exchange. Part 156 outlines the proposed standards for health insurance issuers with respect to participation in an exchange, including the minimum certification requirements for Qualified Health Plans. These regulations are described in the Notice of Proposed Rule Making (NPRM), which can be found at http://bit.ly/cpnexchanges.

Later regulations will be developed that address (1) standards for individual eligibility for participation in the exchange, cost-sharing reductions, and related health programs and appeals of eligibility determinations; (2) defining essential health benefits, actuarial value and other benefit design standards; and (3) standards for exchanges and QHP issuers related to quality.

So, why do we care about this? Because we have seen what has happened in the past when managed care established discriminatory practices that added barriers to receiving psychiatric and substance abuse treatment, resulting in a dramatic shrinkage of behavioral health care expenditures along with excessive growth in complicated and time-consuming administrative procedures that resulted in unnecessary barriers to access to care and psychiatrists voting with their feet to escape the red tape. Armed with the Mental Health Parity Act of 2008, we are committed to not repeating the same mistakes again. Educating ourselves about these proposed regulations – and submitting public comments (by Sept. 30) that seek to improve the process -- becomes necessary in order to have final regulations that are acceptable to psychiatrists and our patients.

The proposed regulations require exchanges to consult with certain stakeholders as they develop and maintain their programs, including “[a]dvocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder,” and to educate and reach out to these hard-to-reach populations. They are required to consult with these stakeholders on an ongoing basis, meaning that psychiatrists and other mental health advocates will need to be alert to opportunities for input into these state-level decisions.

Section 155.205(b) requires that an exchange must maintain an up-to-date website that contains enrollee satisfaction survey results, levels of benefits, quality ratings, the medical loss ratio (what proportion of premium income is spent on medical care), and an online provider directory.

The rules surrounding the provider directory is where I will focus the rest of this column. The Network Adequacy Standards (section 156.230) require that insurance issuers must make their online provider directories available to the exchange so that current and potential enrollees can access them. It also requires them to note providers in the directory that are no longer accepting new patients. The NPRM specifically “seek[s] comment on standards we might set to ensure that QHP issuers maintain up-to-date provider directories” [page 126]. It also requires issuers to be compliant with “network adequacy standards” as defined by the exchanges. “We solicit comment on additional minimum qualitative or quantitative standards for the Exchange to use in evaluating whether the QHP provider networks provide sufficient access to care.”

There are many accounts of health plans that have robust-looking mental health provider networks in their directories, but when patients try to get an appointment with one of these providers, they discover that only a handful are now accepting patients, because the provider is retired or deceased, the practice is full, they have moved, or they are no longer accepting new patients from that health plan. If the provider is accepting new patients, the waiting time may be weeks or months in the future. A 2009 study found that research assistants posing as patients trying to access an outpatient appointment for depression in the next 2 weeks were able to obtain an appointment only 22% (private insurance) and 12% (Medicaid) of the time (Annals Emerg. Med. 2009;54:272-8.

The term “phantom network” has been used to describe the actual provider network, which differs from the apparent provider network listed in the directory. This discrepancy in network adequacy can sometimes border on fraud. Potential plan enrollees rely on the directory to determine if it has sufficient specialty providers convenient to them. The bait and switch occurs after they have committed to that plan and later find that they need a service that is much more limited in availability than initially implied.

The other trick often employed is to not differentiate between providers who only treat inpatients versus those who treat outpatients. Our hospital has full-time, inpatient-only psychiatrists who are always accepting new patients for admission but do not have an outpatient practice. We get 10-20 calls per day from frustrated patients trying to find an outpatient psychiatrist. Our attempts to get the plans to list us as inpatient-only have been unsuccessful. I once called all 30 providers in a patient’s directory to discover that only three would be able to accept her.

A much more reliable method of conveying more accurate information about a plan’s network adequacy would be to use claims data to indicate next to each providers’ listing some measure of the number of new outpatient claims (CPT codes 90801, 9920x, 9924x) submitted over the most recently available 12 months. This screens out the inpatient-only providers in addition to indicating those providers with no or low volumes of new patients. In the above example, 27 of the 30 providers would have a zero or single digit numbers, while the directory would clearly indicate that only three providers are responsible for most of the new patient appointments. The benefit to this method is that it requires little maintenance, is self-correcting, and exposes the phantom network such that potential enrollees would be able to more accurately assess the network adequacy prior to choosing that plan. It would require additional initial database and programming services to establish the links between the claims database and the provider database.

I invite readers to submit their comments or refinements to this suggestion here in the comment section. More importantly, I urge readers to submit a public comment on this NPRM to the Centers for Medicare and Medicaid Services at http://www.regulations.gov. Refer to file code CMS-9989-P, and specifically to Sections 156.230 and also to 155.1050, which states that “An Exchange must ensure that the provider network of each QHP offers a sufficient choice of providers for enrollees.”

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter@HITshrink and at [email protected].

For years, I supervised residents. They would come in each week and tell me about a patient in crisis. If no one was in crisis, they’d say all their patients were fine and they didn’t know what to talk about, even though I had told them to pick a patient they saw weekly and either audio-record the sessions or take detailed process notes. Psychotherapy, I would say, is a process that occurs over time; it’s not always about the latest crisis. I once inspired a resident to record some sessions, but they were difficult to hear, and another resident took process notes, but those two were the exceptions.

I thought it was me, so I asked some other psychiatrists for suggestions. A psychoanalyst told me the residents were anxious about having their work scrutinized and I should address the anxiety. It seemed like a great idea, but it didn’t work. Another colleague suggested I tell them if they didn’t bring process notes, I would tell their training director. This tactic just didn’t feel right. Even the residents who were interested in learning psychotherapy were not seeing patients weekly, and one told me they were just too busy for regular psychotherapy sessions.

I finally realized that it wasn’t me. The residents were not primed to understand or do psychotherapy, and I was catching them too far along in the process. Many have no interest in ever seeing a patient for psychotherapy, and they’ve bought in to the idea that psychiatrists “manage meds.”

I believe that people in general, and psychiatrists in particular, should do what they like doing. I don’t believe that every psychiatrist in every setting needs to practice psychotherapy, and even if I did, no one would listen. I do, however, think that every resident should learn to do traditional (and I suppose that means psychodynamically-based) psychotherapy, even if they never plan to see another therapy patient after their training is complete. Let me tell you why I believe that:

• Psychotherapy is a fundamental component in the treatment of mental illnesses. Psychiatrists should have a good understanding of what psychotherapy is, how it is done, what problems it treats effectively, what problems it does not address well, and what types of issues may come up in the course of a psychotherapy. It’s not just about symptoms and diagnoses -- just as we don’t know whose depression will lift with Prozac and who will develop a discontinuation syndrome after stopping Paxil, the outcome of psychotherapy remains unpredictable and residents should treat a variety of patients in order to appreciate the variables that influence outcomes. I don’t believe this is something one can learn from a textbook.

• Learning to do psychotherapy well prepares psychiatrists for interactions that will occur with patients outside of a traditional psychotherapy. It helps psychiatrists to learn the importance of active listening and understanding unspoken components of interactions, and these are important during even brief appointments.

• There is a vocal (and growing) body of patients and ex-patients who feel they have been harmed by psychiatric treatments. It may be that patients who meet with psychiatrists for brief, time-pressured encounters are more likely to feel victimized by psychiatric treatments. The media feeds this anti-psychiatry frenzy when it portrays psychiatrists as being all about medications. Psychiatrists are no longer seen as being interested and caring, and this is not good for our profession.

• When treatment is focused solely on diagnosis, symptoms, and medications, it leads psychiatrists to make decisions with tunnel vision. It further encourages patients to identify their symptoms as the result of illness and inadequate, or suboptimal, medication management and it leaves some patients to believe they have no ability to modify their own feelings or behaviors. Since most psychiatric symptoms are also part of the normal human experience in the absence of psychiatric illness, an understanding of the psyche on a richer level gives the psychiatrist a better understanding of how to approach human suffering and how to differentiate these experiences from psychiatric disorders.

• What happens in psychotherapy can certainly influence the course of treatment.  A psychiatrist who is not trained in psychotherapy can not judge whether the therapy provided by other mental health professionals is adequate or appropriate and is certainly not able to direct treatment.

• Good therapeutic skills enhance the therapeutic alliance and this may well improve both adherence to medication regimens and treatment outcomes.

• There continues to be a demand for well-trained psychiatrists who can provide both psychotherapy and medications.

In case you’re wondering, the Accreditation Council on Graduate Medical Education program requirements for psychiatry is 35 pages long. The words “psychotherapy” and “psychotherapies” appear a total of four times.

If you’re a physician and would like to comment on this article here, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

This article is one of a three-site simultaneous discussion on Psychotherapy and Psychiatry.  

On Shrink Rap Today, I discuss psychotherapy, high volume practice models, and what we’ve learned about how Maryland psychiatrists actually practice. Click Here to read “Psychiatry and Psychotherapy: Still Around.

 On our main Shrink Rap blog, there is a brief overview of psychotherapy in psychiatry. Click Here to read “Psychotherapy in Psychiatry: Keeping it Alive.”

Comments on Shrink Rap and Shrink Rap Today are open to all readers.

Dinah Miller, M.D. is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

For years, I supervised residents. They would come in each week and tell me about a patient in crisis. If no one was in crisis, they’d say all their patients were fine and they didn’t know what to talk about, even though I had told them to pick a patient they saw weekly and either audio-record the sessions or take detailed process notes. Psychotherapy, I would say, is a process that occurs over time; it’s not always about the latest crisis. I once inspired a resident to record some sessions, but they were difficult to hear, and another resident took process notes, but those two were the exceptions.

I thought it was me, so I asked some other psychiatrists for suggestions. A psychoanalyst told me the residents were anxious about having their work scrutinized and I should address the anxiety. It seemed like a great idea, but it didn’t work. Another colleague suggested I tell them if they didn’t bring process notes, I would tell their training director. This tactic just didn’t feel right. Even the residents who were interested in learning psychotherapy were not seeing patients weekly, and one told me they were just too busy for regular psychotherapy sessions.

I finally realized that it wasn’t me. The residents were not primed to understand or do psychotherapy, and I was catching them too far along in the process. Many have no interest in ever seeing a patient for psychotherapy, and they’ve bought in to the idea that psychiatrists “manage meds.”

I believe that people in general, and psychiatrists in particular, should do what they like doing. I don’t believe that every psychiatrist in every setting needs to practice psychotherapy, and even if I did, no one would listen. I do, however, think that every resident should learn to do traditional (and I suppose that means psychodynamically-based) psychotherapy, even if they never plan to see another therapy patient after their training is complete. Let me tell you why I believe that:

• Psychotherapy is a fundamental component in the treatment of mental illnesses. Psychiatrists should have a good understanding of what psychotherapy is, how it is done, what problems it treats effectively, what problems it does not address well, and what types of issues may come up in the course of a psychotherapy. It’s not just about symptoms and diagnoses -- just as we don’t know whose depression will lift with Prozac and who will develop a discontinuation syndrome after stopping Paxil, the outcome of psychotherapy remains unpredictable and residents should treat a variety of patients in order to appreciate the variables that influence outcomes. I don’t believe this is something one can learn from a textbook.

• Learning to do psychotherapy well prepares psychiatrists for interactions that will occur with patients outside of a traditional psychotherapy. It helps psychiatrists to learn the importance of active listening and understanding unspoken components of interactions, and these are important during even brief appointments.

• There is a vocal (and growing) body of patients and ex-patients who feel they have been harmed by psychiatric treatments. It may be that patients who meet with psychiatrists for brief, time-pressured encounters are more likely to feel victimized by psychiatric treatments. The media feeds this anti-psychiatry frenzy when it portrays psychiatrists as being all about medications. Psychiatrists are no longer seen as being interested and caring, and this is not good for our profession.

• When treatment is focused solely on diagnosis, symptoms, and medications, it leads psychiatrists to make decisions with tunnel vision. It further encourages patients to identify their symptoms as the result of illness and inadequate, or suboptimal, medication management and it leaves some patients to believe they have no ability to modify their own feelings or behaviors. Since most psychiatric symptoms are also part of the normal human experience in the absence of psychiatric illness, an understanding of the psyche on a richer level gives the psychiatrist a better understanding of how to approach human suffering and how to differentiate these experiences from psychiatric disorders.

• What happens in psychotherapy can certainly influence the course of treatment.  A psychiatrist who is not trained in psychotherapy can not judge whether the therapy provided by other mental health professionals is adequate or appropriate and is certainly not able to direct treatment.

• Good therapeutic skills enhance the therapeutic alliance and this may well improve both adherence to medication regimens and treatment outcomes.

• There continues to be a demand for well-trained psychiatrists who can provide both psychotherapy and medications.

In case you’re wondering, the Accreditation Council on Graduate Medical Education program requirements for psychiatry is 35 pages long. The words “psychotherapy” and “psychotherapies” appear a total of four times.

If you’re a physician and would like to comment on this article here, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

This article is one of a three-site simultaneous discussion on Psychotherapy and Psychiatry.  

On Shrink Rap Today, I discuss psychotherapy, high volume practice models, and what we’ve learned about how Maryland psychiatrists actually practice. Click Here to read “Psychiatry and Psychotherapy: Still Around.

 On our main Shrink Rap blog, there is a brief overview of psychotherapy in psychiatry. Click Here to read “Psychotherapy in Psychiatry: Keeping it Alive.”

Comments on Shrink Rap and Shrink Rap Today are open to all readers.

Dinah Miller, M.D. is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

For years, I supervised residents. They would come in each week and tell me about a patient in crisis. If no one was in crisis, they’d say all their patients were fine and they didn’t know what to talk about, even though I had told them to pick a patient they saw weekly and either audio-record the sessions or take detailed process notes. Psychotherapy, I would say, is a process that occurs over time; it’s not always about the latest crisis. I once inspired a resident to record some sessions, but they were difficult to hear, and another resident took process notes, but those two were the exceptions.

I thought it was me, so I asked some other psychiatrists for suggestions. A psychoanalyst told me the residents were anxious about having their work scrutinized and I should address the anxiety. It seemed like a great idea, but it didn’t work. Another colleague suggested I tell them if they didn’t bring process notes, I would tell their training director. This tactic just didn’t feel right. Even the residents who were interested in learning psychotherapy were not seeing patients weekly, and one told me they were just too busy for regular psychotherapy sessions.

I finally realized that it wasn’t me. The residents were not primed to understand or do psychotherapy, and I was catching them too far along in the process. Many have no interest in ever seeing a patient for psychotherapy, and they’ve bought in to the idea that psychiatrists “manage meds.”

I believe that people in general, and psychiatrists in particular, should do what they like doing. I don’t believe that every psychiatrist in every setting needs to practice psychotherapy, and even if I did, no one would listen. I do, however, think that every resident should learn to do traditional (and I suppose that means psychodynamically-based) psychotherapy, even if they never plan to see another therapy patient after their training is complete. Let me tell you why I believe that:

• Psychotherapy is a fundamental component in the treatment of mental illnesses. Psychiatrists should have a good understanding of what psychotherapy is, how it is done, what problems it treats effectively, what problems it does not address well, and what types of issues may come up in the course of a psychotherapy. It’s not just about symptoms and diagnoses -- just as we don’t know whose depression will lift with Prozac and who will develop a discontinuation syndrome after stopping Paxil, the outcome of psychotherapy remains unpredictable and residents should treat a variety of patients in order to appreciate the variables that influence outcomes. I don’t believe this is something one can learn from a textbook.

• Learning to do psychotherapy well prepares psychiatrists for interactions that will occur with patients outside of a traditional psychotherapy. It helps psychiatrists to learn the importance of active listening and understanding unspoken components of interactions, and these are important during even brief appointments.

• There is a vocal (and growing) body of patients and ex-patients who feel they have been harmed by psychiatric treatments. It may be that patients who meet with psychiatrists for brief, time-pressured encounters are more likely to feel victimized by psychiatric treatments. The media feeds this anti-psychiatry frenzy when it portrays psychiatrists as being all about medications. Psychiatrists are no longer seen as being interested and caring, and this is not good for our profession.

• When treatment is focused solely on diagnosis, symptoms, and medications, it leads psychiatrists to make decisions with tunnel vision. It further encourages patients to identify their symptoms as the result of illness and inadequate, or suboptimal, medication management and it leaves some patients to believe they have no ability to modify their own feelings or behaviors. Since most psychiatric symptoms are also part of the normal human experience in the absence of psychiatric illness, an understanding of the psyche on a richer level gives the psychiatrist a better understanding of how to approach human suffering and how to differentiate these experiences from psychiatric disorders.

• What happens in psychotherapy can certainly influence the course of treatment.  A psychiatrist who is not trained in psychotherapy can not judge whether the therapy provided by other mental health professionals is adequate or appropriate and is certainly not able to direct treatment.

• Good therapeutic skills enhance the therapeutic alliance and this may well improve both adherence to medication regimens and treatment outcomes.

• There continues to be a demand for well-trained psychiatrists who can provide both psychotherapy and medications.

In case you’re wondering, the Accreditation Council on Graduate Medical Education program requirements for psychiatry is 35 pages long. The words “psychotherapy” and “psychotherapies” appear a total of four times.

If you’re a physician and would like to comment on this article here, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

This article is one of a three-site simultaneous discussion on Psychotherapy and Psychiatry.  

On Shrink Rap Today, I discuss psychotherapy, high volume practice models, and what we’ve learned about how Maryland psychiatrists actually practice. Click Here to read “Psychiatry and Psychotherapy: Still Around.

 On our main Shrink Rap blog, there is a brief overview of psychotherapy in psychiatry. Click Here to read “Psychotherapy in Psychiatry: Keeping it Alive.”

Comments on Shrink Rap and Shrink Rap Today are open to all readers.

Dinah Miller, M.D. is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

osh Taylor is an attorney who is now in his 40s with a history of asthma, borderline hypertension, and bipolar disorder, all of which are stable. He sees a psychiatrist three times per year, who prescribes lithium and gets periodic blood tests. He sees his regular physician every year or 2, especially when he has asthma exacerbations. She prescribes an inhaler and, rarely, steroids. Josh is junior partner in his law firm.

Josh is scared. He’s scared of his state’s Health Information Exchange (HIE).

While Josh is actually a fictional character from my book, his situation is very real. When it comes to making decisions about allowing his personal health information to be shared with others, he is balancing three competing interests – privacy, safety, and convenience. And health information exchanges are in the middle of it all.

What were previously Regional Health Information Organizations have morphed into HIEs, organized by geographic, organizational, and payer-based consortia of individuals working together to share health information in an affordable and desirable manner. Some have statewide, government-sponsored HIEs -- like Chesapeake Regional Information System for our Patients or CRISP, which is the state-designated HIE for Maryland. Others have multiple regional HIEs that are still in the process of forming statewide coalitions, such as the New York eHealth Collaborative (NYeHC).

People like Josh are afraid of losing control of their personal health information (PHI) in the mad rush to connect disparate electronic health records (EHRs) to the health information exchanges. Josh wants to ensure that only his primary care physician can see his psychiatric history, to minimize the risk that the stigma that is still attached to mental illness doesn’t affect his job prospects. But neither Maryland nor New York, for example, give individuals control over which records can be accessed by which providers. In fact, they don’t yet have even a simple audit process that permits a consumer to know who has accessed which records and for what purpose. Very few of the HIEs even have a mechanism that allows one to see what records are available.

So, you don’t know what is in there, you don’t know who has accessed it, and you can’t control access based on type of information. HIEs are generally built for physicians and other health care providers, not patients or “consumers.” You can, however, usually control access via a master switch that either shuts off access to everyone or opens access to everything -- all or nothing. Of course, only those with proper authorization are permitted access to your PHI. But for someone with Josh’s concerns, this is cold comfort. 

This is dilemma #1: making the decision to allow access to all one’s records, versus shutting off all access to maximize privacy, while reducing convenience and safety. This is also called “opting out.” A majority of HIEs default to an automatic opt-in status, requiring one to take an action to opt-out of participation in the HIE. Opting out would mean that Josh’s psychiatrist would not find out that his PCP started him on hydrochlorothiazide for his hypertension unless Josh mentioned it or his PCP sends a note to the psychiatrist. Knowing this could prevent an episode of lithium toxicity due to drug interactions. When he shows up in the ER confused and unable to provide a good history due to lithium toxicity, ER physicians would not be able to access his clinical details via the HIE if he has opted out. If he becomes manic, his psychiatrist might not otherwise become aware of the fact that he had been started on a rapid prednisone taper the week before an ER visit for shortness of breath and pneumonia.

Another strategy that some HIEs have discussed is to establish more restrictive access policies for “sensitive health information.” The idea is that certain categories of information, like mental illness, substance abuse, HIV status, domestic violence, and genetic data, be treated differently, with additional safeguards to prevent unauthorized access.

This brings us to dilemma #2: how to determine which PHI should be considered “sensitive.” Some may want their mental health history to marked “sensitive,” while others may want all their health care providers to be aware of this information. Others may feel that all of their PHI should have maximal safeguards and want it all to be “sensitive.” Categorically making mental health and substance abuse information “sensitive” and subject to excessively restrictive protocols may result in unintended consequences. Such a move would likely add to the stigma of mental illness. It would also make it more difficult to share important information among providers. There is already an identified problem of receiving adequate primary care for individuals in the public mental health system, who die prematurely by 25 years or more (Psychiatr. Serv. 2006;57:1482-7). Requiring consumers with mental illness to choose between opting in and opting out requires them to choose between privacy and safety. Other options must be made available.

One of these options involves granular consent policies for HIEs and EHRs. Such policies would provide consumers with the ability to decide for themselves which types of PHI would have extra access restrictions, such as “only my PCP can see my psychiatrist records, while ED physicians cannot see these unless I am unconscious and cannot provide history.”

Another option allows consumers to see what information is available for other providers to view. This, along with robust audit log reporting, might provide a greater sense of trust in the system. Both of these options would hopefully result in lower opt-out rates and a greater sense of involvement in ones own medical care. 

What can you do to help bring about these changes? First, learn about the HIE policies in your region and in your state. Learn about the governance structure, read the meeting minutes, and participate in the decision-making process by writing letters or attending meetings and speaking up. Also let your legislators know that this is an important issue. Second, educate your patients about the privacy and safety issues around HIEs, and discuss their participation status with them. Third, provide clear information to your patients about your participation status with the HIE and understand what their wishes and fears are. Finally, if you have access to your state’s HIE, sit down with your patients and show them how it works and what information is available about them. You are a patient, too, so use the opportunity to understand what your rights and responsibilities are as an HIE participant.

Share your experiences with your HIE by commenting on this article below.

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter @HITshrink and at [email protected].

osh Taylor is an attorney who is now in his 40s with a history of asthma, borderline hypertension, and bipolar disorder, all of which are stable. He sees a psychiatrist three times per year, who prescribes lithium and gets periodic blood tests. He sees his regular physician every year or 2, especially when he has asthma exacerbations. She prescribes an inhaler and, rarely, steroids. Josh is junior partner in his law firm.

Josh is scared. He’s scared of his state’s Health Information Exchange (HIE).

While Josh is actually a fictional character from my book, his situation is very real. When it comes to making decisions about allowing his personal health information to be shared with others, he is balancing three competing interests – privacy, safety, and convenience. And health information exchanges are in the middle of it all.

What were previously Regional Health Information Organizations have morphed into HIEs, organized by geographic, organizational, and payer-based consortia of individuals working together to share health information in an affordable and desirable manner. Some have statewide, government-sponsored HIEs -- like Chesapeake Regional Information System for our Patients or CRISP, which is the state-designated HIE for Maryland. Others have multiple regional HIEs that are still in the process of forming statewide coalitions, such as the New York eHealth Collaborative (NYeHC).

People like Josh are afraid of losing control of their personal health information (PHI) in the mad rush to connect disparate electronic health records (EHRs) to the health information exchanges. Josh wants to ensure that only his primary care physician can see his psychiatric history, to minimize the risk that the stigma that is still attached to mental illness doesn’t affect his job prospects. But neither Maryland nor New York, for example, give individuals control over which records can be accessed by which providers. In fact, they don’t yet have even a simple audit process that permits a consumer to know who has accessed which records and for what purpose. Very few of the HIEs even have a mechanism that allows one to see what records are available.

So, you don’t know what is in there, you don’t know who has accessed it, and you can’t control access based on type of information. HIEs are generally built for physicians and other health care providers, not patients or “consumers.” You can, however, usually control access via a master switch that either shuts off access to everyone or opens access to everything -- all or nothing. Of course, only those with proper authorization are permitted access to your PHI. But for someone with Josh’s concerns, this is cold comfort. 

This is dilemma #1: making the decision to allow access to all one’s records, versus shutting off all access to maximize privacy, while reducing convenience and safety. This is also called “opting out.” A majority of HIEs default to an automatic opt-in status, requiring one to take an action to opt-out of participation in the HIE. Opting out would mean that Josh’s psychiatrist would not find out that his PCP started him on hydrochlorothiazide for his hypertension unless Josh mentioned it or his PCP sends a note to the psychiatrist. Knowing this could prevent an episode of lithium toxicity due to drug interactions. When he shows up in the ER confused and unable to provide a good history due to lithium toxicity, ER physicians would not be able to access his clinical details via the HIE if he has opted out. If he becomes manic, his psychiatrist might not otherwise become aware of the fact that he had been started on a rapid prednisone taper the week before an ER visit for shortness of breath and pneumonia.

Another strategy that some HIEs have discussed is to establish more restrictive access policies for “sensitive health information.” The idea is that certain categories of information, like mental illness, substance abuse, HIV status, domestic violence, and genetic data, be treated differently, with additional safeguards to prevent unauthorized access.

This brings us to dilemma #2: how to determine which PHI should be considered “sensitive.” Some may want their mental health history to marked “sensitive,” while others may want all their health care providers to be aware of this information. Others may feel that all of their PHI should have maximal safeguards and want it all to be “sensitive.” Categorically making mental health and substance abuse information “sensitive” and subject to excessively restrictive protocols may result in unintended consequences. Such a move would likely add to the stigma of mental illness. It would also make it more difficult to share important information among providers. There is already an identified problem of receiving adequate primary care for individuals in the public mental health system, who die prematurely by 25 years or more (Psychiatr. Serv. 2006;57:1482-7). Requiring consumers with mental illness to choose between opting in and opting out requires them to choose between privacy and safety. Other options must be made available.

One of these options involves granular consent policies for HIEs and EHRs. Such policies would provide consumers with the ability to decide for themselves which types of PHI would have extra access restrictions, such as “only my PCP can see my psychiatrist records, while ED physicians cannot see these unless I am unconscious and cannot provide history.”

Another option allows consumers to see what information is available for other providers to view. This, along with robust audit log reporting, might provide a greater sense of trust in the system. Both of these options would hopefully result in lower opt-out rates and a greater sense of involvement in ones own medical care. 

What can you do to help bring about these changes? First, learn about the HIE policies in your region and in your state. Learn about the governance structure, read the meeting minutes, and participate in the decision-making process by writing letters or attending meetings and speaking up. Also let your legislators know that this is an important issue. Second, educate your patients about the privacy and safety issues around HIEs, and discuss their participation status with them. Third, provide clear information to your patients about your participation status with the HIE and understand what their wishes and fears are. Finally, if you have access to your state’s HIE, sit down with your patients and show them how it works and what information is available about them. You are a patient, too, so use the opportunity to understand what your rights and responsibilities are as an HIE participant.

Share your experiences with your HIE by commenting on this article below.

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter @HITshrink and at [email protected].

osh Taylor is an attorney who is now in his 40s with a history of asthma, borderline hypertension, and bipolar disorder, all of which are stable. He sees a psychiatrist three times per year, who prescribes lithium and gets periodic blood tests. He sees his regular physician every year or 2, especially when he has asthma exacerbations. She prescribes an inhaler and, rarely, steroids. Josh is junior partner in his law firm.

Josh is scared. He’s scared of his state’s Health Information Exchange (HIE).

While Josh is actually a fictional character from my book, his situation is very real. When it comes to making decisions about allowing his personal health information to be shared with others, he is balancing three competing interests – privacy, safety, and convenience. And health information exchanges are in the middle of it all.

What were previously Regional Health Information Organizations have morphed into HIEs, organized by geographic, organizational, and payer-based consortia of individuals working together to share health information in an affordable and desirable manner. Some have statewide, government-sponsored HIEs -- like Chesapeake Regional Information System for our Patients or CRISP, which is the state-designated HIE for Maryland. Others have multiple regional HIEs that are still in the process of forming statewide coalitions, such as the New York eHealth Collaborative (NYeHC).

People like Josh are afraid of losing control of their personal health information (PHI) in the mad rush to connect disparate electronic health records (EHRs) to the health information exchanges. Josh wants to ensure that only his primary care physician can see his psychiatric history, to minimize the risk that the stigma that is still attached to mental illness doesn’t affect his job prospects. But neither Maryland nor New York, for example, give individuals control over which records can be accessed by which providers. In fact, they don’t yet have even a simple audit process that permits a consumer to know who has accessed which records and for what purpose. Very few of the HIEs even have a mechanism that allows one to see what records are available.

So, you don’t know what is in there, you don’t know who has accessed it, and you can’t control access based on type of information. HIEs are generally built for physicians and other health care providers, not patients or “consumers.” You can, however, usually control access via a master switch that either shuts off access to everyone or opens access to everything -- all or nothing. Of course, only those with proper authorization are permitted access to your PHI. But for someone with Josh’s concerns, this is cold comfort. 

This is dilemma #1: making the decision to allow access to all one’s records, versus shutting off all access to maximize privacy, while reducing convenience and safety. This is also called “opting out.” A majority of HIEs default to an automatic opt-in status, requiring one to take an action to opt-out of participation in the HIE. Opting out would mean that Josh’s psychiatrist would not find out that his PCP started him on hydrochlorothiazide for his hypertension unless Josh mentioned it or his PCP sends a note to the psychiatrist. Knowing this could prevent an episode of lithium toxicity due to drug interactions. When he shows up in the ER confused and unable to provide a good history due to lithium toxicity, ER physicians would not be able to access his clinical details via the HIE if he has opted out. If he becomes manic, his psychiatrist might not otherwise become aware of the fact that he had been started on a rapid prednisone taper the week before an ER visit for shortness of breath and pneumonia.

Another strategy that some HIEs have discussed is to establish more restrictive access policies for “sensitive health information.” The idea is that certain categories of information, like mental illness, substance abuse, HIV status, domestic violence, and genetic data, be treated differently, with additional safeguards to prevent unauthorized access.

This brings us to dilemma #2: how to determine which PHI should be considered “sensitive.” Some may want their mental health history to marked “sensitive,” while others may want all their health care providers to be aware of this information. Others may feel that all of their PHI should have maximal safeguards and want it all to be “sensitive.” Categorically making mental health and substance abuse information “sensitive” and subject to excessively restrictive protocols may result in unintended consequences. Such a move would likely add to the stigma of mental illness. It would also make it more difficult to share important information among providers. There is already an identified problem of receiving adequate primary care for individuals in the public mental health system, who die prematurely by 25 years or more (Psychiatr. Serv. 2006;57:1482-7). Requiring consumers with mental illness to choose between opting in and opting out requires them to choose between privacy and safety. Other options must be made available.

One of these options involves granular consent policies for HIEs and EHRs. Such policies would provide consumers with the ability to decide for themselves which types of PHI would have extra access restrictions, such as “only my PCP can see my psychiatrist records, while ED physicians cannot see these unless I am unconscious and cannot provide history.”

Another option allows consumers to see what information is available for other providers to view. This, along with robust audit log reporting, might provide a greater sense of trust in the system. Both of these options would hopefully result in lower opt-out rates and a greater sense of involvement in ones own medical care. 

What can you do to help bring about these changes? First, learn about the HIE policies in your region and in your state. Learn about the governance structure, read the meeting minutes, and participate in the decision-making process by writing letters or attending meetings and speaking up. Also let your legislators know that this is an important issue. Second, educate your patients about the privacy and safety issues around HIEs, and discuss their participation status with them. Third, provide clear information to your patients about your participation status with the HIE and understand what their wishes and fears are. Finally, if you have access to your state’s HIE, sit down with your patients and show them how it works and what information is available about them. You are a patient, too, so use the opportunity to understand what your rights and responsibilities are as an HIE participant.

Share your experiences with your HIE by commenting on this article below.

-- Steven R. Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter @HITshrink and at [email protected].

It’s a number we see repeatedly in the popular press.  In case you missed the reference, 10.8 is the percent of psychiatrists who saw all of their patients for psychotherapy according to a study published by Mojtabai and Olfson in the Archives of General Psychiatry in August 2008. It represents a decrease from 10 years ago and it is said to prove that psychiatry has come to be about nothing more than prescribing medicines.

I’ve been wondering about this statistic since I first saw it – does it really mean that psychiatrists don’t do psychotherapy anymore? Is the number of psychiatrists who see all of their patients for psychotherapy even relevant to the question of whether psychiatrists practice psychotherapy? I wanted to understand this particular statistic – the press hurls it around to discount the work that we do – and I found that I couldn’t understand the details of the original study in a way that made sense to me.

I decided to ask Dr. Ramin Mojtabai if he would explain the study to me and we met for lunch. He is an animated and energetic man, and conversation came easily. He listened while I explained my fascination with this single statistic and he talked openly about his research.

Using information Ramin gave me, along with statistics from the Centers for Disease Control’s website, I now have a sense of how “10.8 percent” was derived.

The National Medical Ambulatory Care Survey queries randomly selected office-based physicians every year. The physicians, or their office staff, are asked to submit data for patient visits during a one-week period of the year. According to the NMACS website, each year 3,000 physicians submit information on approximately 30 patient visits. For 2007, the number of physicians who actually participated was about half this, or just over 1,500 and the patient visits were closer to an average of 25 per practice.

Specially trained interviewers visit the physicians prior to their participation in the survey in order to provide them with survey materials and instruct them on how to complete the forms. Data collection from the physician, rather than from the patient, provides an analytic base that expands information on ambulatory care collected through other NCHS surveys. Each physician is randomly assigned to a 1-week reporting period. During this period, data for a systematic random sample of visits are recorded by the physician or office staff on an encounter form provided for that purpose. Data are obtained on patients’ symptoms, physicians’ diagnoses, and medications ordered or provided.

If you’d like to see the forms that are used, you can download them at http://www.cdc.gov/nchs/ahcd/ahcd survey instruments.htm.

For this study, Mojtabai and Olfson took the data that had already been gathered for psychiatrists. For each year, an average of 75.6 psychiatrists were surveyed, for a total of 756 psychiatrists for the years 1996-2005. All visits were not included, as the survey uses “a systematic random sample of visits,” and it is not possible to know if psychiatrists submitted data sheets for every patient contact.  The study included data from an average of 19 visits per psychiatrist.  Data was collected by visit, so theoretically, a psychoanalyst who sees the same patient five times a week would be submitting the same data for a few patients, while a psychiatrist with a high volume practice would only have a fraction of his interactions included, and psychotherapy visits might be missed.

To get to the statistic of 10.8%, the researchers looked at the responses to two questions on the form. In the area for “Non-Medication Treatment” there was an option to check “psychotherapy” under “List all ordered or provided at this visit.” (The bolding is on the form, it is not my intention to add emphasis). The second item they looked at was “Time spent with Provider” to be listed in minutes.

Mojtabai and Olfson did a simple cut to define “psychotherapy” for the purpose of this study. If the box for psychotherapy was checked and the time spent with the physician was more than 30 minutes, it was deemed to be psychotherapy. The authors were attempting to capture a traditional psychotherapy session. If a psychiatrist’s data sheets all included psychotherapy as a checked-off treatment, and all lasted over 30 minutes, then allof his patients were seen for psychotherapy. This percentage has dropped from 19.1% in 1996 to 10.8% in 2005. If you’re wondering, as I was, the percentage of surveyed psychiatrists who see some of their patients for psychotherapy sessions lasting over 30 minutes is 59.4%, which represented a non-significant decrease from 10 years earlier.

So is it true that only 10.8% of psychiatrists see all their patients for psychotherapy, as the media likes to tell us? I suppose that depends on whether a systematic random sample of an average of 19 visits submitted by an average of ~75 psychiatrists in a one-week period is a clear extrapolation of the practice of all office-based psychiatrists in the United States, and whether you believe that psychotherapy can take place in 30 minutes or less.  Why doesn’t the popular press mention that 70.2% of psychiatrists provide psychotherapy to all or some of their patients?  That would change the whole slant of the stories.  

“I really don’t think that the actual numbers – especially the 11% – should be taken literally. The strength of our study was to look at trends,” Ramin said.

The overall trends are more clear: whether or not they are providing psychotherapy, the surveyed psychiatrists are seeing their patients for shorter visits. In 1996, 44.4% of visits to these aggregate psychiatrists were psychotherapy sessions lasting over 30 minutes and by 2005 this number had decreased to 28.9%. The authors go on to identify specific factors including age, race, diagnosis, insurance type, and region of the country that are likely to be associated with psychotherapy sessions lasting over 30 minutes and their ideas about why this trend is occurring.

So lunch with Dr. Mojtabai was interesting and we had a lot to talk about. I asked him how he feels about the way the media uses his statistics and he replied, “I have to emotionally distance myself from that.”

As an aside, Ramin is the only person I’ve ever met who is both a psychologist and a psychiatrist, having completed a PhD in clinical psychology and a residency training program in psychiatry, as well as a master’s degree in public health. “I’ve spent my whole life in school,” he said. My response? “Obviously!”

 If you’re a physician and would like to comment on this article here, please register with Clinical Psychiatry News.  If you are already registered, please log in to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here. Comments on Shrink Rap are open to all readers.

 --Dinah Miller, M.D.

It’s a number we see repeatedly in the popular press.  In case you missed the reference, 10.8 is the percent of psychiatrists who saw all of their patients for psychotherapy according to a study published by Mojtabai and Olfson in the Archives of General Psychiatry in August 2008. It represents a decrease from 10 years ago and it is said to prove that psychiatry has come to be about nothing more than prescribing medicines.

I’ve been wondering about this statistic since I first saw it – does it really mean that psychiatrists don’t do psychotherapy anymore? Is the number of psychiatrists who see all of their patients for psychotherapy even relevant to the question of whether psychiatrists practice psychotherapy? I wanted to understand this particular statistic – the press hurls it around to discount the work that we do – and I found that I couldn’t understand the details of the original study in a way that made sense to me.

I decided to ask Dr. Ramin Mojtabai if he would explain the study to me and we met for lunch. He is an animated and energetic man, and conversation came easily. He listened while I explained my fascination with this single statistic and he talked openly about his research.

Using information Ramin gave me, along with statistics from the Centers for Disease Control’s website, I now have a sense of how “10.8 percent” was derived.

The National Medical Ambulatory Care Survey queries randomly selected office-based physicians every year. The physicians, or their office staff, are asked to submit data for patient visits during a one-week period of the year. According to the NMACS website, each year 3,000 physicians submit information on approximately 30 patient visits. For 2007, the number of physicians who actually participated was about half this, or just over 1,500 and the patient visits were closer to an average of 25 per practice.

Specially trained interviewers visit the physicians prior to their participation in the survey in order to provide them with survey materials and instruct them on how to complete the forms. Data collection from the physician, rather than from the patient, provides an analytic base that expands information on ambulatory care collected through other NCHS surveys. Each physician is randomly assigned to a 1-week reporting period. During this period, data for a systematic random sample of visits are recorded by the physician or office staff on an encounter form provided for that purpose. Data are obtained on patients’ symptoms, physicians’ diagnoses, and medications ordered or provided.

If you’d like to see the forms that are used, you can download them at http://www.cdc.gov/nchs/ahcd/ahcd survey instruments.htm.

For this study, Mojtabai and Olfson took the data that had already been gathered for psychiatrists. For each year, an average of 75.6 psychiatrists were surveyed, for a total of 756 psychiatrists for the years 1996-2005. All visits were not included, as the survey uses “a systematic random sample of visits,” and it is not possible to know if psychiatrists submitted data sheets for every patient contact.  The study included data from an average of 19 visits per psychiatrist.  Data was collected by visit, so theoretically, a psychoanalyst who sees the same patient five times a week would be submitting the same data for a few patients, while a psychiatrist with a high volume practice would only have a fraction of his interactions included, and psychotherapy visits might be missed.

To get to the statistic of 10.8%, the researchers looked at the responses to two questions on the form. In the area for “Non-Medication Treatment” there was an option to check “psychotherapy” under “List all ordered or provided at this visit.” (The bolding is on the form, it is not my intention to add emphasis). The second item they looked at was “Time spent with Provider” to be listed in minutes.

Mojtabai and Olfson did a simple cut to define “psychotherapy” for the purpose of this study. If the box for psychotherapy was checked and the time spent with the physician was more than 30 minutes, it was deemed to be psychotherapy. The authors were attempting to capture a traditional psychotherapy session. If a psychiatrist’s data sheets all included psychotherapy as a checked-off treatment, and all lasted over 30 minutes, then allof his patients were seen for psychotherapy. This percentage has dropped from 19.1% in 1996 to 10.8% in 2005. If you’re wondering, as I was, the percentage of surveyed psychiatrists who see some of their patients for psychotherapy sessions lasting over 30 minutes is 59.4%, which represented a non-significant decrease from 10 years earlier.

So is it true that only 10.8% of psychiatrists see all their patients for psychotherapy, as the media likes to tell us? I suppose that depends on whether a systematic random sample of an average of 19 visits submitted by an average of ~75 psychiatrists in a one-week period is a clear extrapolation of the practice of all office-based psychiatrists in the United States, and whether you believe that psychotherapy can take place in 30 minutes or less.  Why doesn’t the popular press mention that 70.2% of psychiatrists provide psychotherapy to all or some of their patients?  That would change the whole slant of the stories.  

“I really don’t think that the actual numbers – especially the 11% – should be taken literally. The strength of our study was to look at trends,” Ramin said.

The overall trends are more clear: whether or not they are providing psychotherapy, the surveyed psychiatrists are seeing their patients for shorter visits. In 1996, 44.4% of visits to these aggregate psychiatrists were psychotherapy sessions lasting over 30 minutes and by 2005 this number had decreased to 28.9%. The authors go on to identify specific factors including age, race, diagnosis, insurance type, and region of the country that are likely to be associated with psychotherapy sessions lasting over 30 minutes and their ideas about why this trend is occurring.

So lunch with Dr. Mojtabai was interesting and we had a lot to talk about. I asked him how he feels about the way the media uses his statistics and he replied, “I have to emotionally distance myself from that.”

As an aside, Ramin is the only person I’ve ever met who is both a psychologist and a psychiatrist, having completed a PhD in clinical psychology and a residency training program in psychiatry, as well as a master’s degree in public health. “I’ve spent my whole life in school,” he said. My response? “Obviously!”

 If you’re a physician and would like to comment on this article here, please register with Clinical Psychiatry News.  If you are already registered, please log in to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here. Comments on Shrink Rap are open to all readers.

 --Dinah Miller, M.D.

It’s a number we see repeatedly in the popular press.  In case you missed the reference, 10.8 is the percent of psychiatrists who saw all of their patients for psychotherapy according to a study published by Mojtabai and Olfson in the Archives of General Psychiatry in August 2008. It represents a decrease from 10 years ago and it is said to prove that psychiatry has come to be about nothing more than prescribing medicines.

I’ve been wondering about this statistic since I first saw it – does it really mean that psychiatrists don’t do psychotherapy anymore? Is the number of psychiatrists who see all of their patients for psychotherapy even relevant to the question of whether psychiatrists practice psychotherapy? I wanted to understand this particular statistic – the press hurls it around to discount the work that we do – and I found that I couldn’t understand the details of the original study in a way that made sense to me.

I decided to ask Dr. Ramin Mojtabai if he would explain the study to me and we met for lunch. He is an animated and energetic man, and conversation came easily. He listened while I explained my fascination with this single statistic and he talked openly about his research.

Using information Ramin gave me, along with statistics from the Centers for Disease Control’s website, I now have a sense of how “10.8 percent” was derived.

The National Medical Ambulatory Care Survey queries randomly selected office-based physicians every year. The physicians, or their office staff, are asked to submit data for patient visits during a one-week period of the year. According to the NMACS website, each year 3,000 physicians submit information on approximately 30 patient visits. For 2007, the number of physicians who actually participated was about half this, or just over 1,500 and the patient visits were closer to an average of 25 per practice.

Specially trained interviewers visit the physicians prior to their participation in the survey in order to provide them with survey materials and instruct them on how to complete the forms. Data collection from the physician, rather than from the patient, provides an analytic base that expands information on ambulatory care collected through other NCHS surveys. Each physician is randomly assigned to a 1-week reporting period. During this period, data for a systematic random sample of visits are recorded by the physician or office staff on an encounter form provided for that purpose. Data are obtained on patients’ symptoms, physicians’ diagnoses, and medications ordered or provided.

If you’d like to see the forms that are used, you can download them at http://www.cdc.gov/nchs/ahcd/ahcd survey instruments.htm.

For this study, Mojtabai and Olfson took the data that had already been gathered for psychiatrists. For each year, an average of 75.6 psychiatrists were surveyed, for a total of 756 psychiatrists for the years 1996-2005. All visits were not included, as the survey uses “a systematic random sample of visits,” and it is not possible to know if psychiatrists submitted data sheets for every patient contact.  The study included data from an average of 19 visits per psychiatrist.  Data was collected by visit, so theoretically, a psychoanalyst who sees the same patient five times a week would be submitting the same data for a few patients, while a psychiatrist with a high volume practice would only have a fraction of his interactions included, and psychotherapy visits might be missed.

To get to the statistic of 10.8%, the researchers looked at the responses to two questions on the form. In the area for “Non-Medication Treatment” there was an option to check “psychotherapy” under “List all ordered or provided at this visit.” (The bolding is on the form, it is not my intention to add emphasis). The second item they looked at was “Time spent with Provider” to be listed in minutes.

Mojtabai and Olfson did a simple cut to define “psychotherapy” for the purpose of this study. If the box for psychotherapy was checked and the time spent with the physician was more than 30 minutes, it was deemed to be psychotherapy. The authors were attempting to capture a traditional psychotherapy session. If a psychiatrist’s data sheets all included psychotherapy as a checked-off treatment, and all lasted over 30 minutes, then allof his patients were seen for psychotherapy. This percentage has dropped from 19.1% in 1996 to 10.8% in 2005. If you’re wondering, as I was, the percentage of surveyed psychiatrists who see some of their patients for psychotherapy sessions lasting over 30 minutes is 59.4%, which represented a non-significant decrease from 10 years earlier.

So is it true that only 10.8% of psychiatrists see all their patients for psychotherapy, as the media likes to tell us? I suppose that depends on whether a systematic random sample of an average of 19 visits submitted by an average of ~75 psychiatrists in a one-week period is a clear extrapolation of the practice of all office-based psychiatrists in the United States, and whether you believe that psychotherapy can take place in 30 minutes or less.  Why doesn’t the popular press mention that 70.2% of psychiatrists provide psychotherapy to all or some of their patients?  That would change the whole slant of the stories.  

“I really don’t think that the actual numbers – especially the 11% – should be taken literally. The strength of our study was to look at trends,” Ramin said.

The overall trends are more clear: whether or not they are providing psychotherapy, the surveyed psychiatrists are seeing their patients for shorter visits. In 1996, 44.4% of visits to these aggregate psychiatrists were psychotherapy sessions lasting over 30 minutes and by 2005 this number had decreased to 28.9%. The authors go on to identify specific factors including age, race, diagnosis, insurance type, and region of the country that are likely to be associated with psychotherapy sessions lasting over 30 minutes and their ideas about why this trend is occurring.

So lunch with Dr. Mojtabai was interesting and we had a lot to talk about. I asked him how he feels about the way the media uses his statistics and he replied, “I have to emotionally distance myself from that.”

As an aside, Ramin is the only person I’ve ever met who is both a psychologist and a psychiatrist, having completed a PhD in clinical psychology and a residency training program in psychiatry, as well as a master’s degree in public health. “I’ve spent my whole life in school,” he said. My response? “Obviously!”

 If you’re a physician and would like to comment on this article here, please register with Clinical Psychiatry News.  If you are already registered, please log in to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here. Comments on Shrink Rap are open to all readers.

 --Dinah Miller, M.D.

In March, a panel chaired by Dr. Gregory Saathoff, commonly known as the expert behavioral analysis panel (EBAP), released a report containing a summary and analysis of the investigation of Dr. Bruce Ivins, the suspected anthrax mailer. (1) The panel was convened at the request of the Chief Judge of the U.S. District Court, Royce C. Lamberth. The full report containing Dr. Ivins’s previously confidential and sealed medical information is being sold online by the Research Strategies Network, a non-profit organization that consults to the Department of Defense and whose president is Dr. Saathoff.(2) After reading the redacted executive summary, I felt compelled to review the work of the panel in light of standards set forth in the American Academy of Psychiatry and Law’s Ethical Guidelines for the Practice of Forensic Psychiatry.(3)

Although the panel undertook the investigation with “no predispositions with regard to [Dr. Ivins’s] guilt or innocence and in fact without a focus on that issue,” it nevertheless concluded that Dr. Ivins was the anthrax mailer. Dr. Ivins’s guilt has never been established in a court of law since he committed suicide in August 2008 and was never charged with the deaths of the five anthrax victims. This pronouncement of guilt is not consistent with the ethics and traditional practice of forensic psychiatry. Ethical guidelines state that forensic psychiatrists should: “...communicate the honesty of their work...by distinguishing, to the extent possible, between verified and unverified information as well as among clinical ‘facts,’ ‘inferences, and ‘impressions.’ ” The panel report concluded guilt based upon “considerable circumstantial evidence” found in the medical records without acknowledging that this conclusion was based on psychodynamic inference. Specifically, the report found that Ivins had the “psychological disposition,” motive, means and the “behavioral history” to carry out the attacks. The use of a psychological profile to infer guilt is particularly problematic, since this evidence is not admissible in most jurisdictions. Bioterrorist profiles are likely more unreliable than most given the paucity of subjects upon which to base a profile.

From an ethical standpoint, the sale of the panel report is particularly problematic. Forensic reports are generated at the request of the retaining agency or individual, and the information in the report is usually not distributed beyond the parties immediately involved in the proceedings. The forensic evaluator himself does not typically distribute a report to non-involved individuals, nor does the evaluator sell the report to the public. While Dr. Ivins signed several releases of information during the course of his career, it is unlikely that he could have foreseen or given knowing consent to worldwide sale of his medical information. The panel report details Dr. Ivins’s social awkwardness and eccentricities, romantic rebuffs, and early childhood abuse while making careful note that his early abuse did not “exonerate” him for the criminal acts of which he is presumed guilty.

Although the investigation was requested by the court, the panel’s work product was intended to benefit national security investigators. According to the website of the Research Strategies Network, which organized the panel, the RSN has previously collaborated with the F.B.I. and the Department of Defense. This creates an appearance of conflict of interest and bias, a common problem among mental health professionals who consult with law enforcement agencies. Psychologists who consult with law enforcement have ethical guidelines that caution against these dual agency roles due to the risk of unintended bias and the danger of distortion when forming an opinion. 

Although the majority of the expert behavioral analysts on the panel are not board-certified forensic psychiatrists, standard practices and ethical guidelines still apply. Many people who read the report will be struck by Dr. Ivins’s distasteful traits and behaviors, and some may be convinced of his guilt. This should not detract from the larger issue of the proper role and duties of psychiatrists in such investigations.

1. Executive summary of the expert behavioral analysis panel. Accessed at https://www.researchstrategiesnetwork.org/pages/view/Amerithrax/ on June 5, 2011

2. The Amerithrax case: report of the expert behavioral analysis panel. Accessed at

http://www.lulu.com/product/paperback/the-amerithrax-case-report-of-the-expert-behavioral-analysis-panel-%28redacted-version%29/15208937 on June 14, 2011

3. American Academy of Psychiatry and Law. Ethics guidelines for the practice of forensic psychiatry. Accessed at http://www.aapl.org/ethics.htm on June 17, 2011

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In March, a panel chaired by Dr. Gregory Saathoff, commonly known as the expert behavioral analysis panel (EBAP), released a report containing a summary and analysis of the investigation of Dr. Bruce Ivins, the suspected anthrax mailer. (1) The panel was convened at the request of the Chief Judge of the U.S. District Court, Royce C. Lamberth. The full report containing Dr. Ivins’s previously confidential and sealed medical information is being sold online by the Research Strategies Network, a non-profit organization that consults to the Department of Defense and whose president is Dr. Saathoff.(2) After reading the redacted executive summary, I felt compelled to review the work of the panel in light of standards set forth in the American Academy of Psychiatry and Law’s Ethical Guidelines for the Practice of Forensic Psychiatry.(3)

Although the panel undertook the investigation with “no predispositions with regard to [Dr. Ivins’s] guilt or innocence and in fact without a focus on that issue,” it nevertheless concluded that Dr. Ivins was the anthrax mailer. Dr. Ivins’s guilt has never been established in a court of law since he committed suicide in August 2008 and was never charged with the deaths of the five anthrax victims. This pronouncement of guilt is not consistent with the ethics and traditional practice of forensic psychiatry. Ethical guidelines state that forensic psychiatrists should: “...communicate the honesty of their work...by distinguishing, to the extent possible, between verified and unverified information as well as among clinical ‘facts,’ ‘inferences, and ‘impressions.’ ” The panel report concluded guilt based upon “considerable circumstantial evidence” found in the medical records without acknowledging that this conclusion was based on psychodynamic inference. Specifically, the report found that Ivins had the “psychological disposition,” motive, means and the “behavioral history” to carry out the attacks. The use of a psychological profile to infer guilt is particularly problematic, since this evidence is not admissible in most jurisdictions. Bioterrorist profiles are likely more unreliable than most given the paucity of subjects upon which to base a profile.

From an ethical standpoint, the sale of the panel report is particularly problematic. Forensic reports are generated at the request of the retaining agency or individual, and the information in the report is usually not distributed beyond the parties immediately involved in the proceedings. The forensic evaluator himself does not typically distribute a report to non-involved individuals, nor does the evaluator sell the report to the public. While Dr. Ivins signed several releases of information during the course of his career, it is unlikely that he could have foreseen or given knowing consent to worldwide sale of his medical information. The panel report details Dr. Ivins’s social awkwardness and eccentricities, romantic rebuffs, and early childhood abuse while making careful note that his early abuse did not “exonerate” him for the criminal acts of which he is presumed guilty.

Although the investigation was requested by the court, the panel’s work product was intended to benefit national security investigators. According to the website of the Research Strategies Network, which organized the panel, the RSN has previously collaborated with the F.B.I. and the Department of Defense. This creates an appearance of conflict of interest and bias, a common problem among mental health professionals who consult with law enforcement agencies. Psychologists who consult with law enforcement have ethical guidelines that caution against these dual agency roles due to the risk of unintended bias and the danger of distortion when forming an opinion. 

Although the majority of the expert behavioral analysts on the panel are not board-certified forensic psychiatrists, standard practices and ethical guidelines still apply. Many people who read the report will be struck by Dr. Ivins’s distasteful traits and behaviors, and some may be convinced of his guilt. This should not detract from the larger issue of the proper role and duties of psychiatrists in such investigations.

1. Executive summary of the expert behavioral analysis panel. Accessed at https://www.researchstrategiesnetwork.org/pages/view/Amerithrax/ on June 5, 2011

2. The Amerithrax case: report of the expert behavioral analysis panel. Accessed at

http://www.lulu.com/product/paperback/the-amerithrax-case-report-of-the-expert-behavioral-analysis-panel-%28redacted-version%29/15208937 on June 14, 2011

3. American Academy of Psychiatry and Law. Ethics guidelines for the practice of forensic psychiatry. Accessed at http://www.aapl.org/ethics.htm on June 17, 2011

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In March, a panel chaired by Dr. Gregory Saathoff, commonly known as the expert behavioral analysis panel (EBAP), released a report containing a summary and analysis of the investigation of Dr. Bruce Ivins, the suspected anthrax mailer. (1) The panel was convened at the request of the Chief Judge of the U.S. District Court, Royce C. Lamberth. The full report containing Dr. Ivins’s previously confidential and sealed medical information is being sold online by the Research Strategies Network, a non-profit organization that consults to the Department of Defense and whose president is Dr. Saathoff.(2) After reading the redacted executive summary, I felt compelled to review the work of the panel in light of standards set forth in the American Academy of Psychiatry and Law’s Ethical Guidelines for the Practice of Forensic Psychiatry.(3)

Although the panel undertook the investigation with “no predispositions with regard to [Dr. Ivins’s] guilt or innocence and in fact without a focus on that issue,” it nevertheless concluded that Dr. Ivins was the anthrax mailer. Dr. Ivins’s guilt has never been established in a court of law since he committed suicide in August 2008 and was never charged with the deaths of the five anthrax victims. This pronouncement of guilt is not consistent with the ethics and traditional practice of forensic psychiatry. Ethical guidelines state that forensic psychiatrists should: “...communicate the honesty of their work...by distinguishing, to the extent possible, between verified and unverified information as well as among clinical ‘facts,’ ‘inferences, and ‘impressions.’ ” The panel report concluded guilt based upon “considerable circumstantial evidence” found in the medical records without acknowledging that this conclusion was based on psychodynamic inference. Specifically, the report found that Ivins had the “psychological disposition,” motive, means and the “behavioral history” to carry out the attacks. The use of a psychological profile to infer guilt is particularly problematic, since this evidence is not admissible in most jurisdictions. Bioterrorist profiles are likely more unreliable than most given the paucity of subjects upon which to base a profile.

From an ethical standpoint, the sale of the panel report is particularly problematic. Forensic reports are generated at the request of the retaining agency or individual, and the information in the report is usually not distributed beyond the parties immediately involved in the proceedings. The forensic evaluator himself does not typically distribute a report to non-involved individuals, nor does the evaluator sell the report to the public. While Dr. Ivins signed several releases of information during the course of his career, it is unlikely that he could have foreseen or given knowing consent to worldwide sale of his medical information. The panel report details Dr. Ivins’s social awkwardness and eccentricities, romantic rebuffs, and early childhood abuse while making careful note that his early abuse did not “exonerate” him for the criminal acts of which he is presumed guilty.

Although the investigation was requested by the court, the panel’s work product was intended to benefit national security investigators. According to the website of the Research Strategies Network, which organized the panel, the RSN has previously collaborated with the F.B.I. and the Department of Defense. This creates an appearance of conflict of interest and bias, a common problem among mental health professionals who consult with law enforcement agencies. Psychologists who consult with law enforcement have ethical guidelines that caution against these dual agency roles due to the risk of unintended bias and the danger of distortion when forming an opinion. 

Although the majority of the expert behavioral analysts on the panel are not board-certified forensic psychiatrists, standard practices and ethical guidelines still apply. Many people who read the report will be struck by Dr. Ivins’s distasteful traits and behaviors, and some may be convinced of his guilt. This should not detract from the larger issue of the proper role and duties of psychiatrists in such investigations.

1. Executive summary of the expert behavioral analysis panel. Accessed at https://www.researchstrategiesnetwork.org/pages/view/Amerithrax/ on June 5, 2011

2. The Amerithrax case: report of the expert behavioral analysis panel. Accessed at

http://www.lulu.com/product/paperback/the-amerithrax-case-report-of-the-expert-behavioral-analysis-panel-%28redacted-version%29/15208937 on June 14, 2011

3. American Academy of Psychiatry and Law. Ethics guidelines for the practice of forensic psychiatry. Accessed at http://www.aapl.org/ethics.htm on June 17, 2011

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

It may seem early, but spring is the right time of year to start thinking about finding a fellowship. You know you're interested in forensic psychiatry and you've already broken the news to your spouse and family that for the next academic year, if all goes well, you will be evaluating murderers, arsonists, psychotic killers and future insanity acquittees. Your family members have resigned themselves to the fact that dinner conversation may turn to bizarre and possibly bloody topics.

How do you find the forensic fellowship that is right for you?

First, start early. Forensic psychiatry fellowships start accepting applications in the early spring, at the end of the third year of residency. Plan to have your application packet completed and submitted by the end of June. The applicant interview season runs from July through September, sometimes later depending on the program, but the majority of the programs have their slots filled by November. There are forty accredited programs nationally, most with at least two training slots (four in some rare larger programs), but there will be many more applicants than available positions. And with many states facing budget crises, some programs are cutting positions.

Your program choice will involve personal considerations as well as discussions with a spouse or other family members, but I’d like to offer some additional factors to consider.

There are no clear criteria or outcome measures to sort out the first tier from the second tier programs. After some preliminary investigation you'll learn that certain programs have reputations for being “the best” or are more competitive to get into than others. These big name programs often have well-known directors, people with lots of publications to their credit or who have held office in the American Academy of Psychiatry and Law (AAPL), the professional organization for forensic psychiatrists.

The problem with these "big name" programs is that they are run by a single guru. Learning from a guru can be an advantage because you will have access to professional connections that will help you advance quickly within the profession, but the problem with this is that your training may be confined to a single dominating philosophy. Forensic reports from programs like this are so uniform that someone can tell where you trained by the phrases you use, and that's a problem. Second tier programs without a single guru may give you a broader exposure to a diversity of opinions and approaches. This is good for a student who enjoys seeking out a variety of opinions and who likes a lot of feedback on a given case, but may be frustrating for someone who gets confused by conflicting advice. The perfect forensic fellowship is one which fits your preferred learning style.

The perfect forensic fellowship is one which has strong institutional support from its affiliated university. There are a number of ways to assess this. Strong institutional support is indicated by paid full time faculty, adequate administrative resources, and good working relationships between training sites. Poor institutional support is indicated by frequent turnover of program personnel or program directors. Newer programs may initially rely upon volunteer faculty; this may be an indicator that the program is not strong in scholarly activity or publishing. However, volunteer faculty teach for the enjoyment of working with students. They sacrifice professional time---and income---to work with you. That dedication could be worth the tradeoff if you aren't planning a career in academia.

For forensic psychiatry in particular, program location is important. If you know the geographic region you want to work in after training, look for a program in that region. Forensic training means learning the law of the land, and laws vary between states. Moving to a new state means you will have to learn the statutory and case law for that state, as well as any administrative procedures governing your work.

While we're on the topic of location, consider logistics and commute time. Forensic fellowships may have three or four different training sites: a primary academic institution, a forensic hospital, a court house and a jail or prison. The amount of time you spend driving between all these locations will be a significant influence on the quality of your life as a fellow. Does the program reimburse for travel expenses like gas or mileage? What about parking?

You may already have a specific interest in a certain aspect of forensic psychiatry: the treatment of sex offenders, or civil forensic work, or juvenile forensic evaluations. Be sure to ask about opportunities to pursue extra training or experience in these areas.

Most programs are good about telling applicants about the "special perks" of their programs since these are usually their best selling points, but if these aren't mentioned be sure to ask. Are there opportunities to attend conferences (and get reimbursed for conference costs!)? Are there chances to teach residents or medical students? How about opportunities to do independent study or research projects?

The last and least important factor to consider is salary. Salaries will vary quite a bit depending on program location, but most are generally consistent with the cost of living in that area. Don't base your program choice upon salary: no amount of money is worth a year of misery in a program you don't enjoy.

Finally, a word about safety: don't worry about it. In spite of the fact that you will be working with very sick or potentially violent people, forensic psychiatry programs are keen on safety. To the best of my knowledge, no forensic psychiatry fellow has been significantly injured during the course of their work.

For a list of forensic psychiatry fellowship programs visit the American Academy of Psychiatry and Law website at http://aapl.org/fellow.php.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

It may seem early, but spring is the right time of year to start thinking about finding a fellowship. You know you're interested in forensic psychiatry and you've already broken the news to your spouse and family that for the next academic year, if all goes well, you will be evaluating murderers, arsonists, psychotic killers and future insanity acquittees. Your family members have resigned themselves to the fact that dinner conversation may turn to bizarre and possibly bloody topics.

How do you find the forensic fellowship that is right for you?

First, start early. Forensic psychiatry fellowships start accepting applications in the early spring, at the end of the third year of residency. Plan to have your application packet completed and submitted by the end of June. The applicant interview season runs from July through September, sometimes later depending on the program, but the majority of the programs have their slots filled by November. There are forty accredited programs nationally, most with at least two training slots (four in some rare larger programs), but there will be many more applicants than available positions. And with many states facing budget crises, some programs are cutting positions.

Your program choice will involve personal considerations as well as discussions with a spouse or other family members, but I’d like to offer some additional factors to consider.

There are no clear criteria or outcome measures to sort out the first tier from the second tier programs. After some preliminary investigation you'll learn that certain programs have reputations for being “the best” or are more competitive to get into than others. These big name programs often have well-known directors, people with lots of publications to their credit or who have held office in the American Academy of Psychiatry and Law (AAPL), the professional organization for forensic psychiatrists.

The problem with these "big name" programs is that they are run by a single guru. Learning from a guru can be an advantage because you will have access to professional connections that will help you advance quickly within the profession, but the problem with this is that your training may be confined to a single dominating philosophy. Forensic reports from programs like this are so uniform that someone can tell where you trained by the phrases you use, and that's a problem. Second tier programs without a single guru may give you a broader exposure to a diversity of opinions and approaches. This is good for a student who enjoys seeking out a variety of opinions and who likes a lot of feedback on a given case, but may be frustrating for someone who gets confused by conflicting advice. The perfect forensic fellowship is one which fits your preferred learning style.

The perfect forensic fellowship is one which has strong institutional support from its affiliated university. There are a number of ways to assess this. Strong institutional support is indicated by paid full time faculty, adequate administrative resources, and good working relationships between training sites. Poor institutional support is indicated by frequent turnover of program personnel or program directors. Newer programs may initially rely upon volunteer faculty; this may be an indicator that the program is not strong in scholarly activity or publishing. However, volunteer faculty teach for the enjoyment of working with students. They sacrifice professional time---and income---to work with you. That dedication could be worth the tradeoff if you aren't planning a career in academia.

For forensic psychiatry in particular, program location is important. If you know the geographic region you want to work in after training, look for a program in that region. Forensic training means learning the law of the land, and laws vary between states. Moving to a new state means you will have to learn the statutory and case law for that state, as well as any administrative procedures governing your work.

While we're on the topic of location, consider logistics and commute time. Forensic fellowships may have three or four different training sites: a primary academic institution, a forensic hospital, a court house and a jail or prison. The amount of time you spend driving between all these locations will be a significant influence on the quality of your life as a fellow. Does the program reimburse for travel expenses like gas or mileage? What about parking?

You may already have a specific interest in a certain aspect of forensic psychiatry: the treatment of sex offenders, or civil forensic work, or juvenile forensic evaluations. Be sure to ask about opportunities to pursue extra training or experience in these areas.

Most programs are good about telling applicants about the "special perks" of their programs since these are usually their best selling points, but if these aren't mentioned be sure to ask. Are there opportunities to attend conferences (and get reimbursed for conference costs!)? Are there chances to teach residents or medical students? How about opportunities to do independent study or research projects?

The last and least important factor to consider is salary. Salaries will vary quite a bit depending on program location, but most are generally consistent with the cost of living in that area. Don't base your program choice upon salary: no amount of money is worth a year of misery in a program you don't enjoy.

Finally, a word about safety: don't worry about it. In spite of the fact that you will be working with very sick or potentially violent people, forensic psychiatry programs are keen on safety. To the best of my knowledge, no forensic psychiatry fellow has been significantly injured during the course of their work.

For a list of forensic psychiatry fellowship programs visit the American Academy of Psychiatry and Law website at http://aapl.org/fellow.php.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

It may seem early, but spring is the right time of year to start thinking about finding a fellowship. You know you're interested in forensic psychiatry and you've already broken the news to your spouse and family that for the next academic year, if all goes well, you will be evaluating murderers, arsonists, psychotic killers and future insanity acquittees. Your family members have resigned themselves to the fact that dinner conversation may turn to bizarre and possibly bloody topics.

How do you find the forensic fellowship that is right for you?

First, start early. Forensic psychiatry fellowships start accepting applications in the early spring, at the end of the third year of residency. Plan to have your application packet completed and submitted by the end of June. The applicant interview season runs from July through September, sometimes later depending on the program, but the majority of the programs have their slots filled by November. There are forty accredited programs nationally, most with at least two training slots (four in some rare larger programs), but there will be many more applicants than available positions. And with many states facing budget crises, some programs are cutting positions.

Your program choice will involve personal considerations as well as discussions with a spouse or other family members, but I’d like to offer some additional factors to consider.

There are no clear criteria or outcome measures to sort out the first tier from the second tier programs. After some preliminary investigation you'll learn that certain programs have reputations for being “the best” or are more competitive to get into than others. These big name programs often have well-known directors, people with lots of publications to their credit or who have held office in the American Academy of Psychiatry and Law (AAPL), the professional organization for forensic psychiatrists.

The problem with these "big name" programs is that they are run by a single guru. Learning from a guru can be an advantage because you will have access to professional connections that will help you advance quickly within the profession, but the problem with this is that your training may be confined to a single dominating philosophy. Forensic reports from programs like this are so uniform that someone can tell where you trained by the phrases you use, and that's a problem. Second tier programs without a single guru may give you a broader exposure to a diversity of opinions and approaches. This is good for a student who enjoys seeking out a variety of opinions and who likes a lot of feedback on a given case, but may be frustrating for someone who gets confused by conflicting advice. The perfect forensic fellowship is one which fits your preferred learning style.

The perfect forensic fellowship is one which has strong institutional support from its affiliated university. There are a number of ways to assess this. Strong institutional support is indicated by paid full time faculty, adequate administrative resources, and good working relationships between training sites. Poor institutional support is indicated by frequent turnover of program personnel or program directors. Newer programs may initially rely upon volunteer faculty; this may be an indicator that the program is not strong in scholarly activity or publishing. However, volunteer faculty teach for the enjoyment of working with students. They sacrifice professional time---and income---to work with you. That dedication could be worth the tradeoff if you aren't planning a career in academia.

For forensic psychiatry in particular, program location is important. If you know the geographic region you want to work in after training, look for a program in that region. Forensic training means learning the law of the land, and laws vary between states. Moving to a new state means you will have to learn the statutory and case law for that state, as well as any administrative procedures governing your work.

While we're on the topic of location, consider logistics and commute time. Forensic fellowships may have three or four different training sites: a primary academic institution, a forensic hospital, a court house and a jail or prison. The amount of time you spend driving between all these locations will be a significant influence on the quality of your life as a fellow. Does the program reimburse for travel expenses like gas or mileage? What about parking?

You may already have a specific interest in a certain aspect of forensic psychiatry: the treatment of sex offenders, or civil forensic work, or juvenile forensic evaluations. Be sure to ask about opportunities to pursue extra training or experience in these areas.

Most programs are good about telling applicants about the "special perks" of their programs since these are usually their best selling points, but if these aren't mentioned be sure to ask. Are there opportunities to attend conferences (and get reimbursed for conference costs!)? Are there chances to teach residents or medical students? How about opportunities to do independent study or research projects?

The last and least important factor to consider is salary. Salaries will vary quite a bit depending on program location, but most are generally consistent with the cost of living in that area. Don't base your program choice upon salary: no amount of money is worth a year of misery in a program you don't enjoy.

Finally, a word about safety: don't worry about it. In spite of the fact that you will be working with very sick or potentially violent people, forensic psychiatry programs are keen on safety. To the best of my knowledge, no forensic psychiatry fellow has been significantly injured during the course of their work.

For a list of forensic psychiatry fellowship programs visit the American Academy of Psychiatry and Law website at http://aapl.org/fellow.php.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Just over five years ago, Anne Hanson, Steve Daviss, and I started a blog we called Shrink Rap. “A blog by psychiatrists for psychiatrists. A place to talk; no one has to listen.” Five years later, and we are still avidly blogging on Shrink Rap. While some of our readers are psychiatrists, many are not. There’s a lot of talking, and perhaps some occasional listening! Later that same year, 2006, we began a podcast Steve called My Three Shrinks—we’ve now had 58 episodes up on iTunes. Somehow, a yellow rubber duck has become our mascot, and spaced in with some humor and playfulness, we and our readers have had a lot to say about the current practice of psychiatry. Over the last few years, we’ve put our ideas together in a more cohesive and serious endeavor as a book, Shrink Rap: Three Psychiatrists Explain Their Work, released last month by the Johns Hopkins University Press. The book is an “old media” thing...you can hold it, touch it, even turn the pages or write on it with a pen, but it also comes in Kindle and other e-readers form for those who won’t go back. In addition, we have a Facebook page and twitter feeds, and we’ve talked together at APA annual meetings, and on Talk of the Nation. We were delighted when Clinical Psychiatry News asked us to add a blog on their website!

So how did three mainstream, middle-career psychiatrists, distinguished fellows of the APA, become involved in all this on-line silliness ? When we started Shrink Rap, blogging was still a fringy activity, and when I told other psychiatrists I had a blog, they looked at me like I’d lost my mind. I would certainly get sued, if not sanctioned, jailed, and exposed to my patients! My co-bloggers spent the first year in disguise. Anne Hanson, a forensic psychiatrist, blogs under the handle ClinkShrink and was convinced I was going to get her fired. Steve Daviss was deep cover “Roy.”

Shrink Rap, My Three Shrinks, emotional support ducks, and banter in a tone that is quite casual at moments, but we retained a clear line of respect for the very important issues, controversies, and clinical sufferings we learned about as we proceeded. And clearly, we learned a lot, often more from those who use mental health services, than from those who provide them. Our on-line adventures turned out to be surprisingly gratifying, as well as fun. But we needed a more professional label, one that would serve as an umbrella title for our different projects, and would explain our work in a meaningful way. We called this The Accessible Psychiatry Project.

Simply put, the Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and print, we hope to foster discussion about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

So who are we? Steve has worked in many different psychiatric settings and for the last few years, he’s been Chair of Psychiatry at the Baltimore-Washington Medical Center where he practices hospital-based psychiatry. Steve has been working at online engagement and education in issues related to psychiatry for nearly 20 years, even before the world wide web was born. In 1993, while working his fellowship in schizophrenia research with Dr. William T. Carpenter's group, he started an online listserv discussion group (SCHIZ-L) to connect schizophrenia researchers with families and consumers affected by schizophrenia. He also penned "An Internet Primer for Mental Health Professionals" back then, accessible only via gopher. In the late '90s, he answered lay questions every Sunday night in AOL's Depression Information Forum chat room, and also worked with the health community, Healant. He later started psychopharminfo.com, a website and weekly newsletter about the latest psychopharm research geared towards the public. This ended in 2004, so he was primed to roll up his sleeves when I approached him in 2006 about writing a blog.

Anne is a forensic psychiatrist who works in corrections and is Director of the Forensic Psychiatry Fellowship for the University of Maryland School of Medicine. She has worked part-time as a computer programmer and she loves a variety of athletic adventures, including Tai Chi, running, rock climbing, and Anne recently learned to swim so she could go scuba diving after the APA’s annual meeting in Hawaii.

I work in outpatient psychiatry and have a private practice and consult to the Johns Hopkins Hospital Community Psychiatry Program. I am passionate about writing, both non-fiction and fiction. All three of us have been involved in leadership roles in our professional associations.

We hope you’ll enjoy Shrink Rap News, a weekly blog we will be featuring here on the Clinical Psychiatry News website. The fun of a blog comes with it’s interactive nature. Please do register on the CPN blog and share your thoughts with us. Please be aware that registration for CPN blogs is limited to psychiatrists. We’d also like to invite you to visit us on our original blog, Shrink Rap, where commenting is open to all, on Shrink Rap Today, on the Psychology Today website, or to listen to the My Three Shrinks podcasts which can be found on iTunes.

--Dinah Miller, M.D.

Just over five years ago, Anne Hanson, Steve Daviss, and I started a blog we called Shrink Rap. “A blog by psychiatrists for psychiatrists. A place to talk; no one has to listen.” Five years later, and we are still avidly blogging on Shrink Rap. While some of our readers are psychiatrists, many are not. There’s a lot of talking, and perhaps some occasional listening! Later that same year, 2006, we began a podcast Steve called My Three Shrinks—we’ve now had 58 episodes up on iTunes. Somehow, a yellow rubber duck has become our mascot, and spaced in with some humor and playfulness, we and our readers have had a lot to say about the current practice of psychiatry. Over the last few years, we’ve put our ideas together in a more cohesive and serious endeavor as a book, Shrink Rap: Three Psychiatrists Explain Their Work, released last month by the Johns Hopkins University Press. The book is an “old media” thing...you can hold it, touch it, even turn the pages or write on it with a pen, but it also comes in Kindle and other e-readers form for those who won’t go back. In addition, we have a Facebook page and twitter feeds, and we’ve talked together at APA annual meetings, and on Talk of the Nation. We were delighted when Clinical Psychiatry News asked us to add a blog on their website!

So how did three mainstream, middle-career psychiatrists, distinguished fellows of the APA, become involved in all this on-line silliness ? When we started Shrink Rap, blogging was still a fringy activity, and when I told other psychiatrists I had a blog, they looked at me like I’d lost my mind. I would certainly get sued, if not sanctioned, jailed, and exposed to my patients! My co-bloggers spent the first year in disguise. Anne Hanson, a forensic psychiatrist, blogs under the handle ClinkShrink and was convinced I was going to get her fired. Steve Daviss was deep cover “Roy.”

Shrink Rap, My Three Shrinks, emotional support ducks, and banter in a tone that is quite casual at moments, but we retained a clear line of respect for the very important issues, controversies, and clinical sufferings we learned about as we proceeded. And clearly, we learned a lot, often more from those who use mental health services, than from those who provide them. Our on-line adventures turned out to be surprisingly gratifying, as well as fun. But we needed a more professional label, one that would serve as an umbrella title for our different projects, and would explain our work in a meaningful way. We called this The Accessible Psychiatry Project.

Simply put, the Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and print, we hope to foster discussion about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

So who are we? Steve has worked in many different psychiatric settings and for the last few years, he’s been Chair of Psychiatry at the Baltimore-Washington Medical Center where he practices hospital-based psychiatry. Steve has been working at online engagement and education in issues related to psychiatry for nearly 20 years, even before the world wide web was born. In 1993, while working his fellowship in schizophrenia research with Dr. William T. Carpenter's group, he started an online listserv discussion group (SCHIZ-L) to connect schizophrenia researchers with families and consumers affected by schizophrenia. He also penned "An Internet Primer for Mental Health Professionals" back then, accessible only via gopher. In the late '90s, he answered lay questions every Sunday night in AOL's Depression Information Forum chat room, and also worked with the health community, Healant. He later started psychopharminfo.com, a website and weekly newsletter about the latest psychopharm research geared towards the public. This ended in 2004, so he was primed to roll up his sleeves when I approached him in 2006 about writing a blog.

Anne is a forensic psychiatrist who works in corrections and is Director of the Forensic Psychiatry Fellowship for the University of Maryland School of Medicine. She has worked part-time as a computer programmer and she loves a variety of athletic adventures, including Tai Chi, running, rock climbing, and Anne recently learned to swim so she could go scuba diving after the APA’s annual meeting in Hawaii.

I work in outpatient psychiatry and have a private practice and consult to the Johns Hopkins Hospital Community Psychiatry Program. I am passionate about writing, both non-fiction and fiction. All three of us have been involved in leadership roles in our professional associations.

We hope you’ll enjoy Shrink Rap News, a weekly blog we will be featuring here on the Clinical Psychiatry News website. The fun of a blog comes with it’s interactive nature. Please do register on the CPN blog and share your thoughts with us. Please be aware that registration for CPN blogs is limited to psychiatrists. We’d also like to invite you to visit us on our original blog, Shrink Rap, where commenting is open to all, on Shrink Rap Today, on the Psychology Today website, or to listen to the My Three Shrinks podcasts which can be found on iTunes.

--Dinah Miller, M.D.

Just over five years ago, Anne Hanson, Steve Daviss, and I started a blog we called Shrink Rap. “A blog by psychiatrists for psychiatrists. A place to talk; no one has to listen.” Five years later, and we are still avidly blogging on Shrink Rap. While some of our readers are psychiatrists, many are not. There’s a lot of talking, and perhaps some occasional listening! Later that same year, 2006, we began a podcast Steve called My Three Shrinks—we’ve now had 58 episodes up on iTunes. Somehow, a yellow rubber duck has become our mascot, and spaced in with some humor and playfulness, we and our readers have had a lot to say about the current practice of psychiatry. Over the last few years, we’ve put our ideas together in a more cohesive and serious endeavor as a book, Shrink Rap: Three Psychiatrists Explain Their Work, released last month by the Johns Hopkins University Press. The book is an “old media” thing...you can hold it, touch it, even turn the pages or write on it with a pen, but it also comes in Kindle and other e-readers form for those who won’t go back. In addition, we have a Facebook page and twitter feeds, and we’ve talked together at APA annual meetings, and on Talk of the Nation. We were delighted when Clinical Psychiatry News asked us to add a blog on their website!

So how did three mainstream, middle-career psychiatrists, distinguished fellows of the APA, become involved in all this on-line silliness ? When we started Shrink Rap, blogging was still a fringy activity, and when I told other psychiatrists I had a blog, they looked at me like I’d lost my mind. I would certainly get sued, if not sanctioned, jailed, and exposed to my patients! My co-bloggers spent the first year in disguise. Anne Hanson, a forensic psychiatrist, blogs under the handle ClinkShrink and was convinced I was going to get her fired. Steve Daviss was deep cover “Roy.”

Shrink Rap, My Three Shrinks, emotional support ducks, and banter in a tone that is quite casual at moments, but we retained a clear line of respect for the very important issues, controversies, and clinical sufferings we learned about as we proceeded. And clearly, we learned a lot, often more from those who use mental health services, than from those who provide them. Our on-line adventures turned out to be surprisingly gratifying, as well as fun. But we needed a more professional label, one that would serve as an umbrella title for our different projects, and would explain our work in a meaningful way. We called this The Accessible Psychiatry Project.

Simply put, the Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and print, we hope to foster discussion about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

So who are we? Steve has worked in many different psychiatric settings and for the last few years, he’s been Chair of Psychiatry at the Baltimore-Washington Medical Center where he practices hospital-based psychiatry. Steve has been working at online engagement and education in issues related to psychiatry for nearly 20 years, even before the world wide web was born. In 1993, while working his fellowship in schizophrenia research with Dr. William T. Carpenter's group, he started an online listserv discussion group (SCHIZ-L) to connect schizophrenia researchers with families and consumers affected by schizophrenia. He also penned "An Internet Primer for Mental Health Professionals" back then, accessible only via gopher. In the late '90s, he answered lay questions every Sunday night in AOL's Depression Information Forum chat room, and also worked with the health community, Healant. He later started psychopharminfo.com, a website and weekly newsletter about the latest psychopharm research geared towards the public. This ended in 2004, so he was primed to roll up his sleeves when I approached him in 2006 about writing a blog.

Anne is a forensic psychiatrist who works in corrections and is Director of the Forensic Psychiatry Fellowship for the University of Maryland School of Medicine. She has worked part-time as a computer programmer and she loves a variety of athletic adventures, including Tai Chi, running, rock climbing, and Anne recently learned to swim so she could go scuba diving after the APA’s annual meeting in Hawaii.

I work in outpatient psychiatry and have a private practice and consult to the Johns Hopkins Hospital Community Psychiatry Program. I am passionate about writing, both non-fiction and fiction. All three of us have been involved in leadership roles in our professional associations.

We hope you’ll enjoy Shrink Rap News, a weekly blog we will be featuring here on the Clinical Psychiatry News website. The fun of a blog comes with it’s interactive nature. Please do register on the CPN blog and share your thoughts with us. Please be aware that registration for CPN blogs is limited to psychiatrists. We’d also like to invite you to visit us on our original blog, Shrink Rap, where commenting is open to all, on Shrink Rap Today, on the Psychology Today website, or to listen to the My Three Shrinks podcasts which can be found on iTunes.

--Dinah Miller, M.D.