Lockup Doc

It’s probably happened to all health care professionals at some point: Patients, especially those considered “difficult” for some reason, fail to improve despite our best efforts. Eventually we become frustrated enough that we then blame them for their lack of progress.

There are endless possible scenarios where this might occur:

• A depressed patient, who transiently appears to have a personality disorder because of her inadequately treated depression, is not progressing in psychotherapy and has not responded to two different medication trials.
• An elderly man bounces back for readmission to the hospital for a CHF exacerbation. He arrives in the ER with a pack of cigarettes in his shirt pocket.
• A morbidly obese woman continues to have poor control of serum glucose, blood pressure, and lipids despite aggressive pharmacotherapy. Yet the patient has lost no weight despite being counseled for years about the need to do so. Read more…

As correctional health care professionals, there may be times when we are tempted to conduct ourselves in a less than professional manner simply because we can.

We may be able to get away with speaking to our patients rudely, using profanity profusely, or wearing inappropriate clothing. After all, we work in jails and prisons. This culture is far from prim and proper. And, our patients are inmates. Many may tolerate misbehavior from us that patients on the outside would not and should not tolerate.

I’ve previously written about how I’ve found the book, Games Criminals Play, to be an invaluable resource. One key point that I learned is that many inmates, especially those trying to set up and manipulate staff, want to know whether each prison worker is a fellow inmate or “the police.” In other words, do we side with the inmates, or are we professional workers who take our jobs seriously? Read more…

Bupropion (Wellbutrin, Zyban) is a unique but commonly prescribed antidepressant that inhibits the reuptake of dopamine and norepinephrine. It is FDA approved for the treatment of major depressive disorder, seasonal affective disorder, and smoking cessation. It is commonly used off-label for the treatment of attention deficit hyperactivity disorder (ADHD).

Anecdotally there have long been reports of abuse and diversion of bupropion in jails and prisons. In my own personal experience in these settings, I have not seen much evidence of such misuse. Inmates rarely present to me seeking this medication. By contrast, and about which I have previously written, quetiapine (Seroquel) is highly desired medication in corrections.

I conducted a literature search on this topic and Read more…

Imagine that as a child you thought you had been born in the body of the wrong gender. If you were biologically male, in your mind you really thought of yourself as female. Likewise, if you were born in a girl’s body, you thought that you were actually a boy.

Yes, you were probably more interested in children’s role-playing games more often associated with the opposite gender as well, but the issue went much deeper than that. It was your core identity that was at stake. You knew that you were the other sex, at least in all ways except for the reproductive organs of your body.

You felt this way during childhood, but nobody seemed to understand or accept this about you.  But you were dressed in the clothing of your biological gender and expected to participate in the activities stereotypically associated with it as well. Imagine that as your body matured in adolescence, you hated your Read more…

As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.

One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.

Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.

Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate,  prescribing habits.

My prescription style inevitably evolved further when Read more…

Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that  patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then Read more…

The prescription of medications for diagnoses, to age groups, or in doses other than the FDA-approved ones, is a common, legal, and necessary practice in medicine today. This practice is known as off-label use or off-label prescribing. Those new to this issue may wonder why physicians and other prescribers would ever deviate from prescribing in territory where the FDA has not given their stamp of approval.

In the ideal world, clinical trials would be conducted for all patient populations and diagnoses for which various medications might be useful. In reality, though, this is neither practical nor possible. Consequently, many patient populations and many patients with particular diagnoses would have few treatment options available if the medical establishment avoided off-label prescribing.

For example, child psychiatry is a huge area where millions of mentally ill children and adolescents depend on off-label medications. The field of general pediatrics is no different. The fact is that most medications are not tested in children. But, does that mean that Read more…

Over the past year we all have been bombarded by media reports of the primary care shortage. It’s bad now but expected to get much worse in the coming decades.

What is not discussed as frequently but ultimately may have just as much negative impact on the future quality of American health care is the dire need for more geriatricians.

This topic is of personal interest to me because I completed a geriatric psychiatry fellowship and am board-certified not only in psychiatry but also in geriatric psychiatry. During my fellowship, I worked alongside the geriatric internal medicine fellows.

During my training and in practice, I’ve treated many elderly patients. I’ve seen them in the nursing home, outpatient, and inpatient settings. Whether a physician comes from an internal medicine, family medicine, or psychiatry background, I understand first-hand the added value of a geriatrics fellowship. I know without a doubt that I am a better physician for having completed this additional training.

Additionally, geriatricians are Read more…

Many people do not realize that in the United States, prison inmates are the only ones who have a constitutional right to health care. This precedent was established in 1976 by the U.S. Supreme Court in the case of Estelle v. Gamble. The court concluded that “deliberate indifference” to “serious medical needs” of prisoners constituted cruel and unusual punishment in violation of the Eighth Amendment.

Not surprisingly, given our country’s current economic and health care crisis, some people are outraged that prisoners are able to access health care and typically can do so either for free or for minimal cost.

From what I’ve seen and read, the quality of health care for inmates varies greatly around the country. There are still many places where the serious medical needs of prisoners are regularly ignored, and many end up with permanent harm or even die as a result. Prisoners have no means of getting themselves to the local emergency room if they believe they need urgent medical care. They are at the mercy of the prison staff.

I realize that some would like to see prisoners “rot” and strongly believe that Read more…

Attention deficit hyperactivity disorder (ADHD), characterized by such symptoms as hyperactivity, impulsivity, and inattention, was previously thought of as a childhood condition that children eventually would outgrow. In recent years, we have realized that ADHD symptoms do not necessarily disappear or lessen by adulthood for many.

In the highly structured prison setting, untreated ADHD does not typically impair daily functioning to the degree that it might for those in the community. Nonetheless, some inmates with untreated ADHD may get into altercations with others and receive conduct reports for violating prison rules because of their impulsivity. Likewise, others may not do as well in prison educational and rehabilitation programs because of difficulty concentrating and staying organized. Read more…