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Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Monday, August 24, 2015

Blessings

City Bakery Melted Chocolate Cookie-Part Cookie, Part Chocolate Bar

I've gone back and forth on whether to write about the termination of my analysis, after the fact. I did write about it in Termination, before it happened. Somehow, this is harder.

So, my analysis ended. The last session was difficult and confusing, and probably will remain confusing for a long time.

First, there was the cookie saga. I decided to get my analyst a parting gift, and since it's impossible to encompass the entirety of an analysis in one object, I decided on cookies. I wanted a specific kind of cookie from a specific bakery (the melted chocolate cookie from City Bakery), but then I wasn't sure I'd be able to get that kind of cookie, so I baked my world-famous-awesome brownies (see This Post for the recipe), but then I felt uncomfortable giving her something I baked myself so I went back to the original cookie idea. And all of this got experienced, acted out, and narrated in the last few days of my analysis.

Another thing I did in the last few sessions was talk about all the things that made me uncomfortable about the process of terminating. Like which words my analyst would choose to end the last session, and how I felt about the intimacy of shaking her hand when I left.

Yet another thing I did, as a larger gesture, was make a blessing. Having been raised as an Orthodox Jew, many, if not all of my fundamental references are Judaic. And one thing observant Jews do is make blessings, which follow the specific formula of, "Blessed are you, lord our God, king of the universe, who is/does something." The italics are the part that varies.

There are blessings for all kinds of things, from rainbows to acknowledging scholarship to thunder to hearing bad news. There is a blessing for every type of food, categorized in very specific ways, of course, but pretty much everything is covered: bread, wine, potato chips, strawberries, and yes, cookies. And even though I'm not as observant as I was growing up, I still make blessings over food. It's a way of reminding myself that I am privileged enough to have food.

In the last few weeks of my analysis, I tried to think of a suitable blessing to make over termination. It was tough. One idea I had was the blessing parents make when a child becomes a Bar or Bat Mitzvah, which goes something like, "Blessed are you....who has removed this one's punishment from me." It sounds awful in translation, but simply means that the child has attained an age at which one begins to take responsibility for ones own actions. That has something of the right idea for a termination, but I told my analyst it seemed more suitable for her to say about me, than for me to say about her.

A friend suggested a blessing about healing a broken heart, which was pretty good, but not quite right.

In the end, I invented my own blessing. It's based on the prayer that's said at funerals and other types of memorial events, such as a Yahrzeit (anniversary of a death), which seemed suitable, since termination has an element of death to it. The end of the prayer translates to something like, "...May he rest in his resting place in peace..."

The Hebrew word that's translated as "resting place" is Mishkav, which literally means, lying-down place. Like a couch. So I used the same word but tweaked it a little to, "Blessed are you, lord our God, king of the universe, who raises (me) up from the couch in peace."
For me, it captures the idea that I leave not "cured", but in more peace than I was in when I started.

So the last session went something like this:

I came in and handed my analyst a bag with the gift. She laughed and asked if these were the brownies or the cookies. I told her they were the cookies, but then I felt bad. Maybe she really wanted to try my world-famous-awesome brownies, and I could have brought both those and the cookies. Oh well. There went that opportunity.

I felt like I should say something momentous that encapsulated the entirety of my analytic experience, but all I could think to say was that my analyst had been very kind. I felt like she should say something broad to summarize our work together, but she just said she'd enjoyed working with me. She also said the door is always open, should I wish to return. I felt like that was decent of her, but it made me wonder if she thought I might not be able to manage on my own.

In the middle of the session, I silently made my blessing, then told her I had made it.

All the old doubts were right there. Have I done enough? Can I manage on my own? Does she like me? Can I share the things I'm inclined to keep to myself? Is she disappointed that I didn't bring her brownies? Can I tolerate the pain of this separation?

It was like a miniature version of my whole analysis, reliving all these feelings that I had grappled with over the years, and made some kind of peace with, only to re-experience them right at the end.

There was a lot more laughing than I had expected, on both our parts. I felt like my preemptively bringing up my discomfort with her final wording, or with shaking her hand, had lessened the pain of those experiences, but also lessened their power. They became more awkward than sad, and I wondered if she was feeling sad too, but was uncomfortable showing it, or felt it was inappropriate to let me see her feeling that way, and maybe the laughter was more nervous than fun. I was disappointed that she wasn't obviously sad. I might have been more disappointed if she had been.

In the end, she said, "We do have to stop." And she laughed. I smiled. I got up, walked to the door, and we shook hands with a quiet, nervous laughter. And then I left.

It wasn't our best session. It wasn't our worst session, either. It was just one of many sessions. I'm grateful for my whole analysis, and I'm also glad, and sad it ended.

So, cookies for closure, discussion for honesty, and a blessing for peace.

Amen.




Saturday, August 22, 2015

Addyi REMS-A Shanda

I seem to be on an Addyi kick lately. I got an email today about the Risk Evaluation and Mitigation Strategy (REMS) for Addyi, the newly approved medication for Hypoactive Sexual Desire Disorder.

There was a lot of fuss about this REMS, because Addyi is known to cause hypotension and syncope particularly alcohol is consumed. So the FDA created a REMS that involved special training and official certification for prescribers of Addyi (as well as pharmacies dispensing Addyi).

I mentioned in a previous post that I didn't want to do the training. I assumed it would be something along the lines of the 8 hour training required to prescribe Buprenorphine, and I didn't want to put that kind of effort into it. More importantly, I don't think the drug works, and I thought it would be easier to tell a patient I'm not certified to prescribe Addyi, than to have a long discussion about why it's not a good idea for her to take Addyi. Yeah, okay, that's a copout. I also didn't want to support this Shanda* of the FDA and Sprout (the company that makes Addyi).

*Shanda is Yiddish for something shameful or scandalous. I think Yiddish has much better words than English for expressing exasperation and outrage. Also sounds. An appropriate one here would be, Feh.

Buuuut...I got curious after I got the email. So I checked it out. What's involved is:

1. Read the Addyi Prescribing Information

2. Complete the Addyi REMS Program Prescriber and Pharmacy Training

3. Complete the Addyi REMS Program Knowledge Assessment

4. Enroll by completing the Addyi REMS Program Prescriber Enrollment Form


I want to go out of sequence for this next bit. I'll start with the Knowledge Assessment. Here it is:



Please note, this is not a section of the Knowledge Assessment. This is it. The whole shebang. I didn't need special training to answer this one.

And the training? It took me less time than reading through this post. The main point of it seems to be the Patient-Provider Agreement Form. This needs to be signed by both prescriber and patient, and states that the prescriber has counseled the patient, and the patient understands the counseling.

It's kind of brilliant. The FDA is covered for approving Addyi by the existence of  this special "training". Sprout is covered for producing and selling a dangerous drug that doesn't work by putting the burden of counseling the patient on the prescriber. And by covered, I mean legally.

This is what's required of the prescriber:


There might have been something useful in the "training" if it included recommendations for assessing a patient's ability to abstain from alcohol, or suggestions about how to encourage a patient not to drink while taking Addyi. But that would place some liability on Sprout or the FDA. So they didn't do it.

I am definitely not gong to enroll as a prescriber.


Thursday, August 20, 2015

Addyi-dendum


Wow! That was fast! On Tuesday, the FDA approves Addyi to treat Hypoactive Sexual Desire disorder (HSDD) in women. And on thursday, the maker of Addyi, Sprout pharmaceuticals, is sold to Valeant for $1 billion.

According to the NY Times article (link above), about $100 million has been invested in Sprout since its formation in 2011. And now it gets $1 billion. Nice.

Let's look at the sequence of events here:

Boehringer Ingelheim develops flibanserin as an antidepressant, but it doesn't work.

They notice that it increases sexual desire, so they test it for that, but the FDA rejects it in 2010, and they give up on it.

Meanwhile, Slate Pharmaceuticals, run by a couple named the Whiteheads, is selling an implantable testosterone product for men. In 2010, Slate receives a warning from the FDA for making exaggerated claims about this drug.

The Whiteheads learn about flibanserin, sell Slate, and form Sprout to acquire it.

Sprout conducts 2 studies that fail to show an increase in sexual desire, change the outcome measure, keep getting rejected by the FDA, then create Even the Score to put political pressure on the FDA to approve flibanserin on the grounds that if they don't, they are guilty of gender bias.

On Tuesday, the FDA caves to this pressure and approves flibanserin, brand name Addyi.

And today, Valeant announces that it is acquiring Sprout for $1 billion cash plus a share of future profits:

Sprout is passionate about women's sexual health and has focused solely on the delivery of a treatment option for the unmet need of premenopausal women with acquired, generalized Hypoactive Sexual Desire Disorder (HSDD)

I'm sure Sprout is as passionate about women's sexual health as Slate was about men's sexual health.

Exactly as passionate.




Tuesday, August 18, 2015

They Caved

It's official. the FDA has approved Addyi, or Flibanserin, the drug purported to treat female Hypoactive Sexual Desire Disorder (HSDD). You can read about it in the NY Times:

FDA Approves Addyi, a Libido Pill for Women

You may recall from my previous post, Addyi, that flibanserin started life as an antidepressant, failed at that job, then tried to reinvent itself as a libido drug, with completely unclear mechanism of action. Its original developer, Boeringer Ingelheim, gave up on it and sold it to Sprout Pharmaceuticals. Sprout measured desire in its original studies of flibanserin via a diary entry. In the first trial, there was no difference between placebo and drug in the outcome measure. Neither was there in the second trial, but then Sprout tried to switch the outcome measure to a subset of questions on a response questionnaire, the Female Sexual Function Index (FSFI), which the FDA considered questionable due, in part, to a 28 day recall period. The FSFI questions were used as the outcome measure in a third trial, with small improvement in desire.

The FDA did not want to approve the drug, mainly because it doesn't work, and it also has significant interactions with alcohol, involving syncopal events. (Notably, these were seen in men, back when it was being tested as an antidepressant.) Flibanserin is a standing medication, not PRN like Viagra, so interactions with alcohol are unavoidable, short of complete abstinence.

But Sprout turned the approval process into a political issue, starting a group called, Even the Score, which claimed the FDA was unwilling to help women with their sexual problems. Sprout got a number of women's organizations involved, and the FDA agreed to a review by an advisory panel.

And now, they've approved it. This is what the FDA has to say about it:

Addyi is being approved with a risk evaluation and mitigation strategy (REMS), which includes elements to assure safe use (ETASU). The FDA is requiring this REMS because of the increased risk of severe hypotension and syncope due to the interaction between Addyi and alcohol. The REMS requires that prescribers be certified with the REMS program by enrolling and completing training. Certified prescribers must counsel patients using a Patient-Provider Agreement Form about the increased risk of severe hypotension and syncope and about the importance of not drinking alcohol during treatment with Addyi. Additionally, pharmacies must be certified with the REMS program by enrolling and completing training. Certified pharmacies must only dispense Addyi to patients with a prescription from a certified prescriber. Additionally, pharmacists must counsel patients prior to dispensing not to drink alcohol during treatment with Addyi.

Addyi is also being approved with a Boxed Warning to highlight the risks of severe hypotension and syncope in patients who drink alcohol during treatment with Addyi, in those who also use moderate or strong CYP3A4 inhibitors, and in those who have liver impairment. Addyi is contraindicated in these patients. In addition, the FDA is requiring the company that owns Addyi to conduct three well-designed studies in women to better understand the known serious risks of the interaction between Addyi and alcohol.

I'm very curious to see whether the FDA follows up on the "required" studies of risks of interactions with alcohol. I don't know what the consequences of non-compliance are, or how the FDA can enforce them.

This is really cynical of me, but I have significant reservations about a drug for women pursuing satisfying sexual interactions that makes them likely to pass out when they drink. Sounds like a new version of roofies.

On the upside, Sprout has agreed not to advertise Addyi on radio or television for 18 months, and to focus marketing on doctors, rather than consumers. Not that huge an upside. To that end, they plan to hire 200 sales reps, to cover 30,000 doctors, mainly OB/GYNs, but also some psychiatrists and primary care docs.

I tried to look up the Addyi REMS to see what's involved, but I couldn't find anything, maybe because Addyi won't be available for sale until October 17th. Personally, I'm not inclined to do the training.


Wednesday, August 12, 2015

You Don't Say

There's a fascinating article in The Atlantic, The Coddling of the American Mind, that has been blogged about and tweeted by Dinah at Shrink Rap. The gist of it is that on college campuses, students and faculty who say things that are offensive are castigated and accused of microaggressions. Offensive comments include, "Where are you from?" if asked of someone Asian, and, "I believe the most qualified person should get the job.” One Harvard law professor was asked not to use the word, "violate", and others were asked not to teach rape law. Professors are supposed to issue trigger warnings for content that might be offensive or upsetting to someone.  

The article uses the phrase vindictive protectiveness to describe the phenomenon of shielding students from anything that might be upsetting. It then goes on to promote the use of CBT to prevent phobic avoidance and encourage mental health.

I'm not so hot on that last part.  To me the issue seems less about phobic avoidance than about the notion that students can only function under ideal conditions, and that everyone's ideal condition needs to be accommodated- a kind of emotional Ponzi scheme.

You can check out the article if you're interested, as well as Dinah's post, which gives a lot more detail than I do. But the reason I'm bringing it up is that it's such a stark contrast to another recent article in the NY Times, FDA's 'Off Label' Drug Policy Leads to Free-Speech Fight

The FDA currently has a policy that prevents drug Manufacturers from promoting a drug for off-label use, even if the content of the promotion is true, but this policy is being challenged under first amendment rights.


Amarin Pharma, a small drug manufacturer, challenged the F.D.A. when it sought to promote the off-label use of its cardiovascular health drug, Vascepa, for patients with a different condition. An F.D.A.-approved study showed that the use of the drug was effective, but the agency had denied approval for use by those patients.

The company and four doctors sued the F.D.A. after it threatened to bring civil charges against them if they used the study to help sell off-label use of Vascepa. They claim that the agency's rule on off-label promotion violates their First Amendment right to free speech...


Judge Paul A. Engelmayer of the Federal District Court in Manhattan found in favor of Amarin. This is tricky. It may well violate someone's freedom of speech to prevent them from stating something true, or that they believe to be true, without intent to defraud. But if a drug rep believes the conclusions of the article he enthusiastically shows to the doctor, that doesn't make those conclusions true. The FDA's policy may exist to prevent drug companies from bypassing the approval process for a new use by producing manipulated, shoddy, not to mention cheap research that they can call "true".

But think about it. On college campuses, the supposed bastions of creative ideas and innovative thought, censorship of speech is rampant. But pharmaceutical companies can say anything they want about their products, as long as they can generate the statistics to support their statements. That can't be the intention of the first amendment.






Saturday, July 18, 2015

Fascinating!

The idea for this post is based on a post by Jim Amos, The Practical Psychosomaticist, entitled, Getting Small Again About MOC. At least, that's how it started.

Dr. Amos wrote to someone at the ABPN to find out if instead of doing PIP modules, often at substantial cost, a diplomate's use of PubMed could be tracked by the Board. He was informed that PubMed use was not an option as a PIP alternative, but that, "You have the option of seeking individual preapproval for either one (PIP) that you develop, or one that you may already be doing as a QI project in your hospital/institution."

And he was given a link to the Individual Part IV Improvement in Medical Practice Approval Request.

So I started to think about the possibility of designing a PIP for the practice of Psychoanalysis.

This is how it works:

Clinical Module: A clinical module requires that you do a chart review of at least five patients in a specific category, (for e.g., diagnosis or type of treatment, treatment setting). You must then compare data from the five patient cases, utilizing a minimum of four quality measures, with a standard specialty practice guideline. Based on the results of the review, develop a plan of improvement, carry out the plan, and in no more than two years, do a second chart review utilizing the same guideline to see if improvement has taken place. The charts may be the same or different patients but must be in the same category utilizing the same guideline and quality measures. (boldface mine)

Where do I get a standard specialty practice guideline for Psychoanalysis? I started looking online, and that's when the idea for this post changed. Because I found an Evidence Based Guideline for Psychoanalysis from BlueCross BlueShield of North Carolina.

This is a short but fascinating document. How to explain?

It has a nice, brief description of Psychoanalysis as a "procedure or service". A bit about theory, how it can be helpful, the logistics, what kind of patient is suitable for analysis, and how analysts are trained. Really quite nice.

Then it goes on to describe the "Evidence Based Guideline", and completely contradicts everything in the preceding section.

For example, in the first section, there's this paragraph:

The person best suited for psychoanalysis is one who is generally successful in most aspects of his/her life but is still unhappy. Psychoanalytic therapy is said to be beneficial for those with troubled relationships, poor self-esteem, anxiety, chronic irritability, unresolved grief, phobias, and many other conditions where they want to understand themselves and see how their own thoughts and behaviors contribute to their difficulties. Psychoanalysis is thought to promote self discovery, personal growth and development. (boldface mine)

But then, in the guideline section, it states, "Psychoanalysis is not recommended for...treatment focused on increasing self awareness, self discovery, or personal growth."

I get that they're saying self-discovery shouldn't be the purpose of analysis-not an analysis they're paying for, anyway, but really, at least change the language so it's not identical.

The guidelines are antithetical to everything an analysis is supposed to be. The "A" criteria are:

Psychoanalysis (PSA) may be appropriate if nothing else has worked.

The patient needs some kind of problem that corresponds to a diagnosis
AND
The patient has distress in work/school/social
OR
an ongoing disorder that requires "behavioral assessment to maintain symptom relief and/or function"
OR
"additional treatment sessions are needed (documented by clinical evidence) to prepare for termination of therapy consisting of a clear treatment plan with well defined goals, methods and time frames to support discharge from therapy"
AND
The patient doesn't need to be in a locked unit.

"Well defined goals, methods and time frames" in an open ended, free associative psychoanalysis. How does that work?

The "B" criteria are even worse. I'm just gonna cut and paste and highlight the phrases that particularly annoy me:

B) All of the following criteria are met;
1. There is documentation of a mental disorder diagnosis, AND

2. There is a medically necessary and documented treatment plan or updated plan
individualized for the patient with at least one of the following outcomes;

a) focuses on alleviating the patient’s distress and/or dysfunction in a timely manner, or
b) pursues achieving maintenance goals for ongoing conditions, or
c) focuses on discharge from therapy, AND

3. The individualized treatment plan includes all of the following:

a) the status of the patient’s dysfunctions being treated and documentation shows
progression toward the treatment goals, and
b) the current treatment is focused on each psychiatric symptom, and
c) treatment framework, and
d) modality of treatment, and
e) frequency, and
f) estimated length of treatment, and
g) the status of the involved family or friends in support of the patient, and
h) the status of any necessary community resources, and
i) an alternative plan if the patient does not make sufficient progress in the time frame
specified, AND

4. The treatment must be rendered by a "certified psychoanalyst" from a nationally recognized
institute for psychoanalysis.

And now my corresponding comments:

How do you define "medical necessity" for PSA?

PSA often increases the patient's distress in the short term

Timely?

Focus on discharge: You better hurry up and change a lifetime's worth of patterns so we can terminate!

Status of dysfunctions?

Symptom focus? That's not PSA.

What do they mean by "treatment framework"?

The modality is PSA, duh!

You don't do family meetings in adult PSA

By their own description, PSA is appropriate for people who are generally successful. What kind of community resources are they talking about?

Define "progress"!


It sounds to me like they just took guidelines for some other kind of psychotherapy and pasted them in.

Now the worst part. The evidence.

There are 4 reference sources listed. The first is:

Dewey R. (2007). Psychoanalysis. Retrieved 7/10/2008 fromhttp://www.intropsych.com/ch13_therapies/psychoanalysis.html

This seems to be some kind of online Psychology Intro text. Psychoanalysis takes up one page. One very short page. It includes no information that would constitute a guideline, evidence based or otherwise. It describes what I consider a misinformed and outdated notion of PSA.

The second source is the "About Psychoanalysis" page on the website of the North Carolina Psychoanalytic Society. It's just a brief blurb about psychoanalysis, the couch, frequency of meeting, and the like. Nothing here in the way of guidelines.

The third source is the American Psychoanalytic Association's Standards for Education and Training in Psychoanalysis. This is a 23 page document that describes requirements for training in PSA. Like, who is eligible to be a candidate. How many case write-ups do they need to complete. It has nothing to do with guidelines for practicing PSA.

The last is the DSM-5. We'll ignore that, since it's just about diagnoses.

What we have is a completely bogus "guideline" that has no evidence base whatsoever, nothing to do with PSA, and everything to do with not wanting to cover the cost of an analysis. If you're an insurance company and you cover mental health, then you really can't afford the cost of an analysis for everyone who would benefit from one. And I guess they can't just outright state that they won't cover PSA because it's too expensive. I get it.

And in case you were wondering, this is not an out-of-date document. It was written in 2008, and reviewed in 2010, 2011, 2012, and last updated a year ago, when some (unspecified) references were removed, and others added. No changes were ever made to the guideline statement other than wording. It's up for another review this month.

I wonder if the ABPN would accept it as part of a PIP module.

Actually, the title of this post is wrong. Mr. Spock says, "Fascinating," when there's something interesting that he doesn't understand. If he does understand it, he just says, "Interesting."




Thursday, July 16, 2015

Video Games-Could They Make You Feel Worse?

A NY Times article, Video Games Could Be Good For Your Mind, writes about a recent study In Psychological Science, Computer Game Play Reduces Intrusive Memories of Experimental Trauma via Reconsolidation-Update Mechanisms, in which subjects were shown a movie with disturbing scenes. The next day, some subjects were asked to play Tetris, some were shown stills of the movie, some were shown stills and then asked to play Tetris, and some did nothing.

The ones who looked at stills and then played “Tetris” had fewer intrusive memories about the movie over the next seven days than the other groups...bringing back the memories via film stills made them vulnerable to change — and Tetris appears to have done the work of changing them.

 [The authors] believe that keeping track of the colored blocks in Tetris “disrupted aspects of the visual memory from being ‘re-laid down’ in the sensory part of the brain.”

There are obvious difficulties with a study like this, such as the fact that it doesn't address real life trauma. But I'm more interested in something else the Times article mentioned, namely, video games currently on the market that directly address mental health conditions.

One such game is, Elude, which is supposed to simulate depression, to help educate friends and family members of a depressed person. Your character wanders in a grim-looking forest, jumping from one branch to another. Sometimes his depression lifts and he's in the sky, like froggy jump, picking up leaves and daisies. Sometimes he sinks into a quagmire of depression. I didn't get that far when I played, but the description of the game seems to indicate that in that stage, the character has less control than usual, and can't just jump out of the muck into which he's sinking.


It's a metaphor for depression, and the music is upsetting, but ultimately, it's just a standard video game with miserable atmospherics. I don't know if it would help someone who's never been depressed understand much about what depression feels like, but it would probably put him or her into a bad mood.

Personally, I think the best metaphor for depression are the Dementors in the Harry Potter books. Foul creatures who live on the misery of others, they will literally suck out your soul if given the chance. The paralyze you, make you relive your worst memories, and feel as though you'll never be happy again, and more broadly, like all happiness has gone from the world. Instant depression.


Another game is Depression Quest, "...an interactive fiction game where you play as someone living with depression. You are given a series of everyday life events and have to attempt to manage your illness, relationships, job, and possible treatment. This game aims to show other sufferers of depression that they are not alone in their feelings, and to illustrate to people who may not understand the illness the depths of what it can do to people."

You can pay what you want, or play for free, and a portion of the proceeds go to the National Suicide Prevention Lifeline. The music is even more depressing than elude's, and I would worry about someone who is moderately depressed sitting down to play this game.

Here's an excerpt from the first decision-making point:


Notice that the non-depressed option isn't even available to you at this stage.

There are all kinds of sympathetic remarks and disclaimers at the beginning of the game, but I have concerns about some depressed teenager searching online for solace and finding this.


On the flip side, a Playstation game like Flower (not mentioned in the Times article) is not intended to treat or even address depression, but I can see where it might help temporarily lift the mood of someone who isn't too seriously depressed. You play a flower petal drifting about through lovely landscapes:



Then there's Sym, a game, "...designed to help players understand how someone with social anxiety feels."

.Sym is a platform puzzle adventure that takes shyness and social anxiety as its theme...

Sym centers on a 2D character called Josh, who exists in two worlds. There is an above ground that is colored white. It is the real world. There is also an upside-down below ground, a negative, that represents Josh's internal landscape.

Puzzles are solved by making use of both worlds, though the levels are not always single-laned, and there is often a progression choice between both plains. The world is full of eyeballs watching Josh's actions. Words appear that draw obvious as well as cryptic allusions to the game's theme.'



I found Sym to be the most disturbing, yet simultaneously, the most energetic of the bunch, with phrases like, "If I could simply die," and, "I am in control...or am I?", as well as some cryptic biblical quotes.

I don't know what to make of these games. What do you think?