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.

Thursday, December 31, 2015

Mourning and Falconry-A Book Review

I recently finished reading, H is for Hawk, by Helen Macdonald. I stumbled across it in a bookstore in Berkeley called, Books Inc. A real bookstore. The small kind that has a mini-review or commentary by the staff every few books on the shelf. It was refreshing to be there.  I didn't realize it was a NY Times Bestseller. It just drew my eye and looked interesting.

According to her page at The Marsh Agency, Ms. Macdonald is a, "writer, poet, illustrator, historian, and naturalist, and an affiliated research scholar at the Department of History and Philosophy of Science at the University of Cambridge. Over the years she's also worked as a Research Fellow at Jesus College, Cambridge, as a professional falconer, assisted with the management of raptor research and conservation projects across Eurasia, and bred hunting falcons for Arab royalty. She's also sold paintings, worked as an antiquarian bookseller, organised academic conferences, shepherded a flock of fifty ewes and once attended an arms fair by mistake."

H is for Hawk is moving and fascinating, but I'm also very happy to report that even if the subject didn't interest me, I would have enjoyed the book because the woman can write. Sometimes I'll read a book, particularly fiction, and while I may be enjoying the story, I find myself editing the writing- this passage was awkwardly phrased, that sentence would have been better at the end of the paragraph, etc. Not so for Macdonald's writing. It's both beautiful and accessible.

Here's a sample (p. 181):

But then the pheasant is flushed, a pale and burring chunk of muscle and feathers, and the hawk crashes from the hedge towards it. And all the lines that connect heart and head and future possibilities, those lines that also connect me with the hawk and the pheasant and with life and death, suddenly become safe, become tied together in a small muddle of feathers and gripping talons that stand in mud in the middle of a small field in the middle of a small county in a small country on the edge of winter.

Shortly after her father's sudden death,  Macdonald decided to train a goshawk. She'd been fascinated by hawks all her life, and had extensive experience training them. But this was her first attempt at training the notoriously challenging goshawk.

There are a number of reasons she made this decision. One early-Spring morning, she felt restless, got up at dawn, and for no discernible reason, drove to the Brecklands to see goshawks, which are rarely visible in the open except at that time of year. The experience reminded her of watching for sparrowhawks with her father, when she was a child. She brought home a piece of reindeer moss she'd been gripping while watching the goshawks that day, and three weeks later, she was staring at the moss when her mother called to tell her her father had died.

That's the first connection. One of the brilliant things about the book, and there are many, is that Macdonald clearly recognizes the complex interactions between her thoughts and feelings, and her behavior. But she does not dwell on them, as one would in a typical psychoanalytic case report. She simply describes them, and leaves the reader to draw conclusions, although she does, occasionally, mention Melanie Klein, Freud, and other analytic thinkers.

The next connection is closer to the heart of her mourning. She describes a summer experience she set up for herself when she was 12, and went to spend several weeks with some gentlemen who flew goshawks:

I was terrified. Not of the hawks: of the falconers. I'd never met men like these. They wore tweed and offered me snuff. They were clubbable men with battered Range Rovers and vowels that bespoke Eton and Oxford, and I was having the first uncomfortable inklings that while I wanted to be a falconer more than anything, it was possible I might not be entirely like these men...

On the first day of that trip, she watched a goshawk kill a pheasant, her first sight of death. She also watched as later that same day, the goshawks seemed to lose interest in their handlers and flew off into the trees. Some took hours before returning:

The disposition of their hawks was peculiar. But it wasn't unsociable. It was something much stranger. It seemed that the hawks couldn't see us at all, that they'd slipped out of our world entirely and moved into another, wilder world from which humans had been utterly erased.

After that summer, she chose to stay away from goshawks:

I never forgot those silent, wayward goshawks. But when I became a falconer I never wanted to fly one. They unnerved me. The were things of death and difficulty: spooky, pale-eyed psychopaths that lived and killed in woodland thickets. Falcons were the raptors I loved...

Yet another connection has to do with T. H. White, best known as the author of, The Once and Future King. He also wrote a book entitled, The Goshawk, his firsthand account of training his own goshawk, who he named, Gos. It was a disaster. It's like an instruction manual for how NOT to train a goshawk, or any other animal, for that matter. As a child, Macdonald reviled White for his inconsistent, and ultimately cruel treatment of Gos. But in H is for Hawk, she comes to view, The Goshawk, differently, as White's account of his conflicts surrounding sadism and love, and his struggle to become himself through his identification with Gos.

Macdonald is a much better trainer than White, although she doubts herself constantly. Is she feeding Mabel (her goshawk) too much, or too little, or the wrong kind of food? The feeding of a goshawk is not a trivial, Jewish mother issue. Goshawks weigh around two pounds, and a couple ounces either way can throw off their flying completely. But the level of Macdonald's worry is indicative of her mourning, which, by her own acknowledgement, is mixed with depression to a degree that would bewilder the most hardcore DSM-5 enthusiast.

Certainly, Mabel is a comfort to Macdonald. She turns out to be not that difficult to train, and is even playful-there's a lovely description of a game involving some rolled up paper, with Macdonald commenting that she hadn't realized goshawks DID play. She attributes at least some of their affinity to their shared gender, and notes that all the falconers and austringers (solitary goshawk trainers) who have described the bird as difficult and sulky have been men.

Incidentally, I attempted to contact Macdonald through her agent to get permission to use a photo of Mabel that I found online, in this post, but I never heard back from either of them-I suspect my message didn't get through-so I'm not comfortable using the picture here. But if you google "Mabel the goshawk" you will see that she was very beautiful.

Macdonald traces her bonding with Mabel, as well as her use of Mabel to isolate herself while she's mourning. We sense the appeal of the hawk's ability to "slip out of this world". By identifying with Mabel, she can distance herself from her pain, or access her father, who has "moved into another, wilder world from which humans had been utterly erased."

And we see the painful, drawn out process of letting go that Freud wrote about in Mourning and Melancholia (Freud, S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV, Pp. 244-5):

In what, now, does the work which mourning performs consist? I do not think there is anything far-fetched in presenting it in the following way. Reality-testing has shown that the loved object no longer exists, and it proceeds to demand that all libido shall be withdrawn from its attachments to that object. This demand arouses understandable opposition—it is a matter of general observation that people never willingly abandon a libidinal position, not even, indeed, when a substitute is already beckoning to them. This opposition can be so intense that a turning away from reality takes place and a clinging to the object through the medium of a hallucinatory wishful psychosis. Normally, respect for reality gains the day. Nevertheless its orders cannot be obeyed at once. They are carried out bit by bit, at great expense of time and cathectic energy, and in the meantime the existence of the lost object is psychically prolonged. Each single one of the memories and expectations in which the libido is bound to the object is brought up and hyper-cathected, and detachment of the libido is accomplished in respect of it.

At some point, Macdonald has to literally let go of Mabel's jesses and allow her to fly free, to have faith that she'll return.

I learned a lot of fun terminology from the book, too. Jesses are the leather straps that fit through the anklets on a hawk's legs. Bating is a, "Headlong dive of rage and terror, by which a leashed hawk leaps from the fist in a wild bid for freedom." That was me quoting Macdonald quoting White.

She describes making jesses as a child. Then she comments, " I have a suspicion that all those hours making jesses and leashes weren't just preparation games...It reminds me of a paper by the psychoanalyst D. W. Winnicott, the one about the child obsessed with string; a boy who tied together chairs and tables, tied cushions to the fireplace, even...Winnicott saw this behaviour as a way of dealing with fears of abandonment by the boy's mother, who'd suffered bouts of depression. For the boy, the string was a kind of wordless communication, a symbolic means of joining. It was a denial of separation. Holding tight. Perhaps those jesses might have been unspoken attempts to hold on to something that had already flown away."

Macdonald had a twin brother who died shortly after birth. She wasn't told about him until years later, but she wasn't that surprised by the news. She wonders if a detailed drawing of a kestrel's jesses, that she drew when she was six, was, "...a way of holding tight to something I didn't know I'd lost, but knew had gone..." And she imagines that the jesses she makes for Mabel are a way of similarly holding on to her father. But I wondered if her father's death hit her as hard as it did, in part, because of the unremembered but somehow perceived loss of her twin, now being re-experienced. And I wondered further what it means to her that she survived, and her brother didn't.

Because we also see the connection between death and aggression. Mabel is beautiful and playful, but she is a powerful killer. That's what she does. That's why Macdonald got her in the first place. So they could hunt together.

Mabel, as she kills her prey, becomes the actualization of Macdonald's rage against her father's death, and against her father, for dying. When she and the bird are one, she becomes the master of death, able to decide who lives and who dies. A powerful wish fulfilled, only too late for her father.

Ultimately, with Mabel's assistance, but also of her own accord, Macdonald gets through her mourning period and is able to resume her life with some joy. To begin again.

Happy New Year!


I really don't get twitter. I couldn't figure out how to send a private message to Helen Macdonald to ask permission to use a photo of Mabel, which is why I contacted her agent. But when I tweeted this post, I added her twitter handle, and she read the tweet, and apparently the post, and gave me permission to use a photo. So, this is Mabel. Wasn't she beautiful? (Disclosure: I grew up with parakeets, and I have a soft spot for birds):

Thursday, December 17, 2015

Thank You, Mickey! Part II

Picking up where I left off in Thank You, Mickey! Part I, I was about to describe how the article I'm examining, Effectiveness of influenza vaccine for preventing laboratory-confirmed influenza hospitalizations in adults, 2011-2012 influenza season, figured out that there is a 71% reduction in flu-related hospitalizations in patients who have been vaccinated against flu, vs. those who haven't.

One of the articles Mickey sent me was from the World Health Organization (WHO), Field Evaluation of Vaccine Efficacy, written in 1985 by Orenstein, et al, and published in the Bulletin of the WHO. This article was, in fact, listed in the bibliography, but I didn't notice it. Thanks again, Mickey.

In general, Vaccine Efficacy (VE) is the difference between the incidence or attack rate of disease among the unvaccinated (ARU) and vaccinated (ARV), divided by the ARU, and multiplied by 100.

VE=(ARU-ARV)/ARU x 100.

So, for a perfect vaccine, the ARV would be zero, and then

VE= (ARU-0)/ARU x 100
     = ARU/ARU x 100
     = 100%

For a vaccine that didn't work at all, the ARU would equal the ARV, and then

VE=(ARU-ARU)/ARU x 100
     = 0/ARU x 100
     = 0%

In the study, we have the following data:

The ARU is the number of those who were unvaccinated and flu positive divided by the total number of unvaccinated.

ARU= 11/65 = 0.169


ARV= 6/104 = 0.058

Therefore, the VE= (0.169-0.058)/0.169 x 100 = 0.111/0.169 x 100 = 66%

It's close, but it's not 71%, and the reason for this is that this is the general formula for VE. The study had a case-control design with unmatched pair analysis, in which case,

VE= (1-RR) x 100,

where RR = relative risk, which is roughly equal to the Odds Ratio (OR) in this case.

OR = (Flu+, Vaccinated)(Flu-, Unvaccinated)/(Flu-, Vaccinated)(Flu+, Unvaccinated)
      = 6x54/98x11
      = 324/1078
      = 0.301

So VE= (1-0.301) x 100
           = 0.700 x 100
           = 70%

The study got 71%, but I'm assuming they had a better calculation of the OR, so 70% is close enough.

Okay, now we know how they determined that the flu vaccine effectiveness was 71%. So I'm going to act like an analyst and ask, "What does this really MEAN?"

The article claims it means that there was a 71% reduction in flu-related hospitalizations in patients who have been vaccinated against flu, vs. those who haven't.

But I don't think that's correct, and it was one of the things I went back and forth about with Mickey.

They looked at patients' vaccination statuses, and at which patients tested positive for flu. The appropriate conclusion to draw from this data is that vaccination resulted in a 71% reduction in flu INFECTION, in this population.

They did NOT look at patients' vaccination status, which patients tested positive for flu, AND which patients ended up hospitalized. They couldn't possibly look at that, because the entire population was hospitalized. So they can't logically draw any conclusions about whether vaccination reduced hospitalization or not.

For example, let's say they looked at 3000 people in the community, 1000 of whom were vaccinated against flu, and 2000 of whom were unvaccinated. And let's say they checked to see who was hospitalized with an illness that looked like flu, and it turned out that 104 vaccinated patients and 65 unvaccinated patients were hospitalized. These are the same numbers as in the study.

Now let's say they checked to see which of the hospitalized patients were flu+, and it turned out that 6 of the vaccinated, and 11 of the unvaccinated patients were flu+.  Again, same numbers.

Then 6/1000 = 0.60% of the vaccinated patients were flu+ and hospitalized,

And 11/2000 = 0.55% of the unvaccinated patients were flu+ and hospitalized.

So how would the vaccination have reduced flu-related hospitalizations by 71%, when the rate of flu-related hospitalization is lower for the unvaccinated patients?

Obviously, I just made up the 1000 and 2000 figures, but my point is you can't know whether vaccination reduced flu-related hospitalizations without knowing how many were NOT hospitalized.

The thing is, I really know very little about statistics. So I suspect I'm missing something here. But I can't figure out what. And in case I'm not missing something, it's a pretty big deal that the CDC is using this result to support their recommendation for universal flu vaccination.

The truth is, a vaccine efficacy of 71% is not so great. By comparison, the inactivated polio vaccine has an efficacy of 90% after 2 doses, and 99% after 3 doses (link). This doesn't mean there isn't good reason to recommend universal flu vaccination. For one thing, older people, who stand to benefit greatly from not getting flu, don't have a good serologic response to the flu vaccine, simply by virtue of age. The best way to protect them, then, is herd immunity, which you can get from having younger adults vaccinated.

I would really appreciate comments on this post. In particular, comments from people who know some statistics and have taken a look at the article. I'd like to know what I'm not seeing correctly, or if perhaps I am seeing things correctly.

Thanks for your help, especially Mickey.

Wednesday, December 16, 2015

Thank You, Mickey! Part I

Where to begin? I got an email with a letter from the commissioner of the NY DOH that covered three topics:

1. Flu Season
2. Synthetic Cannabinoids
3. NY's Medical Marijuana Program

The bit about Synthetic Cannabinoids started with, "The surging popularity of these man-made drugs has created a serious and sustained public health problem in New York State..."

It went on to describe the problem, and ended the next paragraph with, "Be on the lookout for the use of these drugs by your patients. We need to work together to stop this scourge."

This was immediately followed by:

If you have patients with medical conditions that may benefit from the use of medical marijuana, I would also like to remind you that next month is the launch of New York’s Medical Marijuana Program. I encourage you to enroll in the online course to become a registered physician, so you can certify eligible patients to receive medical marijuana. For more information, please access at: https://www.health.ny.gov/regulations/medical_marijuana/practitioner/.

Granted, synthetic cannabinoids are not the same thing as medical marijuana, and the letter even remarks on this point. But you'd think someone would have noticed the irony in the juxtaposition, and the complete absence of any comment about the problems with medical marijuana.

However, this post is really about flu vaccination. I know I've written about this topic before, and it's not a psychiatric topic, but the interpretation of research findings is a psychiatric and clinically relevant topic, and this turned into an exercise in understanding the literature.

 The commissioner's comment on Flu includes the following:

It’s impossible to predict the severity and timing of any flu season. Every year, however, flu causes widespread illness. Last year’s flu sickened approximately 51,000 people in New York, causing more than 11,000 hospitalizations and six pediatric deaths. The Centers for Disease Control and Prevention recommends an annual vaccine for everyone over six months of age... One study showed that flu vaccination reduced flu-related hospitalizations among adults of all ages by 71 percent.

No reference was given for the "one study".

This topic holds personal relevance for me because I don't get the flu vaccination, and as a result, I have to agree that I will not be around patients in my affiliated hospital without wearing a mask.

The reason I don't get the flu vaccine is the Cochrane Review (the link goes to the summary of the review, from which you can access the article). Briefly, they looked at a total of 90 studies, 20% of which had a high risk of bias, and 10% of which had good quality methodology. The evidence is current through May of 2013.

They found that the Number Needed to Vaccinate (NNV) to prevent one case of influenza-like illness (ILI) was 40 (CI: 26-128), and 71 (CI: 64-80) to prevent one case of confirmed influenza, in the case of parenteral inactivated vaccine. For live aerosol vaccine the NNV for ILI was 46 (CI: 29-115).

In addition, "Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates." I view time off work as a good measure of severity of illness, because if you're really sick, you don't go to work.

That's why I don't get the flu vaccine.

But I was curious about this statement from the DOH letter that, "One study showed that flu vaccination reduced flu-related hospitalizations among adults of all ages by 71 percent." I mean, according to Cochrane, vaccination has no effect on hospitalization. And according to this study, it reduces flu-related hospitalization by 71%.

The first thing I looked at were the CDC recommendations, and none of their references seemed relevant. Please note that I was only looking for information about adults. There may be some stuff there about kids.

So then I looked for the 71% study, and I found it through a link on NPR, of all places. The study is entitled,
Effectiveness of influenza vaccine for preventing laboratory-confirmed influenza
hospitalizations in adults, 2011-2012 influenza season, by Talbot et al. It was funded by the CDC,  and ultimately published in Clinical Infectious Diseases.

Talbot, et al did a case-positive control-negative analysis of 169 adult patients admitted to a hospital for something that looked like flu. That is, after eliminating patients who didn't meet eligibility criteria, they had 169 left. They were able to track down the vaccination status for these patients, and they tested them for flu.

It turned out that 11 of 65 (17%) non-vaccinated patients were positive for flu, and 6 of 104 patients (6%) were positive for flu. There were confounding factors, e.g. the vaccinated group was older, and the non-vaccinated group smoked more.

They concluded:

"Unadjusted vaccine effectiveness was 71.1% (95%CI: 17.3%, 89.9%) for all adults and 76.8% (24.1%, 92.9%) for adults ≥50 years. Adjusted vaccine effectiveness for preventing influenza associated hospitalizations was 71.4% (95%CI: 17.1%, 94.9%) for all adults and 76.8% (24.0%, 97.9%) for adults ≥50 years."

This is where I got stuck. There was a table at the end, but it didn't help all that much, except to give me the 11 and 6 numbers above. I didn't know how they got their 71%, and I didn't know how to reconcile their findings with Cochrane's conclusions.

So I asked for help. I emailed Mickey, who writes the 1boringoldman blog. It's a great psychiatry blog-you'll see a link listed on my blog roll, to the right. Please visit it early and often. An embarrassing fact is that when I first started reading it, I thought Mickey's last name must be, "Goldman". Or, "Oldman". It's not.

Three of Mickey's recent posts, In the Land of Sometimes 1, In the Land of Sometimes 2, and In the Land of Sometimes 3, are excellent statistics tutorials. Mickey is also one of the people responsible for republishing Paxil Study 329, which involved quite a bit of statistical knowledge. So I thought he'd probably be able to help.

That I thought he'd be interested in and willing to help is probably a testament to his decency, which comes through in his blog posts. We'd had a couple of email exchanges in the past, so I wasn't contacting him completely cold, but he really didn't need to help at all. And within a few hours of emailing him, he got back to me with an explanation, computation, and references, and I am close to tears over his generosity as I type this.

I'm going to stop here, and continue in the next post with how to compute Vaccine Efficacy, how the 71% statistic came to be, and my discussion with Mickey about the conclusions.

Thanks, Mickey!

Wednesday, December 2, 2015

Summing Up 2015

Here we are at the end of the year. A lot has happened in the world of psychiatry in 2015.

Collaborative Care is alive and scoring a 0 on the PHQ-9. The Clozaril REMS deadline was extended. Tom Insel left NIMH for Google. Mandatory E-prescribing was postponed until this coming March. EHRs continue to disappoint. Meds long past patent have had their prices jacked up 5000%. The FDA is looking to appoint a new head, and Robert Califf, a cardiologist with strong ties to the pharmaceutical industry has been nominated (See NY Times and David Healy).

On the upside, Dinah at Shrink Rap came up with a brilliant way for people to access psychiatric care in Maryland. I hope this approach is replicated more broadly.

I was perusing my posts from this past year, and I made a list of some of the major topics, and their respective posts, both general and personal:

Maintenance of Certification

I studied for:
The Montillation of MOC

And passed:
There and Back Again
Signed, Sealed, Delivered
Switching the Labels

my board recertification exam.

And I was certified by the NBPAS, as well:
Another Board

The ABPN refused to make any significant changes to MOC, especially Part IV:
I Really Should be Studying, But...
An MOC Step?
Follow the Money

Although the Part IV Feedback modules are now optional.

And I developed my own Psychoanalytic PIP Module:
Here Goes Nothin'
A Monkey's Uncle

The best part about all of this is that I've written enough MOC posts that I now misspell "Maintenance" only about 5% of the time.

Affordable Care Act (ACA)

The ACA has kicked in:
Out of Network Benefits in NY

And pushed me over the edge into the realm of blog ads:
Adding Ads and the ACA


I terminated my analysis:

And wrote some other posts about psychoanalytic evidence and topics:
Analytic Evidence
AA Brill
The Blank Screen
Narcissism, Part I
Narcissism, Part 2

Jeffrey Lieberman

His book, Shrinks was published:
"Shrinks" Review: Introduction
Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory over Papa Freud
Shrinks Links, Etc.

And a torrent of posts followed, culminating in the one about his fiasco of a presentation at the White Institute:
Lieberman Speaks


The FDA approved a drug that could hurt you but can't help you:
They Caved

That was immediately sold for $1Billion:

And then the FDA and Valeant pawned off responsibility onto the doctors who prescribe it, and the pharmacies that fill the prescriptions:
Addyi REMS-A Shanda

Paxil 329

Finally, and perhaps most importantly, the restored version of Paxil Study 329 was published, with disturbing conclusions:

Do I have a favorite post from the year? Not really. The Lieberman posts, especially the reviews and the one about his talk at White took the most out of me. But in terms of content, I think the Analytic Evidence and 329 posts are the most important.

On to pastures greener.