Challenges of Psychiatry Blogging: Design

This is part 3 of my series on the challenges of psychiatry blogging. Previous posts covered content and audience.

As a long-time fan of Apple products, I've believed in the simple, not the complex when it comes to design. I also believe that design is how something works, not just how it looks. My favorite technology blogs are ones that are clean, uncluttered, and draw your attention to the content. They do not tend to have anything extraneous, like stock photos. For me, there's an inherent pleasure in using a site that is well-designed, while even little annoyances can add up and detract from the overall experience.

Not surprisingly, I frequent many psychiatry blogs, and unfortunately I often find myself wishing for better design on some of those blogs. First though, I would like to point out Roger Lewin's blog, which still strikes me as one of the best designed psychiatrist blogs. Of course, his site was made by a professional, and I recognize that most people, myself included, just want a free blog. Fortunately, even mainstream blogging sites like WordPress and Blogger have good default templates to choose from these days. Another nice example is Reidbord's Reflections, which is very readable and well-organized.

I recognize that most psychiatrists do not have the time or inclination to endlessly tweak their blog's design, but I would like to present some simple tips that can really help improve the usability of a blog. Wherever possible, I've tried to use examples from non-psychiatry blogs to illustrate my point.

Layout & Navigation

The most basic design question is what happens when a person arrives at your blog for the first time. What will she see? Will it be obvious what content is on the blog and how to get to it? Is he going to have to scroll down right away or click on something in order to start reading the blog? For example, let's take a look at this site:

If I am there for the first time, I am treated to a view of the blog's big fancy name. However, the useful content only takes up a small fraction of the screen, so every time I visit, I would have to immediately scroll down in order to read anything beyond the first bit of the top article. Another example is if a blog uses a "dynamic view" with many pictures, which looks nice at first glance:

However, I have no idea looking at this what any of the posts are about, and in order to actually read anything, I'd have to mouse over each picture to see the title of the post, and then click to read the post itself. I do not think this is a very user-friendly design.

Fonts

This is probably really obvious, but having a font size that is too small makes the blog harder to read. Conversely, a font size that is too large can also diminish usability by decreasing how much one can read on a page before having to scroll down. Too many different typefaces can also be distracting. One major pet peeve of mine is text justification: It looks nice in books because most published books (in paper form, not e-books) are laid out by hand, and long words can be hyphenated. This doesn't ubiquitously happen on the web yet, so unfortunately you can end up with a paragraph like this:

Please, just don't do it! (My apologies to Thought Broadcast, as I couldn't easily find a similar example elsewhere.)

Color

The use of color, I believe, should be sparing and help draw your eye towards certain important elements, but not get in the way of the actual content of blog posts. One might argue that lack of color is boring; I would respond that it's better to focus on the writing and the topic at hand than to try to use lots of colors (or colorful clip art, for that matter) as a way of drawing people in.

I hope that the above tips were helpful and showed that better design does not have to take a ton of effort. I welcome any constructive feedback, so please let me know in the comments how I can improve the design of this blog.

A Child Psychiatrist's Thoughts on DSM-5: PTSD

One of my favorite books about children who have been traumatized is The Boy Who Was Raised As A Dog, by Dr. Bruce Perry and Maia Szalavitz, which highlights Dr. Perry's experiences working with children who have survived all sorts of horrors, usually perpetrated by the adults that the children trusted most. It is one of the most saddening yet hopeful books that I have ever read; I believe everyone should read it.

Trauma during childhood has been found to greatly increase the risk of an individual later having poor health, both mental (depression, psychosis, suicidality) and physical (obesity, chronic inflammation, and heart disease). Thus, recognizing and treating children who have been traumatized can have a very positive impact. Dr. Perry's book shows how much of a difference a nurturing environment and loving caregivers can have, even for the boy who spent months locked up in a cage with dogs.

Historically, children have been under-diagnosed with post-traumatic stress disorder (PTSD) for a multitude of reasons, highlighted in this review article from 2009. For example, children typically would not tell you that they are experiencing disturbing memories or flashbacks, and they often act out in seemingly inexplicable ways. In my own experience working with children in the foster system, I have seen manifestations ranging from extreme tantrums in response to loud noises to hiding feces in closets. Overmedication of such children is a rampant problem.

Academics who specialize in childhood PTSD have already modified the DSM-IV criteria for diagnosing PTSD to make them more appropriate for children. From the review article:

The alternative algorithm for PTSD in young children (PTSD-AA) includes modifications in wording for several items to make them more developmentally sensitive to young children. For example, the DSM-IV item for irritability and outbursts of anger was modified to include extreme temper tantrums. However, the major change is a modification to lower the requirement for the C criterion (numbing and avoidance items) from three out of seven items to just one out of seven items because many of the C criterion items are highly internalized phenomena that appear to be either developmentally impossible in young children (eg, sense of a foreshortened future) or extremely difficult to detect even if they were present (eg, avoidance of thoughts or feelings related to the traumatic event, and inability to recall an important aspect of the event).

The DSM-5 changes the diagnosis of PTSD in several ways. An individual no longer has to have a subjective fear response during the trauma. In addition to the previous symptoms domains of hyperarousal, re-experiencing, and avoidance, there is now a fourth symptom domain of alterations in mood and cognition. In children age 6 and under, there is a lower threshold for making the diagnosis: 2 arousal symptoms are required, along with 1 symptom of re-experiencing the trauma and 1 symptom of either avoidance or negative alteration in mood/cognition. I'm not sure what the implications are for adults with PTSD, but I do think the changes are for the better when it comes to accurately diagnosing PTSD in children.

Of course, many adults, even when properly diagnosed with PTSD, are still treated with multiple antipsychotics and mood stabilizers. But I believe the tide is starting to turn, and even the military is implementing many non-medication interventions for trauma. Even for young children with PTSD, there are effective treatments such as child-parent psychotherapy (CPP) and trauma-focused cognitive-behavioral therapy (TF-CBT). I hope that making the diagnosis of PTSD more widely accepted in abused children will lead to greater availability and use of such therapies.

A Child Psychiatrist's Thoughts on DSM-5: General Impressions

The soon-to-be-published 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been notable for the amount of controversy it has generated, including pointed critiques from Allen Frances, chair of the DSM-IV committee, and Robert Spitzer, chair of the DSM-III committee. There has been widespread media coverage of the controversies involved, in outlets ranging from the New York Times to The Verge. I won't recap all of the areas of contention, but I think the most insightful take about why the chairs of both DSM-III & IV would speak out against DSM-5 is offered by Dr. Nardo at 1boringoldman.com. In short, the DSM-5 committee explicitly set out to change DSM from an "atheoretical" perspective to one in which there are clearly defined biological causes of psychiatric diagnoses, but couldn't quite get there, leaving us with somewhat of a mess.

My own view of the DSM has always been that it's a very imperfect system, a necessary evil given how little we know. It tries to turn a spectrum of human behaviors and suffering into discrete categories, and frequently fails at that given how many patients I see who meet criteria for either multiple disorders (when presenting with one acute episode) or no disorder at all. It is necessarily subjective given that these disorders must cause "clinically significant impairment in functioning."

With the DSM-5, I think the biggest drawback is that the different committees that wrote the new criteria are all made up of experts in those particular areas. I'm not as concerned about their financial conflicts of interests (69% have received pharma funding) as I am about their innate desire to capture every possible case so that no suffering goes untreated. This approach (especially when it's applied outside of more "biologically-based" conditions such as autism or schizophrenia) can't help but lead to over-diagnosis when the manual is applied to an entire population by clinicians from all types of backgrounds.

As someone who treats adults in addition to kids and teenagers, I'm mostly disappointed when it comes to the DSM-5's changes to conditions generally diagnosed in adolescence and beyond. They did not really alter Major Depressive Disorder, which is so heterogenous a category that I highly doubt my patients with MDD who quickly get better after a month have a condition similar to the ones who remain hopeless and suicidal despite months of meds and therapy. I guess it's a diagnostic juggernaut with too many publications written about it already that's just too big to fail, kind of like the DSM itself. The criteria for Generalized Anxiety Disorder, a catch-all diagnosis like MDD, have actually been loosened. I'm also disappointed that there was ultimately no overhaul of the personality disorders to make them more dimensional. Some psychiatrists have complained that the new system would have taken too much effort, but I would argue that a personality disorder is not something that should be diagnosed based on a checklist; a clinician should actually observe a patient carefully over time before reaching the conclusion that a personality disorder is present.

One thing I do like about the DSM-5 is the change in name of the manual from the old Roman numeral system (i.e. "DSM-V"). The intent is supposedly that this is version 5.0, and that we won't have to wait a decade or two before new advances lead to versions 5.1, 5.2, and so on. It might be more aspirational than anything else, but being an optimist, I'm hopeful that this means changes could be more quickly made in response to...well, reality.

When it comes to changes in the DSM-5 for child psychiatry, I feel mostly positive. In future posts, I will explain why, as I examine DSM-5 changes in key areas such as PTSD, autism, ADHD, and the ever-controversial DMDD.

Challenges of Psychiatry Blogging: Audience

Part 1 here, about the challenges of psychiatry blogging when it comes to content. Closely related to content, of course, are the questions of who is the intended audience of a blog written by a psychiatrist, and how does a blogger reach this audience? Along those lines, I found this post by Dinah over at Shrink Rap reminiscing about their blog being almost 7 years old to be very interesting:

Seven years later, and I want to say that Shrink Rap life remains distinctly different from my real life as a clinician.  Before Shrink Rap, the concept of anti-psychiatry was a foreign one to me.  The idea that there were people out there who saw psychiatry as bad, that psychiatric medications cause more harm than good and should be made illegal for all, that psychiatry was about power, that the patient and doctor were anything but on the same side, that diagnosis -- a word -- was inherently stigmatizing or life-destroying, this all was news to me.  Maybe I was in my own little bubble.

Shrink Rap, according to its description, is "A blog by psychiatrists for psychiatrists." Yet judging by Dinah's post and what I've seen over the years, almost all of the comments are from non-psychiatrists, and some are from a vocal minority who have strong views against various aspects of (or anything to do with) psychiatry. Their own poll (n=45, so probably a biased sample) shows that only 20% of respondents identify themselves as psychiatrists, while 51% say they're "Someone who uses Mental Health Services" (I wonder if going to a spa or getting a massage are included in this category). Granted, there are around 50,000 psychiatrists in the U.S. and millions of folks who use mental health services, so psychiatrists are certainly over-represented. The more surprising thing to me is that only 8% of those polled said that they are "A random interested person."

When a mainstream publication like the New York Times publishes almost 100 articles in the past year involving the DSM, chances are that mental health issues have broad interest. For a blog to reach such a wide audience, I don't believe that there is a magic formula, but I think most important factors are having a consistent output of posts and a variety of content. Blogs often die when the neophyte blogger becomes discouraged by lack of pageviews, or if the blog is already established, when the blogger becomes too busy in other areas of life to blog regularly. Some blogs, like 1 Boring Old Man, are very opinionated and focused, and thus seem to attract people who harbor the same points of view (I count myself amongst them, but I wish I could see more comments there from folks who are pro-DSM-5 and biological psychiatry, so there would be more interesting debate).

I will aim for about a post a week, and I am hoping to write articles that would be interesting to a broad audience, but especially those in the mental health field. I hope to elicit comments from those who both agree and disagree with me, while weeding out the trolls. Of course, since this is a hobby, the most important aspect of blogging for me is just getting to write on a regular basis.

Challenges of Psychiatry Blogging: Content

Some of my favorite blogs written by psychiatrists are no longer being updated; of course, this happens all the time on the internet. But starting a new blog has made me think more about the challenges involved in maintaining a "psychiatry blog," what it was that I liked about certain blogs, and what I'm hoping to do with this one. Thus, in this series of posts I will look at some of the different aspects of blogs written by various psychiatrists, and hopefully conclude with some lessons for my own blog.

Of course, the most important aspect of any blog is its content. As psychiatrists, we are privy to the most treasured memories and darkest secrets our patients, not to mention the full range of human emotional expression. My very favorite psychiatry blogs in the past have been ones focussing on stories of interactions with patients. This kind of blogging poses a special challenge, since we must protect the privacy of our patients, so these stories usually have names and other identifying details changed. My favorite blogs of this type have been Roger Lewin and pontificatrix's blog, and sadly neither have been updated in years (I have more to say on blog longevity in another post).

The most important blogs, in my mind, are the somewhat anti-establishment blogs that focus on hot-button issues in psychiatry, which over the last decade have mainly revolved around the relationship of academic "key opinion leaders" to big pharma, over-medicalization and over-medication, and the quagmire of the DSM-5. The very best blog of this genre has been The Carlat Psychiatry Blog, which had a very successful run from 2007 to 2012. It was so successful that Dr. Carlat has gone on to bigger and better things. Recently, the mantle seems to have been taken up by Dr. Nardo at 1 Boring Old Man, and I believe his blog has become vastly more interesting since he started to focus with passion on these topics. Thought Broadcast, though less focused, has a similar independent spirit, along with a level of thoughtfulness that is very appealing.

There are the psychiatrists who cover general topics for psychiatric publications, such as the Psychiatric Times blog. I don't tend to read these, because it makes me feel like I'm doing work. Well, actually I sometimes do read these when I'm at work, so that I feel like I'm doing work. Joking aside, these blogs are useful vehicles for fostering debate within the profession.

Then there's always cultural criticism from a psychiatric perspective, of which The Last Psychiatrist is the exemplar, with his messages of "you are being lied to, by yourself," and "you cannot escape the system." I think I understand, but now I will move on so I don't think about those things too much.

And of course, there are the more generalist blogs that cover anything and everything related to psychiatry. Shrink Rap is one of the earliest and most successful, spawning a book of the same name. I used to read it daily, and I greatly admire the consist productivity of the authors in their postings. I eventually cut back because the blog felt a bit unfocused to me. Plus, the design of the blog feels way too busy. I think The Amazing World of Psychiatry used to cover mainstream psychiatry topics, but the main articles have grown so esoteric that I rarely read them these days. However, Dr. Marley still provides links to interesting articles that he has come across, which remains a valuable service. My favorite general psychiatry blog in the last few years was Peter Kramer's In Practice blog, which was active mainly from 2008 to 2009. Dr. Kramer has a history of being a successful author, publishing several books, and I think his writing skill contributed greatly to this blog's appeal. No matter what he write about, I found myself reading the article and feeling more informed afterwards.

Closely related to content of blogs are the "voice" of the bloggers. The blogs I seem to like best are the ones written by a single individual, rather than an amalgamation of different voices. They seem to have more of a personality and perspective, which makes repeated viewings more interesting and encourages conversation with the blogger via the comments system.

In my next post, I will discuss the challenges related to the audience of a psychiatry blog.

Movie Review: The Perks of Being a Wallflower

I recently watched The Perks of Being a Wallflower, and it is one of the best depictions I have ever seen of an adolescent's struggles with trauma and grief. The protagonist is Charlie, played convincingly by Logan Lerman as a quiet teen entering his freshman year. He is utterly friendless at the start of the movie, and the details of his past experiences are only gradually revealed, bit by bit.

Here's what I loved about the movie, and why I think all psychiatrists should see it: Charlie is never treated like a psychiatric label. In fact, no terms like "depression" are used at all in the movie. He, like most of the patients I see, has been through some pretty terrible things. He suffers from a mix of sadness, grief, guilt, anger, and dissociative tendencies,  yet he probably does not fit neatly into one specific DSM category. Most importantly, his life is not defined by those symptoms. He likes music and writing, he has hopelessly fallen for a girl named Sam (Emma Watson), and he is a loving brother to two older siblings. The best scenes involve him becoming friends with the school's band of misfits, led by Sam and Patrick (Ezra Miller, in a wonderful performance). We clearly see how these relationships give Charlie joy and a sense of identity.

I also thought the depiction of Charlie's psychiatric hospitalization was very well done. The movie takes place in the early 90's, shortly before the DSM-IV era of psychiatry. Back then, the average length of stay on child and adolescent psychiatry units was on the order of weeks to months, rather than the under one week stays that are so common today. Though the movie does not show how much time elapsed in the hospital, it does give the sense that Charlie was moving into his room for a while. The psychiatrist Dr. Burton (Joan Cusack) appears only briefly, but even so, her concern for Charlie comes through. She is not running down a symptom checklist, spewing psychiatric diagnoses, or pushing pills; rather, she tries to engage Charlie as a person first and foremost, hoping to gain his trust so he would feel safe sharing his most hidden secrets.

The story was certainly clichéd in places: There's the obligatory scene of getting high for the first time, and Charlie's English teacher (Paul Rudd) gives Charlie his treasured copy of The Catcher in the Rye. Are there no other books about teenage alienation? Also, Sam seems remarkably well adjusted given her chaotic backstory. Never once did the movie convince me that her character was someone who would have trouble getting into Penn State.

Still, the brilliance of the actors and the compelling story makes this one of the great coming-of-age tales.