Sunday, October 31, 2004
How to Live to be 100...
"The...press is...considerably taken up with...methods of obtaining longevity, and one little item which has the alleged authority of Professor Metchnikoff has been widely (reported). It is that sour milk as a diet is (e)specially conducive to longevity, more so, in fact, than any other form of food..." Here's the JAMA reference. The more things change...
Saturday, October 30, 2004
Making a Commitment Stick
A followup on my post earlier this week, questioning the ease of committing a patient with mental illness relative to a patient with a communicable illness when (depending upon their respective diseases) either might be considered just as dangerous, a letter regarding the opposite problem:
"Several years ago a judge released my husband from a psychiatric hospital after I went to great effort to have him committed there. At the time, my husband believed there was a conspiracy against him from his days in the Marines. He believed that everyone was involved, including me. The judge let him out, and he went off wandering across the country to prove his theory. My husband was very sick, yet there was nothing I could do about it."
The question is: why can't this man be forced to get help? Although these false beliefs (called delusions) may very well be due to a treatable brain disorder, and even though proper treatment may have saved much pain in this family, the law in most states seeks to protect the rights of the mentally ill, so usually a doctor must show that someone is currently dangerous before a judge can force him into treatment.
In this case, the judge likely had no choice but to release the patient because his delusions did not seem imminently dangerous. It is a painful fact that people often must be on the brink of suicide (or homicide) before they can be forced to obtain the help that they needed long before it got to that point.
"Several years ago a judge released my husband from a psychiatric hospital after I went to great effort to have him committed there. At the time, my husband believed there was a conspiracy against him from his days in the Marines. He believed that everyone was involved, including me. The judge let him out, and he went off wandering across the country to prove his theory. My husband was very sick, yet there was nothing I could do about it."
The question is: why can't this man be forced to get help? Although these false beliefs (called delusions) may very well be due to a treatable brain disorder, and even though proper treatment may have saved much pain in this family, the law in most states seeks to protect the rights of the mentally ill, so usually a doctor must show that someone is currently dangerous before a judge can force him into treatment.
In this case, the judge likely had no choice but to release the patient because his delusions did not seem imminently dangerous. It is a painful fact that people often must be on the brink of suicide (or homicide) before they can be forced to obtain the help that they needed long before it got to that point.
Thursday, October 28, 2004
Fears, Phobias and Their Treatment
A reader writes: "I have a fear of high places that I have been trying to overcome for years. Can you advise me about where to turn for help?" Just as with performance anxiety, the most effective way to combat a fear of high places is to face your fears. Look for a psychiatrist or psychologist interested in "behavior therapies" for help with this disorder. The doctor will likely talk with you about your specific worries about high places. For example, are you afraid of falling from a high place? Or, do you just feel uncomfortable if your heart starts beating quickly or if you begin to feel dizzy? These questions can help plan treatment. Different doctors will have different methods, but all will focus on longer and more frequent exposure to your fear. If the results of behavior therapy are not to your liking, medication may enhance the results of behavior therapy, although relying upon medication alone is probably not a good idea.
Wednesday, October 27, 2004
Strategies that Work to Decrease the Uninsured
A study by the National Academy for State Health Policy and reported here says the easiest way to expand the number of insured is to expand eligibility for SCHIP and Medicaid. Incentives for employees who sign up for employer coverage, and state-established high-risk pools, were less effective. "Convenience matters," in improving coverage. The study notes that no approach is cheap. In cash-strapped states like Texas, you can understand (fiscally, if not socially) why the convenient routes are NOT incentivized lately.
Tuesday, October 26, 2004
Managing Performance Anxiety
A reader writes that, "My teenage daughter plays piano very well, but she gets so nervous when she has to perform in front of people that she is never able to do her best. Yesterday at a recital she made several mistakes in a piece that she plays perfectly at home. Is there some way I can help her?"
"Performance anxiety" is a normal part of life. It only becomes a problem when it interferes with our doing our very best. It's rare when district swimming champs or piano competition winners have no performance anxiety at all. It's just that they have learned to overcome it without "choking."
The best way for your daughter to overcome her fear is to perform as often as possible in situations that make her nervous. It's just like with other aspects of playing piano - practice makes perfect! Have her perform for friends, for groups, or in any other public situation that you can arrange. When she does perform, teach her to focus on the task at hand, not on the outcome.
Cognitive therapy has been shown to be effective in performance anxiety. Some professional musicians use low doses of certain medications (especially "beta-blockers") to help with performance anxiety, as well.
"Performance anxiety" is a normal part of life. It only becomes a problem when it interferes with our doing our very best. It's rare when district swimming champs or piano competition winners have no performance anxiety at all. It's just that they have learned to overcome it without "choking."
The best way for your daughter to overcome her fear is to perform as often as possible in situations that make her nervous. It's just like with other aspects of playing piano - practice makes perfect! Have her perform for friends, for groups, or in any other public situation that you can arrange. When she does perform, teach her to focus on the task at hand, not on the outcome.
Cognitive therapy has been shown to be effective in performance anxiety. Some professional musicians use low doses of certain medications (especially "beta-blockers") to help with performance anxiety, as well.
Monday, October 25, 2004
Blame or be Blamed: A Parent's Plight?
Humility sets in for a child psychiatrist once his or her first child is born. Regardless of how much you know about the role that genetics and biology play in the onset of childhood psychiatric disorders, it's still hard to avoid aligning with a teenage patient when she blames her parents for all that ails her until you have experience that allows you to identify with the parents, too.
In an article in the current American Academy of Child & Adolescent Psychiatry News, Dr Diane Schetky worries that "blame the parents" is making a comeback in society, in general. She cites (among others examples) a Connecticut case in which a mother was charged with contributing to her 12-year-old son's suicide, due (in part) to their impoverished home environment. According to Dr Schetky, poverty is not blamed. A society that requires a single mom to work two jobs to make ends meet is not blamed, either. Not even a mental illness is blamed. Instead, the parent is blamed.
It brings to mind, again, parents who now point the finger in the direction of the pharmaceutical industry as a way of placing blame for suicidal behavior in teens. Who can blame them for doing so? In a society so willing to point the finger at parents, in a society so much in denial about the impact of mental illness in teens -- perhaps the best defense for a parent in such a society is a good offense.
In an article in the current American Academy of Child & Adolescent Psychiatry News, Dr Diane Schetky worries that "blame the parents" is making a comeback in society, in general. She cites (among others examples) a Connecticut case in which a mother was charged with contributing to her 12-year-old son's suicide, due (in part) to their impoverished home environment. According to Dr Schetky, poverty is not blamed. A society that requires a single mom to work two jobs to make ends meet is not blamed, either. Not even a mental illness is blamed. Instead, the parent is blamed.
It brings to mind, again, parents who now point the finger in the direction of the pharmaceutical industry as a way of placing blame for suicidal behavior in teens. Who can blame them for doing so? In a society so willing to point the finger at parents, in a society so much in denial about the impact of mental illness in teens -- perhaps the best defense for a parent in such a society is a good offense.
Sunday, October 24, 2004
If a Commitment is Ethical, Why isn't a Quarantine?
If a patient with a mental illness can be committed for fear he will hurt someone due to his disease, why can't a patient with an infectious disease be committed for fear he will hurt someone by passing on his disease? "Nowhere does a physician have an obligation to restrain people," Dr George Annas, chair of Health and Law at Boston University is quoted as saying in this article in American Medical News. That line brings a smile to any psychiatrist's face, because there are times when we are required to "restrain people."
The article intends to visit the ethics of using quarantine and isolation as approaches in public health. But for me, it just reinforces how stigmatized the mentally ill patient remains.
The article intends to visit the ethics of using quarantine and isolation as approaches in public health. But for me, it just reinforces how stigmatized the mentally ill patient remains.
Friday, October 22, 2004
Phone Calls Improve Antidepressant Efficacy
Cognitive therapy over the phone is enough to enhance the effectiveness of antidepressant medication, according to this report. But just routinely calling and checking on medication patients also improved outcomes. The researchers suggest it might be a way to enhance outcomes in patients who otherwise would not ever make it into the clinic for routine psychotherapy. Staff from the family doc's office might improve outcomes just by calling up patients routinely.
Wednesday, October 20, 2004
Which Comes First, Obesity or Anxiety?
Obese children tend to have anxiety disorders, according to a study in Psychosomatic Medicine summarized here. Low self-esteem and other signs of depression are also common. The researchers suggest that the stigma of obesity leads to anxiety in social situations. But I wonder: is overeating a possible form of self-medication of an anxiety disorder? Did the anxiety disorder actually come first?
Tuesday, October 19, 2004
Nature, Endorphins and Stigma
How bad is the stigma toward mental illness? So bad that a depression screening program in Illinois has drawn the ire of political groups concerned about "government overreach." Folks had suggested a prevention measure that would screen pregnant women for depression and young children for severe emotional problems.
The concern? Folks fear children being "labeled." (Why doesn't cholesterol screening induce the same fear?) Here's state representative Chris Lauzen of Illinois: When my kids are upset, they go outside and let nature and endorphins take care of the problem."
Ya reckon endorphins would work for other causes of severe problems in children, say, like this one?
The concern? Folks fear children being "labeled." (Why doesn't cholesterol screening induce the same fear?) Here's state representative Chris Lauzen of Illinois: When my kids are upset, they go outside and let nature and endorphins take care of the problem."
Ya reckon endorphins would work for other causes of severe problems in children, say, like this one?
Monday, October 18, 2004
Genetics of Alcoholism
Research (like that summarized in this editorial from the American Journal of Psychiatry) is starting to suggest an interaction between genes and the environment in the etiology of alcohol dependence. It looks like the fewer dopamine receptors you have in the brain, the more vulnerable you are to alcohol craving, and perhaps addiction. The number of those receptors looks to be a genetic trait. It gives credence to the use of medication to treat addiction, as it would seem that a medicine that impacts the dopamine system might decrease cravings.
Sunday, October 17, 2004
For Depression, Medication Plus Counseling Is Best
Never mind that readers of Consumers Reports said it was so, here's research showing that it's best to treat depression with both psychotherapy and meds. Even when meds were stopped, patients with recurrent depression were much less likely to relapse, even up to six years later, if given psychotherapy.
Saturday, October 16, 2004
Which Saves More Lives? Antidepressants or Black Boxes?
Here's the facts: Antidepressants save lives.
It is true that their too-high cost means that medications take up a bigger chunk of the shrinking mental health dollars available, and so alternative components of comprehensive care (individual counseling, family therapy & case management) are not affordable. And it is true that the high cost leaves many people delaying comprehensive care even when it is available, saying "Let's see if the medication works, first."
But here's the problem: Data is already showing a reluctance among doctors to prescribe antidepressants in children and adults. The "black box" warning will make that trend worse, and no doubt put seriously ill people at risk -- especially if some successfully-treated patients abruptly stop their medication.
So here's the real bottomline: Any lives saved by a black box warning are likely to be far offset by undertreatment of one of the most deadly diseases around -- major depression.
What to do if you are a patient (or have a family member) on these medications? First, get actively involved in the treatment. Talk to your doctor about any worries that you might have. Second, don't settle for a treatment plan that uses medication alone, when all of the research says that medication plus counseling works better.
But don't take it from me. Take it from Dr. Leslie Stalcup-Laws, a Dallas school counselor whose son committed suicide: "Sometimes people look at the medicine as being the magic cure. I think that putting the label on there, maybe the parent will get more involved in the treatment."
I hope she is right. Parents and patients insisting upon greater availability of alternative treatments -- that's about the only thing good that can come out of this black box warning.
It is true that their too-high cost means that medications take up a bigger chunk of the shrinking mental health dollars available, and so alternative components of comprehensive care (individual counseling, family therapy & case management) are not affordable. And it is true that the high cost leaves many people delaying comprehensive care even when it is available, saying "Let's see if the medication works, first."
But here's the problem: Data is already showing a reluctance among doctors to prescribe antidepressants in children and adults. The "black box" warning will make that trend worse, and no doubt put seriously ill people at risk -- especially if some successfully-treated patients abruptly stop their medication.
So here's the real bottomline: Any lives saved by a black box warning are likely to be far offset by undertreatment of one of the most deadly diseases around -- major depression.
What to do if you are a patient (or have a family member) on these medications? First, get actively involved in the treatment. Talk to your doctor about any worries that you might have. Second, don't settle for a treatment plan that uses medication alone, when all of the research says that medication plus counseling works better.
But don't take it from me. Take it from Dr. Leslie Stalcup-Laws, a Dallas school counselor whose son committed suicide: "Sometimes people look at the medicine as being the magic cure. I think that putting the label on there, maybe the parent will get more involved in the treatment."
I hope she is right. Parents and patients insisting upon greater availability of alternative treatments -- that's about the only thing good that can come out of this black box warning.
Thursday, October 14, 2004
Myth of Self-Medication
A reader responds to the last post by saying that he thinks he used to drink because he was depressed, and that he used the alcohol to treat the depression. This possibility is called "self-medicating." Some folks believe that people with mental disorders (like clinical depression) start using alcohol or street drugs as a way to self-medicate their illness. But studies show that when people with mental disorders use drugs, they usually pick drugs that make their disorder worse, not better. It's certainly possible that someone with alcohol dependence can also be depressed, but you'll never know for sure until the alcohol problem is treated first.
Wednesday, October 13, 2004
French Fries, Cholesterol, Alcohol and Depression
A reader writes to tell me he was recently in an alcohol treatment center, and while there a psychiatrist put him on medicine for depression. He thinks he's not depressed and doesn't need the medicine.
And he may be right.
Alcohol is a "depressant drug," so folks who drink heavily can look as if they have a clinical depression. How can your doctor tell if the depression is "real" or caused by too much drinking?
Let's say you go several weeks eating only bacon for breakfast, french fries for lunch and spare ribs for dinner. Then you go to the doctor one afternoon to check your cholesterol. It's likely going to be high! Should your doctor put you on cholesterol medicine, or tell you to change your eating habits first?
Now let's say you go several weeks drinking only beer and whiskey. Then you go to the doctor one afternoon because you feel depressed. Should your doctor put you on depression medicine, or tell you to change your drinking habits first?
I believe you should address the drinking problem first. When making a diagnosis of high cholesterol, your doctor will usually have you go a few hours without food before measuring your blood level. Likewise, before a doctor can diagnose clinical depression you have to be free of drugs and alcohol for awhile. In fact, research suggests you must go several weeks without drinking before you can make an accurate diagnosis of a mental disorder.
And he may be right.
Alcohol is a "depressant drug," so folks who drink heavily can look as if they have a clinical depression. How can your doctor tell if the depression is "real" or caused by too much drinking?
Let's say you go several weeks eating only bacon for breakfast, french fries for lunch and spare ribs for dinner. Then you go to the doctor one afternoon to check your cholesterol. It's likely going to be high! Should your doctor put you on cholesterol medicine, or tell you to change your eating habits first?
Now let's say you go several weeks drinking only beer and whiskey. Then you go to the doctor one afternoon because you feel depressed. Should your doctor put you on depression medicine, or tell you to change your drinking habits first?
I believe you should address the drinking problem first. When making a diagnosis of high cholesterol, your doctor will usually have you go a few hours without food before measuring your blood level. Likewise, before a doctor can diagnose clinical depression you have to be free of drugs and alcohol for awhile. In fact, research suggests you must go several weeks without drinking before you can make an accurate diagnosis of a mental disorder.
Tuesday, October 12, 2004
Going to Great Lengths to Get Help
How bad is the underfunding of mental health services for children, the underfunding that means child psychiatrists have fewer options beyond medications to help children in pain? In Virginia, thousands of parents give up custody of their children just to get help for their mentally or emotionally disturbed children. According to a story in the Richmond Times-Dispatch, children in State custody are eligible for services that others can't get. It makes no sense clinically (most child interventions are family-oriented, how can they be successful if the child doesn't even belong to the parents anymore?), and it makes no sense economically, either.
Monday, October 11, 2004
Depression in the Workplace
Using lost work days to measure the impact of depression in the workplace underestimates the cost of the disease to employers. This study in the American Journal of Psychiatry looked at task focus and productivity. Depression was the only one of seven medical problems that significantly impacted both. So, even if depressed workers make it in to work, their contribution is less than it could be. Given the financial impact, you'd think that employers would bend over backwards to assure easy access to psychiatric care, especially for persistent or recurrent cases. Yet true parity does not yet exist for mental health disorders.
Sunday, October 10, 2004
An Underfunded War
The unfortunate fallout of the concerns over antidepressant use in children begins its snowball effect, as even members of the FDA advisory group feared. Here's from a newspaper article:
"Thousands of poor children in Texas may be taking overly large or too-frequent doses of mental health drugs that have been approved only for adults, according to a preliminary state study released Friday," and published here, as well as in other newspapers across Texas.
Many of my child psychiatrist colleagues have received letters from the State questioning their prescribing to one or more of the "63,118 children (who are) on stimulants, antidepressants or anti-psychotics, with nearly one-third of them simultaneously taking drugs from more than one of those classes of medications...," according to the article.
Yet here is the State's recommendation for treating intermittent explosive disorder in children with ADHD, calling for the use of two drugs simultaneously, including an antipsychotic. The recommended treatment for ADHD with tics calls for two classes of medication, as well. And in this State recommendation, the doc is supposed to use a stimulant and an antidepressant at the same time.
Until the growing disdain in Texas for people who work every day but earn too little to afford more than the basics (food, shelter and clothing) abates, and until society is willing to treat the causes of disruptive behavior in children and adolescents, then my colleagues on the frontlines who treat behavior problems in poor children -- behaviors that are often nothing more than symptoms of larger family and social issues -- will be left to fend with the paucity of weapons at hand, mainly medications.
"Thousands of poor children in Texas may be taking overly large or too-frequent doses of mental health drugs that have been approved only for adults, according to a preliminary state study released Friday," and published here, as well as in other newspapers across Texas.
Many of my child psychiatrist colleagues have received letters from the State questioning their prescribing to one or more of the "63,118 children (who are) on stimulants, antidepressants or anti-psychotics, with nearly one-third of them simultaneously taking drugs from more than one of those classes of medications...," according to the article.
Yet here is the State's recommendation for treating intermittent explosive disorder in children with ADHD, calling for the use of two drugs simultaneously, including an antipsychotic. The recommended treatment for ADHD with tics calls for two classes of medication, as well. And in this State recommendation, the doc is supposed to use a stimulant and an antidepressant at the same time.
Until the growing disdain in Texas for people who work every day but earn too little to afford more than the basics (food, shelter and clothing) abates, and until society is willing to treat the causes of disruptive behavior in children and adolescents, then my colleagues on the frontlines who treat behavior problems in poor children -- behaviors that are often nothing more than symptoms of larger family and social issues -- will be left to fend with the paucity of weapons at hand, mainly medications.
Saturday, October 09, 2004
Suicidal Ideation - Is It Due to the Disease or the Cure?
I notice that eight members (out of 23) of the FDA review panel on antidepressants voted against the "black box" label. Their fear was that it would dissuade family docs from prescribing. The drop in prescriptions since the announcement suggests that the dissenting eight were correct.
The research review on which the decision was based apparently showed 2 or 3 extra patients with suicidal ideation for every 100 kids treated. My recollection is that the rate of suicide (let alone just suicidal ideation) in outpatient-treated depression is higher than that. Makes me worry even more that the etiology of the "suicidal beahvior" is the disease, not the treatment.
The research review on which the decision was based apparently showed 2 or 3 extra patients with suicidal ideation for every 100 kids treated. My recollection is that the rate of suicide (let alone just suicidal ideation) in outpatient-treated depression is higher than that. Makes me worry even more that the etiology of the "suicidal beahvior" is the disease, not the treatment.
Friday, October 08, 2004
Mental Health Patients And Families Who Blog
Just a reminder of the links to patient weblogs on this page. An experience from the patient's side of the encounter, many of which are expressed on these pages, is always helpful.
Some family members also have been willing to talk about their experiences online, and I have added links to some of their weblogs. Outside of mentally-ill patients themselves, nobody has endured more stigma than the parents of those who suffer from neuropsychiatric disorders like schizophrenia and severe bipolar disorder.
Some family members also have been willing to talk about their experiences online, and I have added links to some of their weblogs. Outside of mentally-ill patients themselves, nobody has endured more stigma than the parents of those who suffer from neuropsychiatric disorders like schizophrenia and severe bipolar disorder.
Wednesday, October 06, 2004
Freud Vindicated - Psychotherapy Works
Classical psychotherapy, ala Freud, has endured attacks for as long as I’ve been in the field. Yet slowly but surely research is starting to prove the efficacy of this treatment, known as psychodynamic therapy. For example, a study using standard measures of traditional defense mechanisms shows that psychodynamic therapy changes the defenses from maladaptive ones to helpful ones. The study was published in the American Journal of Psychiatry. Change didn’t happen overnight. Patients were seen from three to five years.
Tuesday, October 05, 2004
Is Fibromyalgia a Form of Major Depression?
If you want to know how stigmatizing it is to have a psychiatric disorder, try mentioning to some patients with fibromyalgia that they might be depressed. Yet studies of relatives of fibromyalgia patients show that the two disorders run together in families. That means that when depression hits the fibromyalgia patient, it is likely not simply a “reactive depression” to living with the disorder. And it leads the researchers to suggest that the two disorders are related nervous system disorders.
Monday, October 04, 2004
Does Marijuana Also Cause Suicidal Behavior in Teens?
I wonder if any of the adolescents with suicidal behavior while taking antidepressants were also using street drugs. Why? Because finally research is starting to show what those of us who care for teens using marijuana have known all along: regular marijuana use is not benign. It has been linked to depression and suicidal behavior. And, it is associated with psychotic symptoms that look a whole lot like early-onset schizophrenia.
I have seen adolescents put on antidepressants because parents and docs bought into the (in my opinion) myth that people “self-medicate” existing depressions with pot. But the research cited above gives evidence that marijuana is not used to self-medicate.
If the teens with suicidal behavior while on antidepressants happened to be using marijuana at the same time, couldnt they perhaps sue the marijuana manufacturer, too?...
I have seen adolescents put on antidepressants because parents and docs bought into the (in my opinion) myth that people “self-medicate” existing depressions with pot. But the research cited above gives evidence that marijuana is not used to self-medicate.
If the teens with suicidal behavior while on antidepressants happened to be using marijuana at the same time, couldnt they perhaps sue the marijuana manufacturer, too?...
Sunday, October 03, 2004
High Deductible Doesn't Equal "Consumer Driven"
Consumer-driven health plans reduce the use of services but may do so at the price of effective healthcare, according to a study in Health Services Research reported in Psychiatric News. But is simply using tiered payments and high deductibles (as in this report) really "consumer-driven" care? I don't think so. I've posted before (here and here and here) about purer forms of consumer-driven healthcare.
Friday, October 01, 2004
Drug with No Risk Redux
In answer to the queries I've received, the answer is no, I've never heard of anyone getting into cardiac problems because a doc was titrating the dose of a tricyclic antidepressant until the "QT interval" on the EKG pattern just starts to change. That's probably because the EKG was so closely monitored in the process.
As is potentially the case with Vioxx patients, the infamous Mellaril black box for its effect on the EKG tracing is another case of a jillion patients perhaps done a disservice over what has been, in real-world clinical settings, a minimal risk. In the real world, here's a medication that is about as benign as an antipsychotic can get, but you'd never know it nowadays.
In Mellaril's case, some folks think that the FDA got into the midst of a marketing war (sort of like this one) between classic (and less expensive) antipsychotics and the new so-called atypical (expensive) antipsychotics.
As is potentially the case with Vioxx patients, the infamous Mellaril black box for its effect on the EKG tracing is another case of a jillion patients perhaps done a disservice over what has been, in real-world clinical settings, a minimal risk. In the real world, here's a medication that is about as benign as an antipsychotic can get, but you'd never know it nowadays.
In Mellaril's case, some folks think that the FDA got into the midst of a marketing war (sort of like this one) between classic (and less expensive) antipsychotics and the new so-called atypical (expensive) antipsychotics.
