Tuesday, November 30, 2004
Worry & Grow Old -- Fast
In successfully demonstrating that stress leads to premature aging, psychiatrist Elissa Epel and her associates turned their attention to a group of moms enduring one of the most stressful situations that I can imagine -- caring for a child with a chronic disorder like autism or cerebral palsy. It turns out that it is the chronicity of the stress that leads to greater "oxidative stress," which in turn leads to DNA damage, and in turn to aging.
Also, perception of the stress level was the best predictor of aging, even in moms who did not have a disabled child. That is, how much stress you feel you're under is a great predictor of how quickly you'll age.
So, it speaks to the role that stress-reduction interventions -- psychotherapy or meditation, for example -- might have in slowing the aging process.
Also, perception of the stress level was the best predictor of aging, even in moms who did not have a disabled child. That is, how much stress you feel you're under is a great predictor of how quickly you'll age.
So, it speaks to the role that stress-reduction interventions -- psychotherapy or meditation, for example -- might have in slowing the aging process.
Monday, November 29, 2004
It's a (Pharmacologically-Induced) Wonderful Life!
My longest, hardest night on psychiatric ER call was Christmas Eve of my intern year, and since doctors are prone to go with their anecdotal experience over data any day of the week (it's the same reason I wouldnt prescribe Prozac for years after the very first patient I tried on it back in '87 got Stevens-Johnson syndrome -- and who knows if it was even cause-&-effect), well, there is no way I believe all that data saying that holidays really aren't a worse time of year for psychiatric problems.
My anecdotal experience says it's big-time more stressful between now and New Year's.
But, wait! Maybe things have changed since that fateful Xmas Eve twenty-odd years ago! Maybe contemporary pharmacology offers alternatives to a post-candlelight-service trip to the ER as ways to cope with holiday stress. Or at least this article would suggest that possibility...
My anecdotal experience says it's big-time more stressful between now and New Year's.
But, wait! Maybe things have changed since that fateful Xmas Eve twenty-odd years ago! Maybe contemporary pharmacology offers alternatives to a post-candlelight-service trip to the ER as ways to cope with holiday stress. Or at least this article would suggest that possibility...
Sunday, November 28, 2004
Whose Life (& Decision) Is It, Anyway?
It speaks to the historic paternalism in medicine that when the topic is "shared medical decision making," the issue most likely is how to give the patient more say in her medical care. That's why I appreciate Dr Robert McNutt's commentary in last week's JAMA on the topic.
"The first problem," Dr McNutt says, "is that the term 'shared decision' is a misnomer...how does a physician share a decision that involves the patient's medical care?" He goes on to say that the misnomer has simply been used to justify the historic paternalism, "a practice of medicine that rewards physicians for making choices for patients."
"Physicians should never make a choice for a patient -- even if the patient wants the physician to do so."
What is "shared" in the patient-physician relationship is information, not decision-making, Dr McNutt says. The doc is a navigator, not a pilot.
"The first problem," Dr McNutt says, "is that the term 'shared decision' is a misnomer...how does a physician share a decision that involves the patient's medical care?" He goes on to say that the misnomer has simply been used to justify the historic paternalism, "a practice of medicine that rewards physicians for making choices for patients."
"Physicians should never make a choice for a patient -- even if the patient wants the physician to do so."
What is "shared" in the patient-physician relationship is information, not decision-making, Dr McNutt says. The doc is a navigator, not a pilot.
Saturday, November 27, 2004
Home-Alone America
In the provocative book with the title above, Mary Eberstadt argues that "it would be better for both children and adults if more American parents were with their kids more of the time." Is that just more propaganda from conservative red America?
No. There's more to this story than propaganda.
As I discussed here, research does suggest that when parents make enough money to work fewer hours and spend more time with their children, it is correlated with less behavior problems in the children.
But would that research show the same effect if the parents studied were working by choice instead of by necessity?
Research on this topic goes both ways. And, in fact, some research suggests that long hours are tougher on the folks than on the children. So I suspect that this is not an either-or issue. I suspect it depends very much upon the child and upon the parents.
Indeed, I suspect that the comfort level of the parents is the critical factor. Couldn't a mom (or dad) who begrudgingly gives up a career be equally problematic to the youngster stuck at home with her?
Children are experts at picking up on cues from their parents, both verbal and non-verbal. And they respond to those cues, behaviorally and emotionally. So as a parent -- whether we're talking about discipline style or parenting style or decisions about whether or not to work -- it is not so much what you do as how you do what you do...
No. There's more to this story than propaganda.
As I discussed here, research does suggest that when parents make enough money to work fewer hours and spend more time with their children, it is correlated with less behavior problems in the children.
But would that research show the same effect if the parents studied were working by choice instead of by necessity?
Research on this topic goes both ways. And, in fact, some research suggests that long hours are tougher on the folks than on the children. So I suspect that this is not an either-or issue. I suspect it depends very much upon the child and upon the parents.
Indeed, I suspect that the comfort level of the parents is the critical factor. Couldn't a mom (or dad) who begrudgingly gives up a career be equally problematic to the youngster stuck at home with her?
Children are experts at picking up on cues from their parents, both verbal and non-verbal. And they respond to those cues, behaviorally and emotionally. So as a parent -- whether we're talking about discipline style or parenting style or decisions about whether or not to work -- it is not so much what you do as how you do what you do...
Friday, November 26, 2004
Confront an Emerging Substance Use Problem
From a reader: "We found some marijuana in the car on the day after our sixteen-year-old took it to a party. We can't decide how big of a deal to make of it. He's not been a behavior problem, and his grades were fine last year. What should we say to him?"
Do not underestimate the risk that marijuana presents to teenagers. In spite of hype to the contrary, marijuana is indeed habit-forming. In addition, teens who use marijuana are usually drinking, as well, and they are one hundred times more likely to use cocaine, which is even more addicting.
So I believe it is important that a discovery such as this be discussed with the teen involved. Don't be hysterical about it, and don't be threatening. Be direct ("we found this in the car") and convey your concerns. Try to get a feel for the types and amounts of substance use. Seek treatment if there is a pattern of use, even if no other conduct problems are occurring.
By the way, I strongly believe in the power of the unconscious. If a teenager manages to forget that the marijuana was in the car, then I believe it is a strong, unconscious cry for help.
Do not underestimate the risk that marijuana presents to teenagers. In spite of hype to the contrary, marijuana is indeed habit-forming. In addition, teens who use marijuana are usually drinking, as well, and they are one hundred times more likely to use cocaine, which is even more addicting.
So I believe it is important that a discovery such as this be discussed with the teen involved. Don't be hysterical about it, and don't be threatening. Be direct ("we found this in the car") and convey your concerns. Try to get a feel for the types and amounts of substance use. Seek treatment if there is a pattern of use, even if no other conduct problems are occurring.
By the way, I strongly believe in the power of the unconscious. If a teenager manages to forget that the marijuana was in the car, then I believe it is a strong, unconscious cry for help.
Thursday, November 25, 2004
Holiday Stress Advice - Sorted by Personality Type
No holiday season is complete without the requisite "how to cope with the holidays" news article, right? Here's a press release out of Saint Louis University School of Medicine on "what can you do to de-stress Thanksgiving." Some excerpts:
- Take a few moments to play a board game with your 5-year-old nephew who’sGood ideas, I reckon -- but they all seem to require lots of reaching out to others. Hmmm....whatever shall the introverts among us do to cope? How about this:
clamoring for your attention
- Ask Aunt Francis...how she celebrated Thanksgiving when she was young
- (G)et everyone off the couch for an after-dinner walk to look at Christmas lights
- Stay on the side-lines and observe...Our you could feign a severe stomach ache right after dinner, then hole up in the back bedroom with the book that last idea came from.
Wednesday, November 24, 2004
Future of Psychiatry
I've mentioned before my belief that studies matching genotypes to the effectiveness of medications seem very promising in ending the trial-and-error process of finding the right medication for any given patient.
Equally promising are studies like this one in Neuron this month that seek to match specific biological markers with specific diseases. In this particular study, the marker was the size of one part of the brain, and the disease was cocaine addiction.
Hopefully the day will come when today's descriptive approach to diagnostic psychiatry is replaced with a brain scan that makes the diagnosis and then a blood test that determines the best medication.
Equally promising are studies like this one in Neuron this month that seek to match specific biological markers with specific diseases. In this particular study, the marker was the size of one part of the brain, and the disease was cocaine addiction.
Hopefully the day will come when today's descriptive approach to diagnostic psychiatry is replaced with a brain scan that makes the diagnosis and then a blood test that determines the best medication.
Tuesday, November 23, 2004
Upon Further Review
This week's JAMA reports on the FDA's decision to go back and look at all of its data on the use of antidepressants in adults to see if there is any increase in suicidal risk that was missed up until now.
Here is more information.
"The FDA previously found no increased risk of suicide in adults but will now
reexamine existing data...in the same detailed fashion it used for analysis
in the young."
Here is more information.
Monday, November 22, 2004
Life as a Non-profit in a For-profit World
An article in American Medical News this week talks about the increased scrutiny over accountability that nonprofit hospitals are receiving. It reminded me of an old article out of the Harvard Biz School (on line here) with this quote:
This double bottom-line reflects the many pressures in the non-profit world that most businesses do not endure. Healthcare non-profits must compete for the same dollars and patients as the for-profits in their community, but they do so while their "investors" insist that they make no profit, frown upon expenditures (eg, computers) that are not directly tied to patient care, ask that they retain little or no rainy-day savings no matter how volatile the healthcare sector might be, and then frown again if they pay high-quality managers so that the mission can survive all of these other pressures.
The Harvard article comes to the conclusion that the business world could learn a lot from the non-profits about real accountability.
"I sometimes laugh when I listen to businesspeople say that 'nonprofits need toThe "double bottom-line" refers to the need not only to make ends meet financially, but to do so while assuring the social mission is met.
become more business-like.' I think if more mainstream businesspeople understood
what it's like to manage to a double bottom-line, they would offer their advice
with a bit more humility and perhaps be more willing to acknowledge the
incredible value offered by nonprofit organizations. "
This double bottom-line reflects the many pressures in the non-profit world that most businesses do not endure. Healthcare non-profits must compete for the same dollars and patients as the for-profits in their community, but they do so while their "investors" insist that they make no profit, frown upon expenditures (eg, computers) that are not directly tied to patient care, ask that they retain little or no rainy-day savings no matter how volatile the healthcare sector might be, and then frown again if they pay high-quality managers so that the mission can survive all of these other pressures.
The Harvard article comes to the conclusion that the business world could learn a lot from the non-profits about real accountability.
Sunday, November 21, 2004
Retired Psychiatrist Among the Heroes of Iraq
The story of retired psychiatrist Paul Hill of Temple, Texas, who volunteered for duty in Iraq is told here, and by other associated press outlets. He talks of treating soldiers with post-traumatic stress disorder, major depression, as well as everyday worries. A Vietnam vet, Dr Hill's story is more remarkable because he objects to the Iraq war as "a big mistake."
"'People over here have no idea how much stress these guys are under,' said Dr. Hill, who returned to Central Texas this month."
"'People over here have no idea how much stress these guys are under,' said Dr. Hill, who returned to Central Texas this month."
Saturday, November 20, 2004
Never Underestimate Alcohol-Related Disinhibition
I'm right there with Indiana Pacers' CEO Donnie Walsh when he is quoted as saying that "responsibility for Friday night's action can be shared by many." But when I review articles on the basketball game incident, or on other similar ones involving baseball fans this past year, I rarely see the suggestion that alcohol played a role.
I found this post by a sociology professor in NY, claiming that research shows that intoxicated people have much greater control over their behavior than generally recognized. He says:
I found this post by a sociology professor in NY, claiming that research shows that intoxicated people have much greater control over their behavior than generally recognized. He says:
"Research in the US has found that when males are falsely led to believe that
they have been drinking alcohol, they tend to become more aggressive."
But why the need to show such aggression toward professional athletes? Psychologically-speaking, I wonder if high salaries and free-agent mobility leave fans feeling emotionally estranged from their once beloved athletes. Or, is a tossed beer the fandom equivalent of a wide receiver's end-zone dance, both seeking notoriety?
Doesn't matter to me whether you blame the physical effects of alcohol or its sociological effects: stop serving alcohol at these games, and you'll stop having fan-player brawls, too.
Thursday, November 18, 2004
Higher Rate of Brain Tumors in the Mentally Ill
I have always been struck by what seemed like a higher rate of serious medical conditions in people who also suffer from severe mental illness. Anecdotally, it has always seemed to me that the severely mentally ill had more medical problems and died younger from them.
Now comes a study in Psychosomatic Medicine demonstrating a high rate of cancer among people with mental illness, and showing they do indeed develop malignancies earlier in life. The authors were especially struck by the high rate of brain tumors. They speculate that some cases may represent brain cancer that looks like severe mental illness at first. It reinforces the need for a thorough workup in patients first presenting with psychiatric symptoms.
Now comes a study in Psychosomatic Medicine demonstrating a high rate of cancer among people with mental illness, and showing they do indeed develop malignancies earlier in life. The authors were especially struck by the high rate of brain tumors. They speculate that some cases may represent brain cancer that looks like severe mental illness at first. It reinforces the need for a thorough workup in patients first presenting with psychiatric symptoms.
Wednesday, November 17, 2004
More on the Over-Diagnosis of ADHD
Thanks to a reader of my grand rounds 8 story on the notion of overmedication of children for pointing me toward this report of a study by the Western Australian (WA) government that suggests as many as 75% of WA kids diagnosed with attention deficit disorder (ADHD) are, in fact, not ADHD at all. It suggests that the mis-diagnosis leads to excessive use of stimulant medications.
Here's my favorite line in the report:
ADHD is way over-diagnosed in lots of places other than Western Australia...
Here's my favorite line in the report:
"(The report) says the greater use of the drugs in WA (Western Australia) is outIt'd be interesting to compare the rate of Ritalin-prescribing in WA with the rate in, say, TX. Maybe WA wouldnt feel so out of step!
of step with practices in other states."
ADHD is way over-diagnosed in lots of places other than Western Australia...
Tuesday, November 16, 2004
Medication Cost as an Untenable Side Effect
Dr Alex Federman described his systematic query of his patients' ability to afford prescription copays in JAMA last week:
The article also mentions that many physicians are unaware of the cost of medications they prescribe. In public health systems with limited funding, I've seen overall pharmaceutical costs come down through changes in prescribing patterns simply from educating docs about the relative costs of similar medications. In my experience, most docs want to be good stewards of taxpayer dollars.
"Many of the patients we see in this community have incomes of maybe $600 aSo, out-of-pocket medication costs can be a "side effect" that leads to non-compliance.
month, they may take anywhere from 6 to 10 medications, and they have to pay
rent of about $200 or $300 a month," he says. "That doesn’t leave much money
for other things, and paying for medications is a very real financial strain."
The article also mentions that many physicians are unaware of the cost of medications they prescribe. In public health systems with limited funding, I've seen overall pharmaceutical costs come down through changes in prescribing patterns simply from educating docs about the relative costs of similar medications. In my experience, most docs want to be good stewards of taxpayer dollars.
Monday, November 15, 2004
Easing Involuntary Commitment
A while back I shared the story of a woman who had trouble getting her husband committed. Today I notice that they have changed the law in Utah so that it is easier to get someone the help they need.
The Susan Gall Involuntary Commitment Act lowered the legal threshold to obtain involuntary commitments after the slaying of Susan Gall, a teacher who was killed by her son after the family had tried to have him committed but could not prove he was "an immediate danger," as most commitment laws require.
With the new law, commitments require proof of "a substantial danger." This year, commitments are up 50% in Utah.
Remember, commitment need not be to an institution. A commitment can also be an order to participate in a prescribed outpatient treatment program.
The Susan Gall Involuntary Commitment Act lowered the legal threshold to obtain involuntary commitments after the slaying of Susan Gall, a teacher who was killed by her son after the family had tried to have him committed but could not prove he was "an immediate danger," as most commitment laws require.
With the new law, commitments require proof of "a substantial danger." This year, commitments are up 50% in Utah.
Remember, commitment need not be to an institution. A commitment can also be an order to participate in a prescribed outpatient treatment program.
Sunday, November 14, 2004
Melt That Fat Away
I realize I am off-blog-task here, but I must admit my intrigue with the notion (offered in JAMA this week) that taking 50-mgs of an over-the-counter dietary supplement might melt away two pounds of fat directly from my gut.
And no side effects!
Well, at least one doc would disagree...
And no side effects!
Well, at least one doc would disagree...
Saturday, November 13, 2004
Are Children Overmedicated?
Here in Texas, the care of child mental health patients has been dragged into the race for governor, a full two years before the election. If I read her press release correctly, Texas Comptroller Carole Strayhorn (who most believe intends to run for governor or lieutenant governor) is claiming that children in foster care are being over-medicated as a way for doctors and drug companies to make money. The incumbent governor and the Texas Medical Association have already expressed their disagreement with her.
I disagree, too.
I do find that I spend more time taking children off of medications started elsewhere than I do writing new prescriptions. But I can't ever recall completing a child psychiatric consultation where I thought the prior treatment was sinister.
More typically, a harried physician has bowed to pressure from an exasperated case worker or teacher or parent to do a trial of medication in an attempt to manage behavior problems that have everyone feeling miserable. It takes time (and a tolerance for angry glares) to say "no," and to insist that underlying causes of the behavior -- undiagnosed learning disorders, marital conflict in the home, poverty -- be addressed first.
I have mentioned before (here and here and here) that the problem is inadequate funding for non-drug interventions that are effective, and for interventions that impact causes rather than manage effects.
I know from experience that the thought process for docs who start meds goes like this: "If I have nothing else to offer, shouldn't I at least try the medication?"
Blasting docs in that catch-22 is like blasting the messenger who reports: "It's hell being poor in Texas..."
I disagree, too.
I do find that I spend more time taking children off of medications started elsewhere than I do writing new prescriptions. But I can't ever recall completing a child psychiatric consultation where I thought the prior treatment was sinister.
More typically, a harried physician has bowed to pressure from an exasperated case worker or teacher or parent to do a trial of medication in an attempt to manage behavior problems that have everyone feeling miserable. It takes time (and a tolerance for angry glares) to say "no," and to insist that underlying causes of the behavior -- undiagnosed learning disorders, marital conflict in the home, poverty -- be addressed first.
I have mentioned before (here and here and here) that the problem is inadequate funding for non-drug interventions that are effective, and for interventions that impact causes rather than manage effects.
I know from experience that the thought process for docs who start meds goes like this: "If I have nothing else to offer, shouldn't I at least try the medication?"
Blasting docs in that catch-22 is like blasting the messenger who reports: "It's hell being poor in Texas..."
Thursday, November 11, 2004
Antidepressants in Children - Update
The American Academy of Child and Adolescent Psychiatry has recommended that child psychiatrists continue to prescribe antidepressants, citing the research evidence for their effectiveness. "Although antidepressant treatment carries risks, untreated depression has potentially greater risks." Out of 4400 kids in research studies on antidepressants, only 78 showed suicidal behavior (less than 2% -- whereas I've seen studies of the rates of suicidal thoughts in "normal" teens with it as high as 20%!). By the way, a reminder that only Prozac has ever been shown to be effective in the treatment of pediatric depression.
Wednesday, November 10, 2004
Parity in Health Coverage, and the Lack Thereof
A reader writes, "You say over and over that medication plus psychotherapy is best for depression. But my insurance won't pay for me to see a psychiatrist more than twice a year, and it will only pay for a few visits to a therapist. I imagine I make too much money to go to a public clinic. What are people like me supposed to do?"
In spite of laws intended to stop the practice, most insurance still does not cover mental illness in the same way as other medical illnesses -- and the public dollars for health care are not distributed equally, either. It's a shame, because researchers have made tremendous progress in the care of depression, anxiety and schizophrenia. But all of that progress is worthless if people cannot get access to proper treatment.
You know, brain scans show that people with some mental illnesses have problems inside the brain. That's no different from showing how people with diabetes have problems in the pancreas. Why should someone with diabetes have his insulin paid for while so many people with depression can't get medication?
So, one thing you need to do is to let your public officials know about your problem, and let them know that mental illnesses should not take a back seat to heart disease, diabetes or any other illness when it comes to funding for public health.
Most community mental health clinics will see you regardless of your ability to pay. So, you should be able to work out a payment plan that is comfortable for you. If for some reason they will not see you, then there are usually other sliding scale clinics around funded by other sources, like United Way.
In spite of laws intended to stop the practice, most insurance still does not cover mental illness in the same way as other medical illnesses -- and the public dollars for health care are not distributed equally, either. It's a shame, because researchers have made tremendous progress in the care of depression, anxiety and schizophrenia. But all of that progress is worthless if people cannot get access to proper treatment.
You know, brain scans show that people with some mental illnesses have problems inside the brain. That's no different from showing how people with diabetes have problems in the pancreas. Why should someone with diabetes have his insulin paid for while so many people with depression can't get medication?
So, one thing you need to do is to let your public officials know about your problem, and let them know that mental illnesses should not take a back seat to heart disease, diabetes or any other illness when it comes to funding for public health.
Most community mental health clinics will see you regardless of your ability to pay. So, you should be able to work out a payment plan that is comfortable for you. If for some reason they will not see you, then there are usually other sliding scale clinics around funded by other sources, like United Way.
Tuesday, November 09, 2004
Severe Depression in -- Three-year-olds
Yep, that title says "3." An article in the latest American Journal of Psychiatry talks about the reality of pre-school depression so severe that it includes "anhedonia," the loss of pleasure in all activities. Given that early childhood is "an inherently joyful time," the researchers show that if anhedonia exists at that age, the diagnosis of major depression is essentially guaranteed. The cause? Evidence suggest these kids have a biological disorder of the brain.
Monday, November 08, 2004
Good Nutrition, Homes & Jobs: Preventive Medicine
If you let a toddler become malnourished, you increase his chances of behavior problems throughout childhood, according to this research in the American Journal of Psychiatry. Poor early nutrition leads to deficits in cognitive thinking, and these are related to later behavior problems. I've always been amazed at the high rate of speech disorders and learning disorders in children with behavior problems. Learning disorders lead to trouble verbalizing frustration in the classroom, and kids who cant talk about their frustration resort to showing it through their behavior, instead.
By the way, that's not the first study to show that treating poverty is preventive medicine for mental health problems. Here is another one from JAMA.
Last week, I saw a teenage mom who just moved here from Central America at her parents' insistence. She worked back home and she wants to work here, but she doesn't have the proper credentials to get a job. Without a job, she is dependent upon the public health system for care. Since it is difficult to get a public clinic appointment, she is likely to wait until her daughter's ear infection is bad enough for an ER visit before seeking medical care.
For folks concerned about efficient use of tax dollars -- doesn't it make sense to assure that a toddler gets enough cheap food, rather than have him take expensive Ritalin and attend special ed in grade school, or require juvenile detention cell in his teen years? And doesn't it make sense to let a single mom get a legal job with insurance, rather than have to pay for the care of meningitis through the public ER when a week's worth of ear-infection antibiotics from the company-plan doc wouldn't cost the taxpayers a dime?
By the way, that's not the first study to show that treating poverty is preventive medicine for mental health problems. Here is another one from JAMA.
Last week, I saw a teenage mom who just moved here from Central America at her parents' insistence. She worked back home and she wants to work here, but she doesn't have the proper credentials to get a job. Without a job, she is dependent upon the public health system for care. Since it is difficult to get a public clinic appointment, she is likely to wait until her daughter's ear infection is bad enough for an ER visit before seeking medical care.
For folks concerned about efficient use of tax dollars -- doesn't it make sense to assure that a toddler gets enough cheap food, rather than have him take expensive Ritalin and attend special ed in grade school, or require juvenile detention cell in his teen years? And doesn't it make sense to let a single mom get a legal job with insurance, rather than have to pay for the care of meningitis through the public ER when a week's worth of ear-infection antibiotics from the company-plan doc wouldn't cost the taxpayers a dime?
Sunday, November 07, 2004
Pigeonholing and its Defense
Shrinkette mentions that she is “someone who is both coastal and inhabiting a university town,” ie, living in blue America, citing a David Brooks op-ed regarding the innate need we have to simplify complicated issues, such as voting patterns.
By contrast, I live in one of those towns often simplified into “conformist and intolerant,” ie, very red America.
At the local "red America" high school, some serious post-election op-ed’ing has been going on in the senior class blogring on Xanga. In addition to blowing away any possible pigeonholing about a single set of beliefs in a red American community like mine, the depth and breadth of the issues analysis by some of these teens gives me much hope for the future of this country of ours. Agree or disagree, at least they are thinking through the issues.
I'll stick to a couple of samples from one site on the issue of healthcare, but these guys debate the "values vote" issue, as well -- and it sure ain't a concordant voice:
By contrast, I live in one of those towns often simplified into “conformist and intolerant,” ie, very red America.
At the local "red America" high school, some serious post-election op-ed’ing has been going on in the senior class blogring on Xanga. In addition to blowing away any possible pigeonholing about a single set of beliefs in a red American community like mine, the depth and breadth of the issues analysis by some of these teens gives me much hope for the future of this country of ours. Agree or disagree, at least they are thinking through the issues.
I'll stick to a couple of samples from one site on the issue of healthcare, but these guys debate the "values vote" issue, as well -- and it sure ain't a concordant voice:
“I find it such an odd concept that people would be against helping others in
this way. Not everyone was born in West Plano, and these people deserve quality
healthcare despite being poor. Not only does the system provide healthcare to
the less affluent, but it also provides for care for the disabled as well.
The public healthcare system, at least in Texas, has been losing vital funding
in the last few years, and it is has been sad to watch the changes occur.”
“Having hospitals like Parkland is of course awesome. It's a teaching hospital
that never refuses a patient and gives premium health care for free.
However, socializing medicine is a terrible idea. The best system is what we
have -- private with a little bit of public mixed in. All of the good that
happens in Dallas is because the hospital has technology, educated doctors,
incredible research, and top of the line treatments. This would be simply
impossible to provide in a socialized health care environment. Everyone would be
in worse shape. Doctors would be paid not nearly what they are worth by the
government, and doctors wouldn't even be able to pay for the medical school it
took them to get where they are. The quality of doctors would diminish."
Saturday, November 06, 2004
Weblogs by Mental Health Consumers and Their Families
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.
Thursday, November 04, 2004
More on the Adult ADHD Controversy
As I've mentioned before, I am one of those docs who struggles with the concept of an adult form of ADHD, in spite of evidence of its existence. Some of us in clinical practice are skeptical due to the high rate of at-least-co-occurring disorders in patients who think they have ADHD. A new article in American Journal of Psychiatry acknowledges the controversy. It persuades me of the validity of an adult ADHD diagnosis that requires retrospective childhood diagnosis, validation of the childhood history by an additional informant, and a whole lot of socially-impairing symptoms. If I obtained all that history in a patient who wasn't using cocaine or speed, well, I reckon I'd agree with the diagnosis. But I still think it's over-diagnosed, in adults and in children.
Wednesday, November 03, 2004
Stomach Aches: How to Save on Child Psychiatrist Fees
Yesterday I wrote about what is known as "somatization" in children in the form of stomach aches. Kids rarely have a problem with the idea that their worries and their aches & pains might be related. They are young enough to remember how mind and body are linked. It's much more common for their parents to be uncomfortable with the idea that emotional stress can cause physical pain. Isn't it odd that it's acceptable for stomach pain to be caused by an ulcer or by too much acid, but it's a sign of weakness if it's "just" psychological?
If parents could just consider this idea as possible, then they probably could give some thought to what kind of stress their child might be under without recognizing it. Even if they can't pinpoint something, just asking the child about some possibilities might do the trick. Link the worries to the pain for the child, and you can save big bucks on the child psychiatrist bill...
If parents could just consider this idea as possible, then they probably could give some thought to what kind of stress their child might be under without recognizing it. Even if they can't pinpoint something, just asking the child about some possibilities might do the trick. Link the worries to the pain for the child, and you can save big bucks on the child psychiatrist bill...
Tuesday, November 02, 2004
On Stomach Aches and "Worry-Tummies"
A reader writes: "My eight-year-old has had off-and-on stomach pain. Even after trips to specialists, we cannot figure out the cause. Now I've been told to take him for counseling. How would counseling help stomach aches?"
When I hear this story, I wonder if the child has a "worry-tummy." That's the term I use to explain to children that an upset stomach can be caused by emotional stress. "But I don't feel worried!" That's the reply I often get when I first share my explanation for stomach pain with a child. But, you see, that's how a "worry-tummy" works! You don't feel any stress or worries in your head -- you feel "upset" in your stomach instead.
One time I was pushing a four-year-old on a backyard swing set. I gave her a good, hard push so that she was going high into the air. "Stop pushing so hard!" my little friend shouted after a bit. "You're making my tummy scared!" My four-year-old playmate understood that the butterflies in her tummy when she went too high were there, in part, because she was scared.
Somehow when we get old enough for grade school we forget how closely our minds and our bodies work together. But usually once I re-link the "pain in your tummy" with the "worries on your mind," then it's not long before a child's stomach discomfort goes away.
When I hear this story, I wonder if the child has a "worry-tummy." That's the term I use to explain to children that an upset stomach can be caused by emotional stress. "But I don't feel worried!" That's the reply I often get when I first share my explanation for stomach pain with a child. But, you see, that's how a "worry-tummy" works! You don't feel any stress or worries in your head -- you feel "upset" in your stomach instead.
One time I was pushing a four-year-old on a backyard swing set. I gave her a good, hard push so that she was going high into the air. "Stop pushing so hard!" my little friend shouted after a bit. "You're making my tummy scared!" My four-year-old playmate understood that the butterflies in her tummy when she went too high were there, in part, because she was scared.
Somehow when we get old enough for grade school we forget how closely our minds and our bodies work together. But usually once I re-link the "pain in your tummy" with the "worries on your mind," then it's not long before a child's stomach discomfort goes away.
Monday, November 01, 2004
Meds Therapy Combo Best for OCD, Too
In JAMA, another study showing a combination approach works best for psychiatric disorders. This time it is obsessive-compulsive disorder in children. But there is good news and bad news. Children who received Zoloft and cognitive psychotherapy had an advantage over kids treated with one or the other. Unfortunately, even the combined approach led to remission in only half of those treated. Patients on therapy alone were more likely to remit than those on meds alone. The researchers note how common it is for patients to get two meds (usually an antidepressant and an antipsychotic) rather than meds plus therapy, and advocate for wider availability of cognitive therapy.
