Mental Notes

I am asked (by a young woman on the phone): "Doctor, is it you who had me followed home from the clinic yesterday by a man who told me he works there and is preparing me for a job working there, too?"

Yes, she has a history of paranoia. But working in the public sector, I have been burned more than once when I thought a story like this was symptomatic of a psychiatric disorder.

It's hell being poor, worse being poor and mentally ill, even worse to be a young mentally ill woman living on meager disability benefits but among the street-savvy who live on even less.

Aware of this young woman's particular version of hell, I asked her case worker to check out the story...

I am asked: "I have an eleven-year-old grandson who is never in trouble at school, but always seems to be in trouble at home. He's been in and out of therapy for years, ever since his father left when he was six years old. He has temper tantrums and always feels deprived. After he gets in trouble he is always remorseful, and I've even heard him talk about hurting himself. I'm thinking he is depressed. What is your opinion of using Prozac for this?"

When behavior symptoms occur at home and not at school, then it always makes me suspicious of a family conflict rather than a psychiatric disorder.

In addition, I believe that a parental split always has a tremendous and persistent emotional impact on children. That impact can show in many ways, but a behavior problem is a common one.

However, there is also little doubt that parental separation can trigger depression in children, and behavior problems can be a symptom of depression, as well.

So I certainly encourage an evaluation to make sure that your grandson is not suffering from a severe depression. If he is, then Prozac is the one antidepressant that has been shown to be effective in treating childhood depression.

However, keep in mind that a pill cannot make the hurt and pain of a loss go away, no matter how long ago that loss occurred. And a pill can't fix a family conflict. That's why I suspect that the child psychiatrist who evaluates your grandson might recommend some therapy again -- especially family therapy, since the problems are happening at home but not at school.

"A 10-year-old child accused of fatally shooting his father this summer has become a national poster boy for a controversial and unofficial psychiatric disorder: Parental Alienation Syndrome," according to a Houston Chronicle article:

...41-year-old Rick Lohstroh, who was killed on Aug. 27 outside his ex-wife's
Katy home. After a bitter divorce in 2003, Lohstroh was picking up his two sons
for a visit under a joint-custody agreement when the 10-year-old shot him from
the back seat of the car, police said. Since then, advocates have pointed to
Lohstroh's death to illustrate that acrimonious divorces can prompt an angry
parent to turn a child against another parent.

According to Dr Richard Gardner:

...parental alienation syndrome (PAS) is a disorder that arises almost
exclusively in the context of child-custody disputes. In this disorder, one
parent induces a program of denigration against the other parent. However, this is not simply a matter of "brainwashing" or "programming" in that the children contribute their own elements into the campaign of denigration. It is this combination of factors that justifiably warrants the designation PAS.

Dr Gardner is carrying on a campaign to get the concept incorporated into the official diagnosis manual of the American Psychiatric Association.

But the theory has many critics, particularly among workers in the child-abuse field who fear that it may perpetuate denial about the rate of child abuse. (That is, a parent reporting abuse by an ex-spouse might have the report ignored under the guise that the real issue is PAS.) So, an interesting war of words (here, for example) has developed over the issue.

By the way, antidepressants have also been blamed in the case above. In fact, the grandparents reportedly are suing Prozac's maker, claiming the medication caused the child's aggression.

More evidence for the traditional view that biology and environment interact to cause many psychiatric disorders:

Mice with brains that lack a protein important in the normal response to stress develop symptoms that look like major depressive disorder in humans.

The study is in the online issue of Proceedings of the National Academy of Sciences.

The gold-standard pharmacotherapy for depression, imipramine, "normalized" the symptoms.

Thus, the evidence just continues to mount suggesting genetics make some people more vulnerable to depression in the face of a major life stress.

Indeed, the Wash U researchers apparently plan to search for a gene that is related to the problem protein, hoping that would help identify more effective antidepressants.

In July, an article in the NEJM suggested that the rate of depression, anxiety and PTSD for soldiers coming out of Iraq was around 16%. An article in an Austin paper questions that number:

On March 25, Dr. James Scully, medical director of the American Psychiatric
Association, testified to the House Appropriations Subcommittee on VA, HUD, and
Independent Agencies. Scully, a Navy veteran, reported a 42% explosion in VA
patients with severe PTSD, with only a 22% increase in money spent on PTSD
services.

It brings to mind the reality that inadequate funding for veteran mental health services is another one of those pay-me-now-or-pay-me-later issues:

...Yet the VA's mental health programs are chronically underfunded, and the
agency currently projects a $1.65 billion shortfall in those programs by the end
of 2007. "If we don't give the VA what it needs immediately, the consequences
will be lifelong and devastating," says Steve Robinson, executive director of
the National Gulf War Resource Center."

A billion and a half short? Incredible...

Read the whole story, which includes great descriptions of the painful symptoms some of our returning heroes must endure.

Worries about the medications that doctors prescribe are not new. Garrison Keillor's Fearmonger's Shoppe has carried a "prescription safety kit" for over four years, now:

"Poor penmanship among doctors is estimated to cause as many as 198,000 deaths a year. Imagine. Your doctor prescribes Viagra and the druggist gives you fifty
capsules full of Niagara laundry starch. How can you protect yourself against
this mistake? By carrying a safety kit from the Fearmonger's Shoppe,
which includes a box full of large, easy-to-read gummed letters."

After watching the misery of two friends who each stiffened up overnight when their Celebrex was abruptly stopped, I'm wondering where the proper balance might be in decisionmaking on whether or not to prescribe the many medications currently under scrutiny, and who really should be making the decisions.

Would it not be better if these patients could make an informed decision for themselves? It brings to mind again the JAMA comments by Dr Robert McNutt that I first mentioned here:

"Physicians should never make a choice for a patient -- even if the patient
wants the physician to do so."

Certainly I understand the decision of the physicians of these two patients, given the current public climate around medications and drug companies. And I am certainly not expert enough to know whether my friends should be on or off Celebrex.

That's not my expertise.

But the psychology of fear is my expertise, and this I know: a lot of power can be gained and wielded through fearmongering -- including, I'm afraid, intrusive power over the patient-physician relationship.

Now, that's scary...

Over the centuries since the angels first announced Christ's birth, the Christian world has done its best to set up Christ’s kingdom here on Earth.

Unfortunately, the result speaks for itself...

The original notion seems so easily lost: God will do for the human race what it cannot do for itself. Still we persist in trying, do we not?

Remember Longfellow's Civil War lament?

I heard the bells on Christmas day
Their old familiar carols play,
And wild and sweet the words repeat
Of peace on earth, good will to men.

Then from each black, accursed mouth
The cannon thundered in the South,
And with the sound the carols drowned
Of peace on earth, good will to men.

It was as if an earthquake rent
The hearth-stones of a continent,
And made forlorn, the households born
Of peace on earth, good will to men.

And in despair I bowed my head
“There is no peace on earth,” I said,
“For hate is strong and mocks the song
Of peace on earth, good will to men.”

Apparently there is no consensus on what the angels actually sang that night long ago. We dont know if they sang:

"Glory to God in the highest, and on earth peace, good will toward men."

or perhaps:

"Glory to God in the highest, and on earth peace to men on whom his favor rests."

or:

"Glory to God in the highest, and on earth peace to men of good will."

I'm no Biblical scholar, but with Longfellow and those scenes from the Mosul mess hall in mind, I'll take the latter...

Then pealed the bells more loud and deep:
"God is not dead, nor doth He sleep;
The Wrong shall fail, The Right prevail,
With peace on earth, good will to men."

Sometimes the best shrink advice comes from -- well, not from a shrink, at all!

In today's Dallas Morning News, Jacquielynn Floyd shares an overheard conversation between two women that went something like this:

"I'm exhausted," one of them said wearily. "I just want it to end."
"I can't wait for it to be over," the other agreed. "It just gets worse and worse."

Their topic? Christmas, of course.

Ms Floyd's take on the cause of holiday blues is that "we're all trying way too hard."

Instead of trying "to create and experience magic moments that will linger in our memories for a lifetime," she suggests:

Give yourself a break. Have a wonderful holiday, but don't kill yourself
trying. It might just happen anyway.

I second that notion...

Two newspaper articles today (here and here) talk about the quandary that I've discussed (here and here) previously: what do you do in a society that wishes to label the readily-available treatment for depression (antidepressant medications) as dangerous while maintaining the scarcity of the only alternative (psychotherapy)?

In the New York Times article, the wait time for psychotherapy in Britain is said to be six- to nine- months for kids. Even worse, since family practice docs have been advised not to use more antidepressants, the wait to get in to see a child psychiatrist may mean these are equally as scarce.

It is hard for me to believe that the lives saved by these restrictions would outweigh the suicides unaverted, compounded by the misery left untreated.

It makes me believe that the ol' stigma about mental illness is behind all this, leading to less availability of treatment, overall.

Says the NYT article: "Some experts believe the government's action was rashly taken."

Indeed.

Or as Dr Benjamin puts it in the WSJ article: "I don't want to lose a child by prescribing an antidepressant. I don't want to lose a child by failing to treat them."

I've not wanted to comment on the recent case of the Plano woman who killed her 10-month-old and then called her husband to report it, perhaps avoiding the case due to my own sense of social-corporate guilt.

No, it is more likely due to the fact that I see a pattern amongst the (now) four cases along these lines that have occurred in Texas, dating back to Andrea Yate in 2001.

They have more in common than just presumptive diagnoses of postpartum depression (or some other disorder with delusions), but no one talks much about those other common features...

But people do talk about one elicited issue: Texas law concerning the mentally ill who commit crimes. Rick Casey commented this weekend in the Houston Chronicle, and Dr Jones does so here.

OK, here's what my kid wants for Xmas (and is this a good thing? A positive form of identification? Do I encourage her to try pre-med at Rice next year?) :

When it comes to getting psychiatric care for themselves, a new study (described here on page 460 and summarized here) shows that two out of three psychiatric residents choose psychotherapy alone. Most of the rest choose meds plus psychotherapy. Less than 1% choose meds alone.

When they choose a form of psychotherapy, 90% of those surveyed chose psychodynamic treatment (that is, treatment in the Freudian tradition).

Question: why is it that the treatment that virtually all the surveyed doctors-who-know chose for themselves is the treatment least likely to be authorized or funded by insurance companies?

On Tuesday, I talked about a reader whose comments about my holiday blues post made me wonder about the existence of holiday-related seasonal affective disorder.

Another reader brings up another possible cause of holiday blues:

"My husband keeps telling me that I need professional help because I'm not all
excited about the holidays being here. But I think I have a good reason. My mother died around Christmas two years ago, and the last two holiday seasons just haven't been the same."

I wonder if this reader might be experiencing an "anniversary reaction." There are lots of folks who become depressed at a certain time of the year. The date on which this happens is usually the time of a meaningful loss from the past, often the date of a loved one's death.

This kind of reaction does not necessarily mean that you are clinically depressed. Instead, it is a reminder of the power and importance of our early relationships, especially with our parents.

If I am correct, then unfortunately this reader's anniversary reaction comes at the same time as the holidays. So, at a time when her family has an expectation that she be especially happy, instead she is feeling especially low.

An anniversary reaction does not necessarily mean that you need professional help. However, if signs and symptoms of clinical depression last beyond the weeks around the anniversary, then perhaps a consultation with a psychiatrist would be a good idea.

In my experience, the pain of a loss fades with time, so that (in this case) Christmases to come will likely be marked by happy memories of her mother, instead of by the pain of her loss.

If I am correct, then hopefully this reader's husband can understand this, and give her a break this year.

In this week's Psychiatric News, American Psychiatric Association President Michelle Riba notes the importance of another criterion in picking your child's college, something beyond how the dorms look and how the food tastes.

College life is full of new stressors for teens, and college is also a place that many kids with pre-existing (often quite major) psychiatric problems go hoping that a new venue will mean fewer symptoms.

Given these facts, Dr Riba encourages parents to assure that the college-of-choice offers adequate access to mental health care, as well. (Need to make sure your behavioral health insurance benefits cover providers in the new city, too.)

Don't miss this post over at PsychNotes about new evidence on how genes play a role in the etiology of many depressive episodes. My, we've come a long ways -- haven't we? -- from the days of the myth of the "schizophrenogenic mother" to the modern reality of the mutant tryptophan hydroxylase-2 gene?

This evening I'm really enamored of the above possibility, or some variant of it, based upon the below email from a reader, responding to my holiday blues post:

"...I feel weather has a huge impact on one's emotion state during the yuletide season. In past years I've frequently gotten depressed around this time
of year as I sloshed through slush, drove over ice patches, and otherwise got
annoyed by the omnipresent snow. This year, though, the weather...has been
unusually mild - ...clear, sunny skies, and I'm no more stressed than I would be
during a cold early March day."

My vote is to switch out Christmas and the Fourth of July for awhile, do a little experiment...

In this New York Times editorial, another plight of the poor with mental illness is addressed.

As the article says, jails all over this country are de-facto mental hospitals nowadays, and it serves neither the jail system nor the patients well. Many state mental hospitals have closed down, so now people with mental illness who cant make it on the streets often end up living in our jails, instead.

In a not-atypical case, I recall evaluating a man at a county jail who had been living on the street since rejecting the squalor of the unregulated boarding home into which he had been dumped following his hospital discharge. He was hungry, psychotic, untreated. So he walked into a convenience store, fully aware of the police car parked out front, seeking three hots and a cot at one place he knew he could get them: the county jail.

While jails are pretty good at supplying meals and beds, they are not so good at assuring that their sick get treatment. In defense of sheriffs, it is hard to balance the competing pressures on overcrowded and underfunded jails nowadays. Yet if we collectively tolerate a system that waits until someone is in jail to assure that his medical disorder is treated, we should not be surprised at the rising costs of both jails and medical care.

I get asked the question above a lot. That is, why does a stimulant medication have the opposite effect on the brain of a hyperactive child?

Here’s the answer: no one knows.

Theories have evolved over the years, but the most recent version goes something like this: There is a part of your brain that acts like a foot on the brake pedal for the rest of your brain. It chemically taps on the brakes and stops the rest of the brain from speeding up too much, sort of like keeping the brain from getting stuck in fast-forward.

In this theory, hyperactivity happens because that chemical brake-pedal isn’t working properly. Ritalin acts to step on that brake pedal (“stimulates” it), and that slows down the rest of the brain.

Early theories proposed that the problem was too little dopamine in the brake-pedal part of the brain. But nowadays, one theory is exactly the opposite: too much dopamine in the brain. That is, dopamine seems to be the gas pedal. So, what’s the brake pedal?

Recent research suggests that another chemical, norepinephrine, is the brake pedal. So, Ritalin “stimulates” the amount of norepinephrine, norepinephrine hits the brake pedal, and the rest of the brain slows. Put another way, it's the proper balance between the amount of gas-pedal-dopamine and brake-pedal-norepinephrine that perhaps really counts.

Still with me? OK, then, here’s the next part of the theory: There are enzymes in the brain that acts like recycling trucks for norepinephrine and dopamine. Each of the two has its own "truck" that picks up the chemical floating between brain cells, and takes it back into the cells to be re-used.

One theory is that the brake pedal isn’t working right because there are too many recycle-truck-enzymes for norepinephrine, so before the norepinephrine can even push on the brake pedal, a recycle-truck has already picked it up and thrown it in the recycle bin. In this theory, Ritalin acts like a roadblock for the norepinephrine recycling truck.

One more step: the amount of recycling enzymes in the brain seems to be a genetic trait. And research suggests that how well Ritalin works depends on which genes you have for the recycling enzymes.

Of course, other theories abound. But as I mentioned here, it does look as if some day we will be able to predict whether Ritalin will work by doing a genetic blood test, rather than through trial and error.

A reader writes:

"I'm having trouble feeling good about the holidays. Everyone around me seems happy, and sometimes I feel that way, too. But mostly I feel overwhelmed and sad. I wonder if maybe I'm depressed..."

I don't think emotional ups and downs at holiday time are unusual at all.

During the holidays we all tend to set our expectations too high, for ourselves and for our loved ones. If you think about it, what more stressful time could there possibly be? Shopping crowds, credit card bills, "hyper" kids, too much time with too many family members -- surely this isn't the recipe for happiness!

And why shouldn't we have mixed emotions this time of year? The holidays stir up so many feelings. They bring back memories of loved ones no longer alive to share the holidays with us, and childhood fantasies of unlimited gifts that even the most benevolent Santa could never live up to. They can make separations feel more painful, and they can magnify a small conflict into one that suddenly has the power to ruin the holidays for everyone.

So I think we need to lower our expectations this time of year -- our expectations of ourselves, of our families, and our expectations of the holidays themselves. But until we do so, emotional ups and downs during the holidays are not a sign of clinical depression. They are to be expected during such an emotionally charged and highly stressful time.

Shrinkette has posted a very cool list of all the indications for antidepressants, both FDA-approved and so-called, off-label uses.

It was in response to a question many patients ask about meds: has my medication been approved for treating my disorder?

Fact is, most of the uses for most medications have never been approved. Put another way, almost all uses for most medications are off-label uses.

This is especially true for children, and it is because it is so hard to do solid research in kids. That's why although only Prozac is FDA-approved for treating depression in kids, almost every other antidepressant is being used.

Nowadays, I wonder if a better question to ask the doc is this: is my medication part of accepted practice guidelines for treating my disorder (like this example of a guideline for treating depression in children)?

I have not taken time to do a self-analysis of how enamored I am of late with this quote from football coach Lou Holtz:

"Don't tell your problems to people: eighty percent don't care; and the other
twenty percent are glad you have them."

But I think it may have to do with trying to provide public-sector mental health services while living in a state ranked last in the number of uninsured people, and in a county where the indigent population continues to grow while the dollars available for mental health care actually went down.

Clearly the majority of taxpayers in Texas are too overwhelmed with their own issues to focus upon the problems of the poor and the sick.

But, let's re-frame the issue:

We're #1! Texas is first in the number of people without access to health care. If only the UT football team could shine that way. [Well, scratch that last rude comment from this OU grad...]

A reader responds to yesterday's post on the research suggesting variations of OCD:

"My fight with OCD is against contamination obsessions. On one hand I understand
how it's irrational and on the other it is frighteningly real. I have shared
with a fellow contamination OCD sufferer that while I sympathise with a hoarding
OCD person, I just do not identify with their condition - it seems illogical and
my fellow OCD'er agreed with me. He felt the same. "

Thanks to this brave reader for allowing me to share his insight into just how powerful these diseases can be, and how they are even experienced as a collection of disorders.

Yesterday I mentioned the notion that perhaps many of the psychiatric diagnoses we use are too inclusive, and so cover more than one disorder. A recent article, originally in the New York Times, talked about this inexactness of diagnosis in psychiatry.

For example, I see a considerable number of people who are dually diagnosed with mental illness and mental retardation, and I can attest to the unsatisfactory nature of the available diagnostic array in describing what I see in my patients. As the NYT article suggests, I use a lot of "NOS" diagnoses (which stands for "not otherwise specified").

An example of the possibility that we lump disorders together is obsessive-compulsive disorder (OCD). A study in the June edition of the American Journal of Psychiatry suggests that obsessive-compulsives who hoard & save may not be the same as others with OCD, citing a difference in their metabolism of sugar in the brain.

More evidence: in this study in the same journal, OCD patients seemed to have a difference in their dopamine metabolism. That would suggest that antipsychotics would be the best treatment. Yet, right now, medications that impact serotonin (not dopamine) are the first line of treatment for OCD.

From a patient's perspective, the bottomline is this: do not give up after trying the first-line treatment for any psychiatric disorder. It could be that the diagnosis you are going on is just not specific enough to choose the best treatment the first time around.

Nothing I've written here gets more hits than these couple of paragraphs from last August entitled "Why Antidepressants Don't Work."

Hmmm...

Makes me worry that a lot of patients are being misdiagnosed and/or undertreated -- more so the former.

As I said in August, you can be pretty down about a bad marriage or a miserable job or the loss of a loved one -- and typically an antidepressant wont help with any of these. Put another way: there's a difference between unhappiness and clinical depression, and meds don't treat unhappiness.

But a couple of other thoughts, on the assumption that the diagnosis is correct:

First, research is very clear that a combination of medication and psychotherapy works more often than medication alone. Indeed, it may be that psychotherapy is often a better approach. And the definition of psychotherapy here does not include a couple of sessions with the EAP counselor...

And second, there are best practices (like this one) about how to systematically adjust medications to get the best effect from antidepressants. Patients should not give up until every step has been taken.

It all makes me wonder if even "major depression" is a spectrum of disorders, not a single one. More on that tomorrow...

I know there are many mental health patients, and family member of patients, who check in here from time to time. If you live with a mental illness and would like to have the personal blog of your journey considered for inclusion on the "Living with Mental Illness" sidebar, just send along the link.

An experience from the patient's side of the encounter, many of which are expressed on the sidebar sites, is always helpful. Some of the sites belong to family members. Outside of people with mental illness themselves, no one has endured more stigma than the parents of those who suffer from neuropsychiatric disorders like schizophrenia and severe bipolar disorder.

To all the good folks who responded so emphatically and negatively to my comments on how to handle the discovery of marijuana in a teen's car -- some who disagree that the discovery may represent an emerging substance use problem, some who don't buy the notion of its unconscious message (or even an unconscious, for that matter) -- well, all I can say is "denial is bliss."

That is, I am sure that the power of denial can be strong enough to convince a young abuser's family that there is no problem. I am also sure that denial can lead family members to protect the abuser from the consequences of substance abuse.

So while finding marijuana in a youngster's car is not diagnostic of an abuse problem, failing to confront it is a sign of a family capable of falling under the spell of a shared denial.

A reader asks: "Do you have any advice on how to handle my eight-year-old boy's questions about Santa Claus? Will I leave emotional scars if I avoid telling him the truth? Will he grow up thinking I'm a liar?"

If your child is to grow up happily, your greatest task is to help him find meaning in his life. Life can be bewildering and frustrating -- even for an eight-year-old! One of the best sources that children have for finding meaning for their lives is through the heritage of myths and fairy tales.

Myths and fairy tales -- including the story of Saint Nicholas -- aren't lies. Indeed, they are full of meaning and full of truths. And they speak to children at a deeper, more real level than any television show or movie could possibly do.

You know, maturity is not about developing a grown-up view of the world -- a view in which witches don't have special powers, where death cannot be conquered with a kiss, and where there is nothing but snow at the North Pole.

Rather, maturity is when you understand that a "witch's" power can be used for good as well as evil, and that the "kiss" of love can overcome the most brutal tyrant. In maturity, Santa Claus is as real as the spirit that he represents -- the spirit of giving, and the spirit of caring for the poor and for the sick.

Santa is real -- and it does not make you a liar to tell your child that this is so. Instead, it is a sign that you know that a meaningful life can grow from the wisdom and truth condensed into our great myths and fairy tales -- just as sure as the strongest tree grows from the mysterious contents of a tiny seed.

So, when your child asks you about Santa -- tell him that you're a believer! (That's not a lie, is it?) Then, give him the freedom to explore his own thoughts and feelings about Saint Nick. Ask him, "What do you think?" Let his own truth emerge. His life will grow more meaningful through your efforts.