Monday, January 31, 2005
"What if the psychiatrist is wrong?"
Q (well, sort of): "I was scanning through the archives of your blog, and came across your statement about antidepressants: 'Patients should not give up until every step has been taken.'
"Yes, but...Psychiatrists may lead you into saying that you're doing much better, when you're not. Psychiatrists may be so obsessed with finding the magic bullet that they ignore obvious indications that it's not working. Psychiatrists may give up too easily.
"So, what if the psychiatrist is wrong? How is a depressed person suppose to have the energy to argue with him? Oh, well. It's just a whine that's been running around in my head."
Ah, yes. The age-old dilemma of the patient: how to get the message across to the typically narcissistic doc that ain't listening, without pushing the narcissistic buttons that will make the doc so mad that he ignores you even more?
Well, it's not an easy problem -- especially in the course of a ten- to fifteen-minute med check appointment. It'd be easy to tell you to go find another doc -- but aren't most of us docs just as troublesome, anyway? And if you're a public-sector patient, oftentimes you have no choice of docs, anyway.
So, here's my idea (on the assumption that your diagnosis is correct):
Next doc visit, take in a copy of this algorithm (the "steps" to which your quote above refers). Then say to the good doc: "I know you are very busy, and forgive my tiny-bit of knowledge behind this question, but -- can you show me which step of this treatment algorithm we are on with me?"
Then tell him it ain't workin', and that you'd like to move on to the next step...please.
[I've started pulling the algorithms up on the internet during appointments with my patients, especially on complicated cases. I show patients where we are, and what I recommend next.]
Also, dont hesitate to mention your feeling that there is no "simple magic bullet" for depression. In fact, tell him that you've heard that meds work best when combined with psychotherapy, and then ask for both.
Got a doc who gets offended by all this? That's when it's time to hit the road, Jack -- that is, if you even have a choice...
"Yes, but...Psychiatrists may lead you into saying that you're doing much better, when you're not. Psychiatrists may be so obsessed with finding the magic bullet that they ignore obvious indications that it's not working. Psychiatrists may give up too easily.
"So, what if the psychiatrist is wrong? How is a depressed person suppose to have the energy to argue with him? Oh, well. It's just a whine that's been running around in my head."
Ah, yes. The age-old dilemma of the patient: how to get the message across to the typically narcissistic doc that ain't listening, without pushing the narcissistic buttons that will make the doc so mad that he ignores you even more?
Well, it's not an easy problem -- especially in the course of a ten- to fifteen-minute med check appointment. It'd be easy to tell you to go find another doc -- but aren't most of us docs just as troublesome, anyway? And if you're a public-sector patient, oftentimes you have no choice of docs, anyway.
So, here's my idea (on the assumption that your diagnosis is correct):
Next doc visit, take in a copy of this algorithm (the "steps" to which your quote above refers). Then say to the good doc: "I know you are very busy, and forgive my tiny-bit of knowledge behind this question, but -- can you show me which step of this treatment algorithm we are on with me?"
Then tell him it ain't workin', and that you'd like to move on to the next step...please.
[I've started pulling the algorithms up on the internet during appointments with my patients, especially on complicated cases. I show patients where we are, and what I recommend next.]
Also, dont hesitate to mention your feeling that there is no "simple magic bullet" for depression. In fact, tell him that you've heard that meds work best when combined with psychotherapy, and then ask for both.
Got a doc who gets offended by all this? That's when it's time to hit the road, Jack -- that is, if you even have a choice...
Sunday, January 30, 2005
Drug companies, docs and our collective credibility
In a Dan Ratheresque move, The British Medical Journal retracts its story alleging that Lilly withheld information on the potential suicide risk of Prozac.
And Psychiatric News reports efforts to reanalyze the original data on the risk, with folks now saying that the "initial relationship [between antidepressants and suicide] went away" after such an analysis.
So, are the warning labels on these medications warranted?
My opinion on this is unchanged: antidepressants save lives. Efforts to restrict their accessibility are more concerned with collecting attorney fees than with collective patient outcomes.
But I am struck by what appears to be various sorts of (psychologically-speaking) "undoing" by many of those involved in the academic-industry relationship, a defense mechanism invoked only now, while the controversy appears to have been around for at least 20 years. That is, after years and years of tolerance of an increasingly cozy relationship between "a great profession and the forces of capitalism," the efforts at distancing coming this late in the game seem reactive.
My worry is that the public recognizes this, that it actually exacerbates a crisis of confidence among those we serve, and thus threatens the trust that physicians have worked so hard to earn over the past century.
And it troubles me greatly that any mistrust might grow from (of all things) our financial investment in the development of new drugs. Because I'm with Sir William Osler on that issue:
And Psychiatric News reports efforts to reanalyze the original data on the risk, with folks now saying that the "initial relationship [between antidepressants and suicide] went away" after such an analysis.
So, are the warning labels on these medications warranted?
My opinion on this is unchanged: antidepressants save lives. Efforts to restrict their accessibility are more concerned with collecting attorney fees than with collective patient outcomes.
But I am struck by what appears to be various sorts of (psychologically-speaking) "undoing" by many of those involved in the academic-industry relationship, a defense mechanism invoked only now, while the controversy appears to have been around for at least 20 years. That is, after years and years of tolerance of an increasingly cozy relationship between "a great profession and the forces of capitalism," the efforts at distancing coming this late in the game seem reactive.
My worry is that the public recognizes this, that it actually exacerbates a crisis of confidence among those we serve, and thus threatens the trust that physicians have worked so hard to earn over the past century.
And it troubles me greatly that any mistrust might grow from (of all things) our financial investment in the development of new drugs. Because I'm with Sir William Osler on that issue:
Trust is critical. For ours is a profession that treats people, not diseases."The young physician starts life with 20 drugs for each disease, and the old
physician ends life with one drug for 20 diseases."
Saturday, January 29, 2005
Herbs, spells, massage -- and denial
Q: "Obviously no herbs or laying-on-of-hands or 'spells' are going to help psychosis or schizophrenia. But have you seen any studies or anecdotal evidence that mild herbs (such as chamomile and lavender) or meditation or massage therapy would have added benefit to a more conventional treatment plan?"
I'm not up on the literature on the evidence for (or against) unconventional treatments. However, I've seen plenty of "anecdotal evidence," in the form of single cases, where an unusual intervention was helpful. So I never rule out much of anything as potentially helpful, nowadays.
Unfortunately, it is much more common for patients to put their faith in an unorthodox treatment as a form of emotional denial about the illness they have. So, it is hard for me to endorse any such interventions, for fear of reinforcing that sort of denial.
I've just had too many cases of severe, debilitating psychiatric disorders in which the patient spent months or years trying herbs and pseudotherapists and the like -- only to be relieved of symptoms within weeks once permitting themselves to receive "conventional" care.
Wish they'd have come to me sooner...
I'm not up on the literature on the evidence for (or against) unconventional treatments. However, I've seen plenty of "anecdotal evidence," in the form of single cases, where an unusual intervention was helpful. So I never rule out much of anything as potentially helpful, nowadays.
Unfortunately, it is much more common for patients to put their faith in an unorthodox treatment as a form of emotional denial about the illness they have. So, it is hard for me to endorse any such interventions, for fear of reinforcing that sort of denial.
I've just had too many cases of severe, debilitating psychiatric disorders in which the patient spent months or years trying herbs and pseudotherapists and the like -- only to be relieved of symptoms within weeks once permitting themselves to receive "conventional" care.
Wish they'd have come to me sooner...
Friday, January 28, 2005
this & that
** Facial trauma patients should be screened for psychiatric disorders. A study showed significantly higher rates of depression, anxiety, hostility and phobic and obsessive-compulsive tendencies than a control group -- probably because of the high rate of physical violence involved in the injuries.
** Mobile medical units have provided counseling for about 4,000 tsunami victims in Thailand, so far...
** ...while in Indonesia, The World Health Organization says as many as 500,000 people could be facing some form of mental distress. [That's five hundred thousand...]
** In Oregon, Senate Bill 40 would no longer consider such behavior as voyeurism, exhibitionism and fetishism as mental diseases for which the insanity plea could be used. "Salem Hospital isn't equipped to treat such offenders..."
** ...and the Conservative Voice claims that labeling "behavior problems" like pedophilia as mental disorders is just "psychiatry poking its nose into social policy." [So to speak...]
** A Mass school district moves ahead with a campaign to demystify and destigmatize mental health issues through a new education program. "We are not trying to turn teachers into mental health professionals, but we are trying to help them recognize the early warning signs and where there is a problem.."
** Think such programs are not needed?
** And finally, if you think psychiatry is not among the big-bucks specialties: think again...
** Mobile medical units have provided counseling for about 4,000 tsunami victims in Thailand, so far...
** ...while in Indonesia, The World Health Organization says as many as 500,000 people could be facing some form of mental distress. [That's five hundred thousand...]
** In Oregon, Senate Bill 40 would no longer consider such behavior as voyeurism, exhibitionism and fetishism as mental diseases for which the insanity plea could be used. "Salem Hospital isn't equipped to treat such offenders..."
** ...and the Conservative Voice claims that labeling "behavior problems" like pedophilia as mental disorders is just "psychiatry poking its nose into social policy." [So to speak...]
** A Mass school district moves ahead with a campaign to demystify and destigmatize mental health issues through a new education program. "We are not trying to turn teachers into mental health professionals, but we are trying to help them recognize the early warning signs and where there is a problem.."
** Think such programs are not needed?
** And finally, if you think psychiatry is not among the big-bucks specialties: think again...
Wednesday, January 26, 2005
Another critique of single-payer...
...is in this book reviewed in JAMA. It focuses on the "myth" of administrative cost savings in a national health plan. It also refutes the claim that outcomes are better in national health plans, at least for chronic disorders.
The authors argue for a better division of direct and third-party payment, a proposal with which I agree, as I believe we need to figure out how to have patients pay for more of their healthcare directly as a way to drive down the cost and improve outcomes at the same time.
Employers should empower their employees by giving them (not insurance companies) the money to buy their medical care.
The authors argue for a better division of direct and third-party payment, a proposal with which I agree, as I believe we need to figure out how to have patients pay for more of their healthcare directly as a way to drive down the cost and improve outcomes at the same time.
Employers should empower their employees by giving them (not insurance companies) the money to buy their medical care.
Tuesday, January 25, 2005
Prozac as a way of life...
...is the title of a book reviewed here in JAMA. The book looks at the social perception that "Prozac (is) elective 'enhancement technology' for normals rather than medical treatment for suffering patients. " And apparently most of the authors who wrote articles for the book agree:
"Most assume that [Prozac]...threatens healthy social alienation, authenticity, Emersonian self-reliance, mysticism, or existential angst. Prozac is likened to spiritual cheating: authors consider self-advancement through studious work, philosophy, or psychotherapy [to be] noble, but pills [are] an unfair shortcut."
Where does that "social perception" come from? It makes me wonder if the marketing of antidepressants for such a broad array of problems has somehow added to the perception that even truly debilitating disorders like major depression are really just personal faults.
Monday, January 24, 2005
this & that
** "Mephistopheles said, 'The older you get, the more you learn how the devil works.' That's how schizophrenia is: The older you get, the more you understand how it works." Words of wisdom on how to live with schizophrenia from Sam Irvin, Mental Health Association of Licking County's Consumer of the Year.
** In post-tsunami Sri Lanka, they are learning about depression, although they did not even have a word for "depression" until recent years.
** In Oregon, NAMI members let legislators really know how it feels to be psychotic.
** Lacking enough mental health services, kids in California are stuck in jails, instead. [Not much different than in Dorothea Dix's day, is it?]
** A neat article on docs who live and work with a disability: "You have to do better than average to be accepted...In a sense that's wrong, and everyone should be weighed on the same scale, but the truth is you do have to do better. That's the way it is."
** And finally...
** In post-tsunami Sri Lanka, they are learning about depression, although they did not even have a word for "depression" until recent years.
** In Oregon, NAMI members let legislators really know how it feels to be psychotic.
** Lacking enough mental health services, kids in California are stuck in jails, instead. [Not much different than in Dorothea Dix's day, is it?]
** A neat article on docs who live and work with a disability: "You have to do better than average to be accepted...In a sense that's wrong, and everyone should be weighed on the same scale, but the truth is you do have to do better. That's the way it is."
** And finally...
Do you suffer from seasonal affective disorder?
Sunday, January 23, 2005
Maintaining the parental blame game
"Throughout last summer and into the fall the news crept across websites and spilled onto talk radio: The Bush administration was planning to screen every American child for mental-health problems and put those deemed in need of help on powerful psychotropic drugs. Parental rights would be taken away, and the stigma of mental illness would stain the school records of innocent children..." Thus begins an article in January 20th edition of the Christian Science Monitor.
And who can blame the folks (like here & here) who are concerned?
After all, on the one hand we have British Medical Journal data leading to suggestions of a conspiracy to conceal the adverse effects of Prozac on children, and on the other hand we have Psychiatric News reports of work well under way to refute the data ("...we tried to tease out as much as we could... and when we did, that initial relationship [between antidepressants and suicide] went away.")
Put together, it just fuels the flames of cynicism. What's a parent to believe?
Screening children for severe emotional disorders should be no more controversial than screening for vision or hearing problems. Appropriate interventions -- counseling, training, and even medication -- should be no more controversial than a pair of glasses or a 10-day course of antibiotics.
So why is the New Freedom Commission's recommendation (which, by the way, does not call for widespread use of medications) stirring such a fuss?
I believe it's because it also stirs up a major worry of every good parent: have I done something wrong that hurt my child? After all (in the words of one critic of the screening recommendation), "Who knows a child better than his or her parents?"
Well, no one.
But why should a parent be expected to "know" about a severe emotional disorder any more than about poor vision or the cause of a sore throat? Because severe emotional disorders are not "bad parent" disorders, any more so than nearsightedness or Strep throat.
Why does the New Freedom Commission rec stir up such a fuss? One word answer: stigma.
In the words of one who lives with a mental disorder: "people don't feel like they've failed if they have asthma or diabetes, why should those of us who suffer from mental illness feel that, somehow, all we are is "crazy?"
Likewise, why must the thought of screening and discovery of a childhood disorder lead parents to feel like they've failed?
And who can blame the folks (like here & here) who are concerned?
After all, on the one hand we have British Medical Journal data leading to suggestions of a conspiracy to conceal the adverse effects of Prozac on children, and on the other hand we have Psychiatric News reports of work well under way to refute the data ("...we tried to tease out as much as we could... and when we did, that initial relationship [between antidepressants and suicide] went away.")
Put together, it just fuels the flames of cynicism. What's a parent to believe?
Screening children for severe emotional disorders should be no more controversial than screening for vision or hearing problems. Appropriate interventions -- counseling, training, and even medication -- should be no more controversial than a pair of glasses or a 10-day course of antibiotics.
So why is the New Freedom Commission's recommendation (which, by the way, does not call for widespread use of medications) stirring such a fuss?
I believe it's because it also stirs up a major worry of every good parent: have I done something wrong that hurt my child? After all (in the words of one critic of the screening recommendation), "Who knows a child better than his or her parents?"
Well, no one.
But why should a parent be expected to "know" about a severe emotional disorder any more than about poor vision or the cause of a sore throat? Because severe emotional disorders are not "bad parent" disorders, any more so than nearsightedness or Strep throat.
Why does the New Freedom Commission rec stir up such a fuss? One word answer: stigma.
In the words of one who lives with a mental disorder: "people don't feel like they've failed if they have asthma or diabetes, why should those of us who suffer from mental illness feel that, somehow, all we are is "crazy?"
Likewise, why must the thought of screening and discovery of a childhood disorder lead parents to feel like they've failed?
Saturday, January 22, 2005
elsewhere
** Is attention-seeking bad, wonders Talitha? I dont know, but..
** ...my favorite quote on the topic comes from intueri's post, skirts: “If you keep hiding your assets, no one is going to notice them—including you.”
** Gail at The Right Coast reports that San Diego has a lower-than-you'd expect rate of mental illness, especially compared to the rest of Cal.
** Both The John and Ken Show and Untergeek worry that Congress might actually implement the President's New Freedom Commission's recommendations to improve the nation's mental health. [Not to worry. The DC types aren't willing to pay for it.]
** Perhaps they share Dr Chodoff's concern, posted by Rebel Doctor.
** Put another way, "there's this modern tendency to overmedicalize everything and to treat a rambunctious child ... or a sullen child as mentally ill when that's just his personality or he's a high-strung kid," Mr. Deist says. "We would rather be accused of being alarmist than just stand back and let this gather quiet momentum." [Unfortunately, the tendency right now is towards under-diagnosis for most disorders, not over-diagnosis.]
** The route to psychotherapy substitutes is apparently through Cymbalta's website. [When meds dont work it's because they cant fix a misery-making marriage or job or life. They work if the problem is in the brain. Even then, they work best when combined with psychotherapy.]
** And finally, "people don’t feel like they’ve failed if they have asthma or diabetes, why should those of us who suffer from mental illness feel that, somehow, all we are is “crazy?” [Why? One word: Stigma...]
** ...my favorite quote on the topic comes from intueri's post, skirts: “If you keep hiding your assets, no one is going to notice them—including you.”
** Gail at The Right Coast reports that San Diego has a lower-than-you'd expect rate of mental illness, especially compared to the rest of Cal.
** Both The John and Ken Show and Untergeek worry that Congress might actually implement the President's New Freedom Commission's recommendations to improve the nation's mental health. [Not to worry. The DC types aren't willing to pay for it.]
** Perhaps they share Dr Chodoff's concern, posted by Rebel Doctor.
** Put another way, "there's this modern tendency to overmedicalize everything and to treat a rambunctious child ... or a sullen child as mentally ill when that's just his personality or he's a high-strung kid," Mr. Deist says. "We would rather be accused of being alarmist than just stand back and let this gather quiet momentum." [Unfortunately, the tendency right now is towards under-diagnosis for most disorders, not over-diagnosis.]
** The route to psychotherapy substitutes is apparently through Cymbalta's website. [When meds dont work it's because they cant fix a misery-making marriage or job or life. They work if the problem is in the brain. Even then, they work best when combined with psychotherapy.]
** And finally, "people don’t feel like they’ve failed if they have asthma or diabetes, why should those of us who suffer from mental illness feel that, somehow, all we are is “crazy?” [Why? One word: Stigma...]
Friday, January 21, 2005
this & that
** "We do not wish to alarm the public, but we need to make them aware of and alert them to potential dangers..." This from the Lancashire police about a psychiatric patient who left a hospital where he was being treated. Police were concerned about his potential for "increasingly unpredictable behavior." [Geez, stigma...I can think of a lot of people with unpredictable behavior who have never been diagnosed or hospitalized, let alone reported in the new media.]
** Then again...
** On the other hand, half of people who die in police custody have mental illness.
** And being a policeman is stressful. Two Chinese policeman commit suicide, leading to concern about the job's stress.
** And finally, here in Texas we gave up over $100 million in health care services to children by refusing to match federal funding. "I regret that another significant allotment of Texas taxpayer dollars that could have helped local governments pay for their health care bills has again been voluntarily forfeited," said Sen. Hutchison, a member of the Senate Appropriations subcommittee on health and human services. "As a simple matter of fiscal conservatism, this does not make sense." [Nor does it make sense in lots of other ways...]
** Then again...
** On the other hand, half of people who die in police custody have mental illness.
** And being a policeman is stressful. Two Chinese policeman commit suicide, leading to concern about the job's stress.
** And finally, here in Texas we gave up over $100 million in health care services to children by refusing to match federal funding. "I regret that another significant allotment of Texas taxpayer dollars that could have helped local governments pay for their health care bills has again been voluntarily forfeited," said Sen. Hutchison, a member of the Senate Appropriations subcommittee on health and human services. "As a simple matter of fiscal conservatism, this does not make sense." [Nor does it make sense in lots of other ways...]
Tuesday, January 18, 2005
Not all panic is psychological
Q: "I wondered what you thought of the growing evidence that panic disorder is linked to mitral valve prolapse. I run across people who have been in treatment for panic disorder only to learn that their symptoms are because of the mitral valve prolapse. Are people in psychiatry aware of this connection? "
A few days ago I used dizziness as an example of a symptom that is common in many disorders, both psychiatric and non-psychiatric. Anxiety is another example. (Here, under "differential diagnosis," is a list of causes of anxiety/panic.)
One of my favorite stories from my residency (a long, long time ago in a place far, far away...) was being called down to the ER by the internal medicine chief resident to evaluate "hallucinations" in a patient who was agitated, strapped to the gurney on which the paramedics had brought him.
"This is organic," I said to the chief resident after a few minutes, meaning that the problem was something physiological, not "mental." The chief resident gave the patient sugar by IV, and his "hallucinations" cleared in a few minutes, along with his agitation. He was a diabetic in crisis from low blood sugar.
Hallucinations, paranoia, depression, mania, anxiety -- I've seen all of these caused by medications, all of them caused by street drugs, all of them caused by a medical disorder.
So, a good psychiatric evaluation should always include a search for medical problems that can cause the psychiatric symptoms. Most people in psychiatry do, indeed, look for those connections.
A few days ago I used dizziness as an example of a symptom that is common in many disorders, both psychiatric and non-psychiatric. Anxiety is another example. (Here, under "differential diagnosis," is a list of causes of anxiety/panic.)
One of my favorite stories from my residency (a long, long time ago in a place far, far away...) was being called down to the ER by the internal medicine chief resident to evaluate "hallucinations" in a patient who was agitated, strapped to the gurney on which the paramedics had brought him.
"This is organic," I said to the chief resident after a few minutes, meaning that the problem was something physiological, not "mental." The chief resident gave the patient sugar by IV, and his "hallucinations" cleared in a few minutes, along with his agitation. He was a diabetic in crisis from low blood sugar.
Hallucinations, paranoia, depression, mania, anxiety -- I've seen all of these caused by medications, all of them caused by street drugs, all of them caused by a medical disorder.
So, a good psychiatric evaluation should always include a search for medical problems that can cause the psychiatric symptoms. Most people in psychiatry do, indeed, look for those connections.
Monday, January 17, 2005
this & that
** "The emotions experienced by women after the break-up of a romantic relationship can change their brains," according to new research reported here.
** A Miami-based psychiatrist is "the nation's foremost practitioner of past-life regression therapy," and believes that his patients can recover memories from previous incarnations. [Most in the psychiatry biz are pretty skeptical about "recovered memories" from childhood, let alone from previous lives...]
** Held involuntarily for twelve years, Rodney Yoder gains his freedom from jail by arguing the myth of mental illness. [Some in the psychiatry biz might argue the myth of his original diagnosis, at least...]
** "More Europeans take their own lives each year than have them claimed in traffic accidents or murders," leading the World Health Organization to sponsor a conference to tackle the problem. "Of the ten countries with the highest rate of suicide in the world, nine are in Europe."
** The societal denial about the link between marijuana use and "heavier" drug use, schizophrenia and depression is "putting millions of young people's mental health at risk." [I've mentioned before my anecdotal experience about the way pot affects teens.]
**And finally, others express the concern I wrote about here, regarding the influence of drug companies on academia. "A simple motivation can give companies the upper hand..."
** A Miami-based psychiatrist is "the nation's foremost practitioner of past-life regression therapy," and believes that his patients can recover memories from previous incarnations. [Most in the psychiatry biz are pretty skeptical about "recovered memories" from childhood, let alone from previous lives...]
** Held involuntarily for twelve years, Rodney Yoder gains his freedom from jail by arguing the myth of mental illness. [Some in the psychiatry biz might argue the myth of his original diagnosis, at least...]
** "More Europeans take their own lives each year than have them claimed in traffic accidents or murders," leading the World Health Organization to sponsor a conference to tackle the problem. "Of the ten countries with the highest rate of suicide in the world, nine are in Europe."
** The societal denial about the link between marijuana use and "heavier" drug use, schizophrenia and depression is "putting millions of young people's mental health at risk." [I've mentioned before my anecdotal experience about the way pot affects teens.]
**And finally, others express the concern I wrote about here, regarding the influence of drug companies on academia. "A simple motivation can give companies the upper hand..."
Sunday, January 16, 2005
When Ritalin doesn't work
Q: "The school said my 7-year-old is hyperactive, so our family doctor put him on Ritalin. His behavior at school did not get better, so we were referred to a psychiatrist. The psychiatrist added a second medicine, and then a third but the school still complains about him not doing what he is told and talking back and getting into fights. We are worried about how much medicine he is on, and we dont know what to do next..."
Ritalin, nor any other medication, will help the behavior problems that you describe. Ritalin is a medication that helps children with attention deficits to concentrate better. It is not a good-behavior pill.
As I have said before, attention deficit disorder (ADHD) is overdiagnosed. The symptoms that you describe sound more like "oppositional defiant disorder (ODD)." Counseling, behavior management and parenting skills training work better than medication for ODD.
In fact, even if the child's diagnosis is truly ADHD, alternative strategies like programs combining medication and behavior management are likely to be most successful.
Ritalin, nor any other medication, will help the behavior problems that you describe. Ritalin is a medication that helps children with attention deficits to concentrate better. It is not a good-behavior pill.
As I have said before, attention deficit disorder (ADHD) is overdiagnosed. The symptoms that you describe sound more like "oppositional defiant disorder (ODD)." Counseling, behavior management and parenting skills training work better than medication for ODD.
In fact, even if the child's diagnosis is truly ADHD, alternative strategies like programs combining medication and behavior management are likely to be most successful.
Saturday, January 15, 2005
elsewhere...
** BU takes a screening test and now is worried that her cleanliness has turned into diagnosable OCD.
** Post-tsunami ghost sightings are considered a form of PTSD by mental health workers -- but are they something else?
** A psychotherapist in Sri Lanka shares photos.
** geena talks of a situation when its the family that needs the treatment -- and sometimes the staff.
** There is a new psychiatrist blog.
** Saint Nate gives his descriptions of some favorite med bloggers.
** The notion persists that escalating healthcare costs are about technology or innovation or high utilization or the like (when it's really because the patient is not the customer).
** Finally, "there is no psychiatrist in the world like a puppy licking your face," and other advantages of dog over man.
** Post-tsunami ghost sightings are considered a form of PTSD by mental health workers -- but are they something else?
** A psychotherapist in Sri Lanka shares photos.
** geena talks of a situation when its the family that needs the treatment -- and sometimes the staff.
** There is a new psychiatrist blog.
** Saint Nate gives his descriptions of some favorite med bloggers.
** The notion persists that escalating healthcare costs are about technology or innovation or high utilization or the like (when it's really because the patient is not the customer).
** Finally, "there is no psychiatrist in the world like a puppy licking your face," and other advantages of dog over man.
Friday, January 14, 2005
this & that
** In Thailand, over 5000 people have sought post-tsunami psychiatric help. "Most of the complaints coming in are for stress, insomnia, fear, guilt and confusion, with some survivors refusing to go anywhere near the sea," according to Dr. Wachira Phengchan.
** Meanwhile, Indonesia is "launching its biggest mental health drive yet for traumatised tsunami survivors, many of whom have never heard of counseling before."
** The story of the stigma-bear from Vermont is everywhere (like here), but the best editorial is at Shrinkette.
** A Texas rule that had required doctors to report drug-abusing pregnant women to Child Protective Services as unborn-child abusers was struck down. [A big relief to many docs down here who were worried about the choice between prosecution for failure to report and a lawsuit for breach of confidentiality.]
** "Special services available for children are just appalling in many respects, as are those available for homeless people, for prisoners, for other marginalised groups...Right across the board, I think the Government itself has conceded that services available are patchy, poorly co-ordinated and severely under-resourced." That's a comment on mental healthcare in Ireland [but it sounds familiar].
** Stigma in England, in the form of the ol "not in my back yard" problem: "This is in the centre of our community on a totally unsuitable site, 200 yards from a primary school." [I guess people with mental illness are to be marginalized -- literally?]
** No wonder, then, that "only 70 of 315 patients at the psychiatric hospital in the capital town of Banda Aceh stayed put, as hospital staff rushed to open the gate wide so that patients could flee when the tsunamis hit." No word on the fate of those who fled.
** And finally, Prozac aint so hot for not-so-severe depression in the elderly, suggesting that "treatments effective for young adult dysthymic patients may not be as useful in elderly dysthymic patients."
** Meanwhile, Indonesia is "launching its biggest mental health drive yet for traumatised tsunami survivors, many of whom have never heard of counseling before."
** The story of the stigma-bear from Vermont is everywhere (like here), but the best editorial is at Shrinkette.
** A Texas rule that had required doctors to report drug-abusing pregnant women to Child Protective Services as unborn-child abusers was struck down. [A big relief to many docs down here who were worried about the choice between prosecution for failure to report and a lawsuit for breach of confidentiality.]
** "Special services available for children are just appalling in many respects, as are those available for homeless people, for prisoners, for other marginalised groups...Right across the board, I think the Government itself has conceded that services available are patchy, poorly co-ordinated and severely under-resourced." That's a comment on mental healthcare in Ireland [but it sounds familiar].
** Stigma in England, in the form of the ol "not in my back yard" problem: "This is in the centre of our community on a totally unsuitable site, 200 yards from a primary school." [I guess people with mental illness are to be marginalized -- literally?]
** No wonder, then, that "only 70 of 315 patients at the psychiatric hospital in the capital town of Banda Aceh stayed put, as hospital staff rushed to open the gate wide so that patients could flee when the tsunamis hit." No word on the fate of those who fled.
** And finally, Prozac aint so hot for not-so-severe depression in the elderly, suggesting that "treatments effective for young adult dysthymic patients may not be as useful in elderly dysthymic patients."
Thursday, January 13, 2005
Nature nurture, again
Can't resist revisiting the issue of environmental factors in the development of mental health disorders after spending more time with the Michael Rutter article I first mentioned here.
The article is completely full of references to research studies that demonstrate that there are, indeed, environmental factors at work. (Here is the review article.)
** When Moms use a lot of "negative expressed emotion" with their toddlers, it appears to lead to behavior problems (by teacher report) when the kids get to grade school.
** Moms who are depressed seem to have kids with behavior problems, too, but only when the depression occurred after the child's birth.
** Take a child out of a high-risk environment and place her in an adoptive home, and many areas of development improve, including IQ.
** Find a good marriage partner for an antisocial teen, and the behavior often gets better. Or, send him to the army and the same improvement often happens.
Most of these studies point to the fact that something changes in the brain in response to stressors in the environment. Put another way, genes make you vulnerable to a disorder and a risky environment switches on the genes.
But (in Dr Rutter's words) "the effects of such risky environments are quite small in the absence of genetic susceptibility."
The article is completely full of references to research studies that demonstrate that there are, indeed, environmental factors at work. (Here is the review article.)
** When Moms use a lot of "negative expressed emotion" with their toddlers, it appears to lead to behavior problems (by teacher report) when the kids get to grade school.
** Moms who are depressed seem to have kids with behavior problems, too, but only when the depression occurred after the child's birth.
** Take a child out of a high-risk environment and place her in an adoptive home, and many areas of development improve, including IQ.
** Find a good marriage partner for an antisocial teen, and the behavior often gets better. Or, send him to the army and the same improvement often happens.
Most of these studies point to the fact that something changes in the brain in response to stressors in the environment. Put another way, genes make you vulnerable to a disorder and a risky environment switches on the genes.
But (in Dr Rutter's words) "the effects of such risky environments are quite small in the absence of genetic susceptibility."
Wednesday, January 12, 2005
"Family therapy" for medical errors
In business school, Toyota's quality management approach is held up as a shining example. The story goes like this: anyone on the Toyota assembly line is allowed to shut down the whole line if he sees an error in someone else's work as it passes by his station.
That is, there is a collective sense of responsibility for reducing errors. Why is there not the same collective process and ownership in medicine?
In a review by Dr David Bates, he cites earlier work suggesting that doctors have a "guilt culture" around errors, instead of a "we're in this together" mentality like Toyota. That is:
That is, there is a collective sense of responsibility for reducing errors. Why is there not the same collective process and ownership in medicine?
In a review by Dr David Bates, he cites earlier work suggesting that doctors have a "guilt culture" around errors, instead of a "we're in this together" mentality like Toyota. That is:
"the medical approach (is) focused on who made the error so that that person (can) be punished."Instead, medicine needs to:
"concentrat(e) on the system factors that made it possible for well-trained, well-intentioned practitioners to commit errors" because "substituting a system approach for a 'find the culprit' approach has paid off impressively" in other businesses.
It's sort of like the approach that a family therapist takes. When a family presents for treatment, someone is always identified to the therapist as the bad family member. It's either a child with behavior problems or a dad who is drinking, or the like. But family therapists know that the "identified patient" is just showing that there is a problem in the family system. To stop the bad behavior or the drinking, you have to treat the larger problem.
Likewise, doctors need to understand that the goal should be to identify the problem within the "hospital family" that leads to medical errors, instead of having an identified bad-doctor in the hospital family.
For example, most medical errors are medication-related, so "the focus should be on error-prone factors in the medication delivery process: prescription, transcription, dispensing, administration, and monitoring pharmacotherapy."
By the way, medical errors are a problem in psychiatry, too. Dr Benjamin Grasso notes that one out of four hospital admissions is for a psychiatric problem. So, a lot of psychiatric patients are at risk. The problem is made worse because of the powerful nature of the medications used in psychiatry, and because poor adherence to medication regimen is a common cause of psychiatric hospitalizations.
Tuesday, January 11, 2005
Is some depression normal in the new mom?
Q: "I've been reading the news stories about women with postpartum depression and it makes me wonder if I have it. It's not that I want to hurt my baby, but I do think I have other symptoms. Ever since my baby was born I've felt tired. I look terrible, too, and when I look at myself in the mirror I just start crying and wishing that someone would help me. Does that sound like postpartum depression to you?"
Caring for a new baby is emotionally and physically draining even in the best of circumstances. Mood swings and fatigue are to be expected during this stressful time. In fact, almost all new mothers experience this. New mothers need to call upon family and friends to provide support during the adjustment period. So, my first thought is that you should muster up your support network.
However, postpartum depression does include many of the symptoms that you describe. And it is very common: one out of every ten new mothers gets it. So if your crying spells, low energy and poor self-esteem persist even when you have the support you need, then I encourage you to see a psychiatrist to see if you might, indeed, have this disorder.
Caring for a new baby is emotionally and physically draining even in the best of circumstances. Mood swings and fatigue are to be expected during this stressful time. In fact, almost all new mothers experience this. New mothers need to call upon family and friends to provide support during the adjustment period. So, my first thought is that you should muster up your support network.
However, postpartum depression does include many of the symptoms that you describe. And it is very common: one out of every ten new mothers gets it. So if your crying spells, low energy and poor self-esteem persist even when you have the support you need, then I encourage you to see a psychiatrist to see if you might, indeed, have this disorder.
Monday, January 10, 2005
This & that
** "The final step in the suppression of psychiatry," says an Indiana psychiatrist in an editorial, "was the pretense that primary-care physicians could take over most functions of a psychiatrist."
** Mental health parity has been extended as part of the Working Families Tax Relief Act signed into law at the end of last year. [Of course, with special copays and deductibles still in place, there really isnt parity, at all...]
** A Japanese study says that while "...for a woman, nothing can be worse than being told that she has put on weight," such is not the case with men, for whom "...jibes about weight and body shape tend to simply bounce off..." [Literally, I imagine.]
** Britain shuts down a mental health helpline (called Saneline) that was serving "thousands of Britain's most desperate and isolated people." [These sorts of money-saving moves actually end up increasing costs. Cheaper to fund a helpline, or a bigger ER?]
** A Sri Lankan psychiatrist, an expert in war-induced trauma, cautions against the proposed seawall to protect against tsunamis (ala the one in Galveston that followed the great hurricane of 1900), saying it will "alienate the people from the sea," and that "the fear of the sea created by the tsunami would get entrenched." He advises counseling, instead.
** Perceiving the need to be at least that great, India is willing to train 26,000 volunteers to provide counseling to tsunami victims.
** And finally, a psychiatrist was among those killed by the tsunami on Thailand.
** Mental health parity has been extended as part of the Working Families Tax Relief Act signed into law at the end of last year. [Of course, with special copays and deductibles still in place, there really isnt parity, at all...]
** A Japanese study says that while "...for a woman, nothing can be worse than being told that she has put on weight," such is not the case with men, for whom "...jibes about weight and body shape tend to simply bounce off..." [Literally, I imagine.]
** Britain shuts down a mental health helpline (called Saneline) that was serving "thousands of Britain's most desperate and isolated people." [These sorts of money-saving moves actually end up increasing costs. Cheaper to fund a helpline, or a bigger ER?]
** A Sri Lankan psychiatrist, an expert in war-induced trauma, cautions against the proposed seawall to protect against tsunamis (ala the one in Galveston that followed the great hurricane of 1900), saying it will "alienate the people from the sea," and that "the fear of the sea created by the tsunami would get entrenched." He advises counseling, instead.
** Perceiving the need to be at least that great, India is willing to train 26,000 volunteers to provide counseling to tsunami victims.
** And finally, a psychiatrist was among those killed by the tsunami on Thailand.
Sunday, January 09, 2005
Recent posts by people living with mental illness
Experience mental illness firsthand through these brave posts by people who live with it every day:
Zakk describes his fight with recent symptoms of his obsessive compulsive disorder.
Jamie talks about the impact that paranoid symptoms had on a holiday gathering.
Blonzila describes the anxiety that an internet search of medication side effects can elicit.
Ewschott talks about the catch-22 for people who try to hold a job while suffering from a chronic relapsing disease -- and its impact on family.
Grumpy Old Man re-posts a description of a not-uncommon way that the chronic mentally ill survive on the streets.
Waveriding wonders about the "bliss" felt during two stays on a psychiatric ward.
And finally, eeyore-na shares with her psychiatrist her discovery of the true cause of her depression...
Take time to visit other weblogs by those living with mental illness, listed in the sidebar.
Zakk describes his fight with recent symptoms of his obsessive compulsive disorder.
Jamie talks about the impact that paranoid symptoms had on a holiday gathering.
Blonzila describes the anxiety that an internet search of medication side effects can elicit.
Ewschott talks about the catch-22 for people who try to hold a job while suffering from a chronic relapsing disease -- and its impact on family.
Grumpy Old Man re-posts a description of a not-uncommon way that the chronic mentally ill survive on the streets.
Waveriding wonders about the "bliss" felt during two stays on a psychiatric ward.
And finally, eeyore-na shares with her psychiatrist her discovery of the true cause of her depression...
Take time to visit other weblogs by those living with mental illness, listed in the sidebar.
Saturday, January 08, 2005
Amidst the devastation, a psychiatrist serves
"He is a father, husband, and the only psychiatrist for 1.3 million of the world's most traumatized people. "
Thus begins an article in Thursday's Washington Post about the role of one psychiatrist in post-tsunami Sri Lanka. But perhaps his role right now is not what you imagine...
Yesterday I mentioned the sacrifice of self that seems inherent in a willingness to care for the psychological needs of those traumatized by a disaster. But back in 1999, this psychiatrist had already sacrificed a well-paying job in England to return to his homeland, willing to care for the needs of a people traumatized by 20 years of war.
He had already signed up to care for a people with the highest suicide rate in the world, victims of domestic abuse, victims of torture, victims of PTSD from every sort of insult imaginable in the midst of a civil war.
Then the tsunami came...
Now "...to talk about psychological needs when you've got thousands of people using one toilet in a refugee camp -- it's absurd."
So he serves as a general practitioner: passes out antibiotics, pain medication and first aid supplies. And sometimes he is a pathologist, of sorts, "tossing dozens of corpses into the back of his pickup..."
If nothing else, his painful story lends some perspective to complaints of high caseloads and barriers-to-care experienced by psychiatrists (like me) who work in this country's public mental health system. Can't ever recall my caseload getting to 1.3 million...
Thus begins an article in Thursday's Washington Post about the role of one psychiatrist in post-tsunami Sri Lanka. But perhaps his role right now is not what you imagine...
Yesterday I mentioned the sacrifice of self that seems inherent in a willingness to care for the psychological needs of those traumatized by a disaster. But back in 1999, this psychiatrist had already sacrificed a well-paying job in England to return to his homeland, willing to care for the needs of a people traumatized by 20 years of war.
He had already signed up to care for a people with the highest suicide rate in the world, victims of domestic abuse, victims of torture, victims of PTSD from every sort of insult imaginable in the midst of a civil war.
Then the tsunami came...
Now "...to talk about psychological needs when you've got thousands of people using one toilet in a refugee camp -- it's absurd."
So he serves as a general practitioner: passes out antibiotics, pain medication and first aid supplies. And sometimes he is a pathologist, of sorts, "tossing dozens of corpses into the back of his pickup..."
If nothing else, his painful story lends some perspective to complaints of high caseloads and barriers-to-care experienced by psychiatrists (like me) who work in this country's public mental health system. Can't ever recall my caseload getting to 1.3 million...
Friday, January 07, 2005
Tsunami PTSD
The Singapore News carried a story yesterday that describes "the first in Galle (Sri Lanka) to be treated for post-traumatic stress disorder." The patients:
The article also notes the vulnerability of relief workers to acute mental disorders. It brings to mind a friend trained in short-term counseling for disaster survivors who returned from a post-9/11 stint in New York looking about as depressed as anyone I have ever seen. In my mind, he turned from volunteer to another victim of that disaster.
(Jan 9th update: I just came across an article in this week's JAMA that says 51% of post-9/11 volunteers had mental health issues on screening instruments.)
...were banging their heads against the walls. Some were just staring vacantly, while others were mumbling "the sea is coming."While I'm not sure I agree with the diagnosis (instead I'd go with the psychiatrist quoted as saying it is "grief...of abnormal proportion"), regardless there will be a significant cost to the mental health sequelae of this disaster, along with everything else.
The article also notes the vulnerability of relief workers to acute mental disorders. It brings to mind a friend trained in short-term counseling for disaster survivors who returned from a post-9/11 stint in New York looking about as depressed as anyone I have ever seen. In my mind, he turned from volunteer to another victim of that disaster.
(Jan 9th update: I just came across an article in this week's JAMA that says 51% of post-9/11 volunteers had mental health issues on screening instruments.)
Thursday, January 06, 2005
Seeing what everyone else sees, thinking what no one else thought
I am asked: "Why are you blaming academic psychiatry for the increase in diagnosis of bipolar disorder in children? Are you saying that researchers have created the diagnosis in order to justify getting money from drug companies for research studies?"
Nothing is more important to progress in our field than research, especially the research done at our medical schools. And certainly more research on mood disorders in children needs to be done.
But I also believe we all tend to "see" what we get paid to see.
For example, consider this symptom: dizziness
Come see me with dizziness, and the first diagnosis that comes to my mind might well be an anxiety disorder.
But go to the cardiologist down the street with the same symptom, and perhaps she first thinks of a heart valve disorder.
And the ENT doc might first think of an inner ear disorder.
And the neurologist...
In psychiatry, there is a similar issue around "mood swings." Lots of diagnoses have mood swings as a symptom.
Is it not possible that a researcher who is funded for exploring medication treatment for bipolar disorder would tend to see bipolar disorder when a new patient has mood swings?
"Discovery consists of seeing what everybody has seen and thinking what nobody has thought."
Nothing is more important to progress in our field than research, especially the research done at our medical schools. And certainly more research on mood disorders in children needs to be done.
But I also believe we all tend to "see" what we get paid to see.
For example, consider this symptom: dizziness
Come see me with dizziness, and the first diagnosis that comes to my mind might well be an anxiety disorder.
But go to the cardiologist down the street with the same symptom, and perhaps she first thinks of a heart valve disorder.
And the ENT doc might first think of an inner ear disorder.
And the neurologist...
In psychiatry, there is a similar issue around "mood swings." Lots of diagnoses have mood swings as a symptom.
Is it not possible that a researcher who is funded for exploring medication treatment for bipolar disorder would tend to see bipolar disorder when a new patient has mood swings?
"Discovery consists of seeing what everybody has seen and thinking what nobody has thought."
Wednesday, January 05, 2005
Local disaster
It was cold today by Texas standards, and raining. I noticed her under the overpass as I drove between clinics this morning -- squatting, shivering, looking about twice my age (although I imagine the reality is that there is little difference at all).
And I wondered: why do flood victims half a world away elicit more empathy than this homeless woman before me? What stigma not endured by the orphaned child exacerbates her plight?
And I wondered: why do flood victims half a world away elicit more empathy than this homeless woman before me? What stigma not endured by the orphaned child exacerbates her plight?
Tuesday, January 04, 2005
The nature-nurture pendulum swings again
The last time the nature-nurture pendulum reversed direction was years ago, back when I was in training. It has swung far enough in the past few years to make it fashionable to invoke genes or biology alone as the cause of most psychiatric disorders.
But not so fast. The next swing seems to have begun:
His call follows on the heels of the article noted here on the impact of environment on the biology of depression.
It's becoming clear that people have a genetic vulnerability to most of these disorders. But it seems to take some sort of stress to "turn on" the genes. For some, it takes a big-time stress. For others, something relatively minor can do it.
But in the nature-nurture debate, it seems as if it's almost never either-or.
But not so fast. The next swing seems to have begun:
"There is robust evidence of environmentally mediated risks for psychopathology."This from Dr Michael Rutter, perhaps the preeminent child psychiatrist of our generation, writing in this article in JAACAP. He goes on:
"Many of the risks deriving from adverse experiences are reliant on nature-nurture interplay."His paper is intended as a call for more robust research on the role of environment in mental illness. It's tough to do that kind of research.
His call follows on the heels of the article noted here on the impact of environment on the biology of depression.
It's becoming clear that people have a genetic vulnerability to most of these disorders. But it seems to take some sort of stress to "turn on" the genes. For some, it takes a big-time stress. For others, something relatively minor can do it.
But in the nature-nurture debate, it seems as if it's almost never either-or.
Monday, January 03, 2005
Sometimes a cigar is just...
From JAMA 43:1977 (1904):
"...A physician received a box of cigars by mail with a bill therefor and with a letter, stating that, although the physician had not ordered the cigars, yet the maker took the liberty of sending them, convinced that he would find them excellent. The cigars were good and the physician smoked them. When the box was empty he sent the maker several prescriptions, accompanied by a bill for the same, which amounted to the same as the bill for the cigars, and accompanied by a letter stating that, although the cigarmaker had not asked for medical advice from him, yet he took the liberty of sending him some prescriptions, convinced that he would find them excellent."
Sunday, January 02, 2005
Pediatric bipolar disorder: why the epidemic?
I am asked (this time as part of the post-quiz on a continuing medical education [CME] program): "A 17-year-old junior from the local high school is brought to you for an assessment because she won't tell her parents where she is spending her nights instead of coming home. The parents say she has been oppositional for months, irritable and has mood swings...A diagnosis of bipolar disorder is made..."
Wait! I thought that would be the quiz question! I thought the vignette would end with: "What diagnoses should you consider?" And the choices would be:
a. conduct disorder
b. substance use disorder
c. oppositional defiant disorder
d. parent-child relational problem
How in the world did we get to the point where an irritable teenager with mood swings and a crummy relationship with her folks is presumed to have bipolar disorder? It wasn't that long ago that it would have been presumed to be normal behavior. Geez...
Actually, it's been almost five years since Dr Angell provided this insight which is easily applied to understanding why there is an epidemic of childhood bipolar disorder, at least on CME quizzes.
Wait! I thought that would be the quiz question! I thought the vignette would end with: "What diagnoses should you consider?" And the choices would be:
a. conduct disorder
b. substance use disorder
c. oppositional defiant disorder
d. parent-child relational problem
How in the world did we get to the point where an irritable teenager with mood swings and a crummy relationship with her folks is presumed to have bipolar disorder? It wasn't that long ago that it would have been presumed to be normal behavior. Geez...
Actually, it's been almost five years since Dr Angell provided this insight which is easily applied to understanding why there is an epidemic of childhood bipolar disorder, at least on CME quizzes.
Saturday, January 01, 2005
Anecdotally, Give Me a Tricyclic...
I am asked: "I was curious why you called imipramine the gold standard. It doesn't seem to be prescribed as frequently as SSRIs. I also thought MAO Inhibitors were more effective. I'd be interested in more on your view of this. "
Well, all you're gonna get today is one shrink's anecdotal views. And as I tell my patients, "Ask ten shrinks and you'll get ten answers." (Although with DSM, I think it's supposed to be 6 or 7 out of 10 agreeing on diagnosis, at least.)
I'm no researcher, so maybe I used the "gold standard" term wrong. But when drug companies were first trying to demonstrate the efficacy of SSRIs, they compared them to imipramine. That's what I intended to convey.
Imipramine (and the other tricyclic antidepressants) work. And the more experience we gain with SSRI's, the less impressed I am with any edge an SSRI might have in side-effect profile (with the one exception of lethality in overdose).
But, you can never underestimate the power of a good marketing campaign -- and I reckon there is much less money to be made in marketing generic imipramine.
I haven't used MAOI's in years. But anecdotally I found no advantage to them back when I did.
Actually, in adults I almost always try Wellbutrin first: fewer side effects, and still first-line on the best practice guidelines.
Hey, I said it was totally anecdotal today...
Well, all you're gonna get today is one shrink's anecdotal views. And as I tell my patients, "Ask ten shrinks and you'll get ten answers." (Although with DSM, I think it's supposed to be 6 or 7 out of 10 agreeing on diagnosis, at least.)
I'm no researcher, so maybe I used the "gold standard" term wrong. But when drug companies were first trying to demonstrate the efficacy of SSRIs, they compared them to imipramine. That's what I intended to convey.
Imipramine (and the other tricyclic antidepressants) work. And the more experience we gain with SSRI's, the less impressed I am with any edge an SSRI might have in side-effect profile (with the one exception of lethality in overdose).
But, you can never underestimate the power of a good marketing campaign -- and I reckon there is much less money to be made in marketing generic imipramine.
I haven't used MAOI's in years. But anecdotally I found no advantage to them back when I did.
Actually, in adults I almost always try Wellbutrin first: fewer side effects, and still first-line on the best practice guidelines.
Hey, I said it was totally anecdotal today...
