Wednesday, September 17, 2008

Psychiatry Stuff in the New York Times.

Has anyone seen my co-bloggers? I think they've vanished.

I'm still here. Life feels a little weird lately-- my oldest teen, the one who makes all the noise-- went away to college a few weeks ago, and younger teen started at a new school. Things feel a little off-kilter, like there's an odd void. It's more peaceful, and college kid sounds very happy. It's all good, just a little unsettling, and I feel like I need to figure myself out all over again.

With that as an aside, two interesting articles in the New York Times:

In The Bipolar Kid, Jennifer Egan explores the increase in the number of children diagnosed with bipolar disorder, the struggles their families face, the maze of treatments and medications these families explore, and how little we know about this disorder. As a parent, I found it a sad read. As a psychiatrist, well, there's this awareness that some people have stories of really horrendous childhood behaviors and grow up to be just fine. Egan writes:

Most clinicians say they believe that there will eventually be clear “biological markers” of bipolar disorder: ways to see and measure the disease as we can seizures, cancer or hypertension. Scientists are working to identify the genes (there appear to be many) involved in creating a predisposition for bipolar disorder. Brain imaging, still in its infancy, can already detect broad differences of size, shape and function among different brains. The hope is to know early on who is at risk so their condition can be diagnosed and treated as early as possible. Mental illness wreaks brutal damage on a life, crippling decision-making, competence and self-esteem to the point where digging out from under years of it can be next to impossible. And there is also a biological theory for why going untreated might worsen a bipolar person’s long-term prognosis. Epilepsy researchers have found that by electrically triggering seizures in the brains of animals, they can prompt spontaneous seizures, a phenomenon known as “kindling.” Simply having seizures — even artificially generated ones — seems to alter the brain in such a way that it develops an organic seizure disorder. Some scientists say that a kindling process may happen with mania, too — that simply experiencing a manic episode could make it more likely that a particular brain will continue to do so. They say this explains why, once a person has had a manic episode, there is a 90 percent chance that he will have another.

And our former guest blogger, Dr. Ronald Pies, had a short piece in Tuesday's NYTimes: Redefining Depression as Sadness. Dr. Pies talks about the difficulties psychiatrists face in differentiating bereavement from normal sadness, the risks of under-diagnosis and the implications of over-diagnosis. He writes:

Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.

Should I give him a diagnosis of clinical
depression? Or is my patient merely experiencing what the 14th-century monk Thomas à Kempis called “the proper sorrows of the soul”? The answer is more complicated than some critics of psychiatric diagnosis think.

My quicky take on his partial vignette, without my usual 2hour psychiatric evaluation, is that it's unusual for someone to seek psychiatric treatment for the first time because of a recent loss-- people generally cry on the shoulders of their friends, talk to their religious leaders, grieve and don't consider this unusual. The subset of people who present to a psychiatrist maybe having a more severe response, or another concern. With the little we know, it sounds to me like this patient has an Adjustment Disorder with Depressed Mood (is it okay if venture a guess based on on a few sentences?) and the patient should be seen often for psychotherapy. I'd give him medications if: 1) he has a history of depression and this looks like a recurrence 2) he's suicidal or unable to function/work 3) he's really insists that he needs a medication and he's intolerably miserable 4) he got no relief after a few weeks of therapy. Oh, and actually, if any of those things were going on, I'd call it Major Depression and not Adjustment Disorder. I just thought I'd stick in my unrequested opinion here, sort of silly given how little we know, but the issue of understandable reactions versus psychiatric illness is one we like talking about here at Shrink Rap.


Anonymous said...

I've just recently been labeled bipolar II, and I don't get it. So now, when I have a brief respite from being horribly depressed, I'm hypomanic?

I already have a hard time enjoying anything and having fun, and now, when I do, I think its hypomania.

It's very frustrating.


Rach said...

I think Egan's article was probably the most even, fair, well-thought & written article I've ever read... and I've read a fair number of them myself... It should be mandatory/required reading for all parents, whose children have, or may have, Bipolar Disorder, or other similar illnesses.

If only other articles about Bipolar Disorder, especially in kids, was as well written... we might be on our way to cutting through some of the stigma associated with the illness, and with mental illness in general.

Novalis said...

If psychiatrists can be allowed any expertise at all in this age of endlessly contestable diagnoses and treatments, it should involve making judgments regarding the meaning of a syndrome in the context of a person's life.

After all, we do have the advantage of having seen many hundreds of patients, and those psychiatrists who have any sense at all to begin with should see it ripen over time into a fine ability to judge whether and when someone crosses the line from "mere" tragedy to the curse of "the black dog." It's the job of psychiatrists to "keep it real."

Of course, when I reflect on some of the people (i.e. colleagues) I've worked with in the past I have to think, "God help us."

Dragonfly said...

That article about bipolar in children was really interesting. Thanks for linking to it!

Anonymous said...

Information Regarding Bipolar Disorder
Bipolar Disorder (manic-depressive illness), if a disorder at all, has been defined as a major affective mood disorder in which one alternates between the mental states of deep and brutal depression and inflated elation- with the depressive episodes occurring more frequently. The disorder affects one’s cognition, emotions, perceptions, and behavior- along with psychosomatic presentations (such as pain with depressive episodes, for example). It is thought to be due to a physiological dysfunctional brain in one affected with bipolar disorder, yet Information Regarding Bipolar Disorder
the etiology remains entirely unknown.
It is also believed that bipolar disorder presents itself when the affected one is between the ages of 15 and 25 years old. The disorder was entered in the psychiatrists’ bible, the DSM, in 1980. Also, bipolar disorder is thought to be correlated with creativity and accelerated growth of neurons if one is affected by it.
Research has determined that as many as 15 to over 30 percent of bipolar disorder patients commit suicide if they are untreated. Also, as many as half of those affected with bipolar disorder also have at times severe substance abuse issues along with this disorder as well. Bipolar patients are also often experiencing anxiety issues that vary, and are treated often as such. The disorder varies as far as severity goes- with some bipolar disorder patients being more affected than others. In fact, there are at least 6 classifications of bipolar disorder, according to the DSM.
Bipolar patients are thought to be symptomatic half of their lives- with depressive episodes occurring more frequently than manic ones. When symptomatic, bipolar patients are thought to be rather disabled, according to some. As many as half of those suspected as having a bipolar disorder are thought to have at least one parent with some sort of mood disorder, which suggests a genetic predisposition to the disorder.
The diagnosis has become more frequent recently. In one decade, the assigned diagnosis of bipolar disorder rose from being about 25 per 100 thousand people to being 1000 per 100,000 people. Most diagnosed with bipolar disorder are not diagnosed based on solid, comprehensive, or psychiatric review that is often absent of valid or standard diagnostic methods. Some believe as many as 5 percent of the human population may be affected by bipolar disorder- which includes as many as 12 million people in the United States.
A subjective questionnaire called the Mental Status Examination is often utilized when diagnosing one suspected has having bipolar disorder. Many believe the diagnosis has increased recently due to the progressive treatment options now available. It is an argument of increased awareness versus over-diagnosis.
Yet the diagnosis is vague, as children and adolescents are often absent in research with bipolar disorder. Many younger than 18 years of age are prescribed atypical anti-psychotics as first line treatment, which is largely not recommended as treatment options. In fact, close to half a million of those younger than 18 years of age are prescribed the atypical anti-psychotic Risperdal alone, it has been determined. The class of medications overall is thought to be prescribed to about 10 percent of those non-adults thought to have bipolar disorder.
While not recommended, one half of all those assessed as being bipolar are prescribed antidepressants, such as SSRIs, as first line treatment. It has been suggested that this class of drugs has decreased the risk of suicide attempts compared with other classes of antidepressants for close to 20 years. Yet tricyclic antidepressants have been determined to be efficacious in over half of those diagnosed with bipolar disorder- with a greater amount of research behind this class of drugs. Yet, entirely recognized treatments for bipolar disorder long term are lithium or lamictal- along with an anti-convulsant. Sugar intake is thought to vex the symptoms of one with a bipolar disorder as well.
Atypical anti-psychotics have been prescribed for bipolar disorder, which change some aspects of the brain, physiologically, as does the disease itself. In fact, one may argue the brain becomes more efficient due to both the disorder and the treatment with the atypical anti-psychotics. Yet many recommend the utilization of this class of drugs with bipolar disorder only if psychosis is present as well. As many as 15 percent of bipolar disorder patients diagnosed as such are prescribed an atypical presently. This class of medications may be particularly beneficial for those women who are diagnosed with bipolar disorder who are pregnant, however.
Lithium, which is essentially a very light metal with low density in which the salts are obtained for medicinal treatment, and an anti-convulsant are believed to be standard bipolar treatment, pharmacologically, studies have shown. This is due to Dr. John Cade and his examination with lithium and its benefits with those who have psychotic excitement close to 60 years ago. Lithium is believed to be both neuro-protective as well as having an anti-suicidal affect in those believed to be bipolar- and is viewed as a mainstay as far as treatment for bipolar goes with many who treat the disorder. Lithium is thought to regulate the calcium molecule in the brain, so this and valporate are historically the medicinal treatment options preferred for those with bipolar disorder.
Bipolar is difficult to detect, and is often diagnosed as major depression with many affected by this disorder. There is no objective criteria protocol available to utilize when assessing any patient believed to be suffering from any mental disorder. So such mental disorders that are diagnosed are ambiguous, yet that does not conclude that such disorders do not exist, such as the case with bipolar disorder.
Yet perhaps a health care provider should be very thorough and knowledgeable when assessing a patient believed to have a mental condition such as bipolar disorder,

Dan Abshear