Monday, August 31, 2015

Provigil: the drug that helps you perform better

There is an article in the Atlantic called "The Rise of Work Doping" that talks about Provigil (modafinil) as a medication that enhances cognition with very few side effects. Medically, we use it to treat narcolepsy -- the uncontrollable urge to fall asleep. But I've also seen patients on it for depression -- often a desperation measure prescribed during a hospitalization. In terms of cognition and motivation, I haven't seen it do amazing things -- maybe the patient has more energy and functions a little better, but it's been no panacea for low motivation or cognitive jump-starting. There's a caveat here:   I've used very little of it for a very practical reason: the medication cause roughly $1000 for 30 pills (give or take a couple of hundred) and it's not a drug that insurances are eager to approve.

 I'd like to tell you something about the practice of psychiatry, or at least about my practice. I see a fair number of patients with mood disorders, and the mood disorders are often pretty easy to treat. The symptoms generally resolve (no, not for everyone, but a for a lot of people). And while many people get better and return to work and to a meaningful, active life, there are some people who stay stuck in a life they are disappointed with despite the resolution of the depressive symptoms. They remain unmotivated (especially for things they don't enjoy doing), may not return to work or do so in notably under-employed ways, and can find it hard to accomplish even little things, like cleaning up a bedroom or closet, or plowing through a to-do list, or organizing a vacation, or coping with a broken car/iphone/computer.   Or perhaps their moving along okay, but they aren't happy with their lives the way they are and just can't seem to do what's necessary to get life to change.

Often these people also have issues with attention to detail and organizing their lives.  They forget appointments, lose their keys and phones, and have trouble planning ahead: what we call Executive Function.  While stimulants may help these folks with concentration and energy, they don't seem to do much for helping with organizational skills.   So while I'm not interested in giving Provigil to healthy executives who want a raise, I am interested in knowing if you have tried it with your patients with Executive Dysfunction, and if it's been helpful to them?

Monday, August 17, 2015

What happened to Parity? Dewar Insurance discriminates against people with mental health disorders.


A colleague wrote into our psychiatric society's Listserv --  his son is starting college and he was solicited to purchase tuition reimbursement insurance in case something goes wrong and his son needs to withdraw.  He was surprised to read that the company offered one amount if a student withdraws for 'medical' reasons and another, lesser percentage, if the student withdraws for 'mental health' reasons.  Oh, and the medical leave needs a doctor's note, while a mental health leave requires that the student must have been hospitalized for two consecutive days for the psychiatric condition.  

That seemed outrageous, and it occurred to me that I have a kid in college and I had the same offer for tuition reimbursement insurance sitting in my spam.  Only my offspring is at a different university in a different state and there is no medical vs. mental health differentiation for her large university.  I clicked on a few schools and concluded this was a quirk of my colleague's son's institution.  He was quick to point out that I was wrong -- colleges and universities are all over the map with this, and I soon realized that every school that offers this policy in Maryland has some inequity for mental health reasons-- either a lesser amount of reimbursement or a requirement for hospitalization.  I don't quite understand -- are they saying that mental illnesses are less real or valid so you have to 'prove' you're really sick, and by the way, you get less of a refund?  Disability of all varieties has the potential to be an individual matter especially when it involves pain or fatigue.  And in Maryland, our governor has set the bar quite high -- he was recently diagnosed with an aggressive form of lymphoma and is undergoing chemotherapy -- certainly a good reason to take some time off -- but his photo (minus hair) is in the paper every day with his declaration about some topic or other.  At some level, a doctor of any specialty is left to trust the patient (or not) when he says he just can't do something because he's in too much pain, too tired, too depressed, or his preoccupation with delusions and hallucinations is getting in the way.  

The company mentioned is Dewar -- you can look up a university they cover here: College Tuition Refund - Home Page, but apparently it's been an issue for years.  Below I'll post some articles about the issue from The  New York Times and Psych Central.  It's disheartening that despite this outcry and confrontation in 2011, Dewar continues to have these discriminatory policies.  I couldn't find anything that indicated that NAMI or APA were part of the conversation, but I could well have missed it (~please let me know if I have).  In the comments section on the third article, one person noted that when she complained to Yale's president, then the policy did change to one of equal coverage, but it seems like a war of many small battles which are mostly not being fought.  In addition, I'm posting a link to an excellent summary about why parity legislation has not resulted in the changes that were hoped for.  

On Psych Central:
And more in the NYTimes (read the comments)

And, finally, for anyone interested in an overview of how and why parity is failing, this is an excellent summary, from earlier this month:
Congress tried to fix mental health care in 2008. Lawsuits charge it isn't working.

And, no, I don't want to talk about why the background is green.  Where is Roy when I need him?


Thursday, August 13, 2015

Flipping the Switch

Last week I met with Dr. Irving Reti to talk about brain stimulation as a psychiatric treatment.  Irving is the editor of a new book, Brain Stimulation: Methodologies and Interventions and he happens to be a stimulating guy to chat with.   He divides his brain stimulation into 'convulsive' -- that would be ECT or electroconvulsive therapy -- and 'nonconvulsive' : transcranial magnetic stimulation, transcranial direct-current stimulation or tDCS, and deep brain stimulation).  I wrote about our conversation over on the Clinical Psychiatry News website and please do click over to "Catching up on brain stimulation with Dr. Irving Reti".  I was particularly interested in tDCS which Irving likened to hooking yourself up to a 9-volt battery and he mentioned that the machinery -- not intended to treat psychiatric conditions -- is readily available at  He also recommended a very interesting New Yorker article, Electrified, by Elif Batuman, which talks about an anesthesiologist in Georgia who uses tDCS to treat patients, and himself, for depression .

So with electricity on my mind (not literally, or at least not yet), today I noticed an article on The Carlat Psychiatry Report talking about the use of both transcranial direct and alternating currents
for the treatment of depression, and in "Fisher Wallace and Alpha-stim for Depression," Gregory Sahlman and Jeffery Borckardt talk about the differences between sending direct versus alternating current through the brain and the evidence for both of them.  Apparently the alternating-current device (made by Fisher Wallace) can also be self-administered, and costs a bit more. Stimulating stuff, be the bottom line is that there hasn't been enough controlled research to know if all this electricity works.

And by all means, if you have your own stimulating stories to share, please post them in the comment section below.

Tuesday, August 11, 2015

Does Watch-Your-Words Political Correctness in Universities Contribute to Mental Illness?

There's an interesting article in The Atlantic about how we now coddle college students by avoiding certain ideas -- and even certain words -- that might be offensive to someone.  The article talks about certain words/ideas being 'microagressions' and that professors offer 'trigger warnings,' if course material might remind people of past traumas.  

In The Coddling of the American Mind, Greg Lukianoff and Johnathan Haidt write, "Last December, Jeannie Suk wrote in an online article for The New Yorker about law students asking her fellow professors at Harvard not to teach rape law—or, in one case, even use the word violate (as in “that violates the law”) lest it cause students distress."  Wait, so we think our top lawyers should not be educated about rape law?  Who will prosecute or defend the rapists?

The list of what might be offensive is long and sometimes a bit oblique for me, and I have to say, I wonder about first amendment rights to free speech (or any speech), when the topics come down to things such as this:
During the 2014–15 school year, for instance, the deans and department chairs at the 10 University of California system schools were presented by administrators at faculty leader-training sessions with examples of microaggressions. The list of offensive statements included: “America is the land of opportunity” and “I believe the most qualified person should get the job.”

America may or may not be the land of opportunity, but if a college professor truly believes that, he can't say it?  And (*beware, possible micro-agression in the rest of the sentence*), I'm totally lost as to what is wrong with expressing the personal belief that the most qualified person should get the job.  

The authors write:
The press has typically described these developments as a resurgence of political correctness. That’s partly right, although there are important differences between what’s happening now and what happened in the 1980s and ’90s. That movement sought to restrict speech (specifically hate speech aimed at marginalized groups), but it also challenged the literary, philosophical, and historical canon, seeking to widen it by including more-diverse perspectives. The current movement is largely about emotional well-being. More than the last, it presumes an extraordinary fragility of the collegiate psyche, and therefore elevates the goal of protecting students from psychological harm. The ultimate aim, it seems, is to turn campuses into “safe spaces” where young adults are shielded from words and ideas that make some uncomfortable. And more than the last, this movement seeks to punish anyone who interferes with that aim, even accidentally. You might call this impulse vindictive protectiveness. It is creating a culture in which everyone must think twice before speaking up, lest they face charges of insensitivity, aggression, or worse....

Today, what we call the Socratic method is a way of teaching that fosters critical thinking, in part by encouraging students to question their own unexamined beliefs, as well as the received wisdom of those around them. Such questioning sometimes leads to discomfort, and even to anger, on the way to understanding.

But vindictive protectiveness teaches students to think in a very different way. It prepares them poorly for professional life, which often demands intellectual engagement with people and ideas one might find uncongenial or wrong. The harm may be more immediate, too. A campus culture devoted to policing speech and punishing speakers is likely to engender patterns of thought that are surprisingly similar to those long identified by cognitive behavioral therapists as causes of depression and anxiety. The new protectiveness may be teaching students to think pathologically.

The authors contend that over time, parents have become more concerned with safety, from bullying which might contribute to mass murders, to peanut butter bans, to unsafe playground equipment.  Children have learned that the world is an unsafe place and adults will provide protection.  

Read the article, because the examples go on and on, one includes a hearing against a young man who was disciplined for reading a book about the Klan (specifically about how a college protested the Ku Klux Klan) because the picture on the cover offended another student.  

The authors go on to note: 

Because there is a broad ban in academic circles on “blaming the victim,” it is generally considered unacceptable to question the reasonableness (let alone the sincerity) of someone’s emotional state, particularly if those emotions are linked to one’s group identity. The thin argument “I’m offended” becomes an unbeatable trump card.
 Furthermore, they contend that avoiding discussion of certain topics is not helpful to people with problems and may create pathology in those without them:
However, there is a deeper problem with trigger warnings. According to the most-basic tenets of psychology, the very idea of helping people with anxiety disorders avoid the things they fear is misguided. A person who is trapped in an elevator during a power outage may panic and think she is going to die. That frightening experience can change neural connections in her amygdala, leading to an elevator phobia. If you want this woman to retain her fear for life, you should help her avoid elevators.

But if you want to help her return to normalcy, you should take your cues from Ivan Pavlov and guide her through a process known as exposure therapy. You might start by asking the woman to merely look at an elevator from a distance—standing in a building lobby, perhaps—until her apprehension begins to subside. If nothing bad happens while she’s standing in the lobby—if the fear is not “reinforced”—then she will begin to learn a new association: elevators are not dangerous. (This reduction in fear during exposure is called habituation.) Then, on subsequent days, you might ask her to get closer, and on later days to push the call button, and eventually to step in and go up one floor. This is how the amygdala can get rewired again to associate a previously feared situation with safety or normalcy.

Students who call for trigger warnings may be correct that some of their peers are harboring memories of trauma that could be reactivated by course readings. But they are wrong to try to prevent such reactivations. Students with PTSD should of course get treatment, but they should not try to avoid normal life, with its many opportunities for habituation. Classroom discussions are safe places to be exposed to incidental reminders of trauma (such as the word violate). A discussion of violence is unlikely to be followed by actual violence, so it is a good way to help students change the associations that are causing them discomfort. And they’d better get their habituation done in college, because the world beyond college will be far less willing to accommodate requests for trigger warnings and opt-outs.

The expansive use of trigger warnings may also foster unhealthy mental habits in the vastly larger group of students who do not suffer from PTSD or other anxiety disorders. People acquire their fears not just from their own past experiences, but from social learning as well. If everyone around you acts as though something is dangerous—elevators, certain neighborhoods, novels depicting racism—then you are at risk of acquiring that fear too. The psychiatrist Sarah Roff pointed this out last year in an online article for The Chronicle of Higher Education. “One of my biggest concerns about trigger warnings,” Roff wrote, “is that they will apply not just to those who have experienced trauma, but to all students, creating an atmosphere in which they are encouraged to believe that there is something dangerous or damaging about discussing difficult aspects of our history.”
The authors conclude, for a number of reasons, that shielding students from potentially controversial or upsetting words and ideas is wrong -- it leaves them too thin-skinned and it creates an intellectual environment of homogeneity.  What's the answer? The authors conclude that college students should all be taught Cognitive Behavioral Therapy to help them deal with uncomfortable ideas.  The whole article was great food for thought, although the idea that we are stifling intellectual innovation and exploration for fear of using a word that might offend someone, well it makes me kind of uncomfortable.