Would You Like Prozac With Your Latte?

The Guardian recently published this story about a longitudinal Harvard study of 51,000 female coffee drinkers followed over ten years. They found that there was a 20% lower risk of clinical depression in the women who drank four or more cups of coffee a day compared to non-drinkers. This is consistent with a previous study of 86,000 female nurses followed over ten years, where they found that the relative risk of suicide was reduced even for moderate to low coffee drinkers, defined as drinking two or three cups per day.

This is good news for me since I usually start my day with a half a pot before I get to work. (Yes, that much, really. No wonder Dinah sent me a link to this story and said, "You've gotta blog about this.")

The trick is, there may be a ceiling effect to all this: once you get to eight or more cups a day this risk of suicide starts to increase again according to one study.

Somewhat gratuitously, the Guardian article threw in reference to our "druggy society" and faulted the researchers for not considering other factors like social supports, involvement in religious groups or community activities, and even whether the women were drinking coffee alone or with friends:

"As the scientists will also tell you, neurotransmitters respond to everything: hugs, kisses, conversation, books, pictures, gardening, hunger, worry, rows, war – all raise or lower chemical levels."

Ah yes, clinical depression and suicide must be the result of not getting enough hugs or the fact that you haven't taken up gardening. Cringe-worthy health reporting, at its best. The reporter concludes:

"...supposedly scientific comments of this sort serve little purpose except to coax women into a state the doctors can then medicate."

Amazing. A simple study about caffeine and depression has somehow been morphed into another nefarous plot by evil Dr. Pillshrink.

Stay Awake

Thank you all so much for your feedback on our survey. I'm still thinking about it, but your suggestions have been excellent!

Please join our Facebook page. Again. I'm taking down the original as I didn't realize when I put it up that it would be one more thing to check and maintain and "Shrink Rap" has been a lousy Facebook friend without reciprocating. Roy put up another page, and his twitter feed populates it so that something actually happens-- on a good day, it announces new blog posts, on a bad day, Roy tweets out funny little incomprehensible tidbits. We're our own fans, so we can post to the wall, and there are some pics of real people. And the duck is there. Our page URL is: http://www.facebook.com/shrinkrapbook
Some day, we'll get it right.

We have a new post up on our Psychology Today blog. A bit more of the same, but check it out if you can stand it.

Okay, so here's the real post in honor of ClinkShrink, our caffeine addict.
It's a century since Coca-Cola went on trial for sticking that caffeine stuff in their drink. 80mg, back then. There was a trial, there was research, and here's the article in today's New York Times: A Century Later, Jury's Still Out on Caffeine Limits and Murray Carpenter writes:

Coca-Cola hired a Barnard College psychology instructor named Harry Levi Hollingworth. He mustered 16 subjects aged 19 to 39, including occasional, moderate and regular caffeine users, along with abstainers. In a Manhattan apartment rented for the research, he tested their mental and motor skills under varying levels of caffeine use and abstinence. They took caffeine capsules and placebos — double blinded, so neither they nor the researcher knew which was which — and “soda fountain” drinks with and without caffeine. The trial looming, Hollingworth did it all in just 40 days.

The subjects kept good notes. On Feb. 22, a regular user was caffeine-free: “Felt like a ‘bone head’ all day. My head was dull more than usual.” On Feb. 25, an abstainer was dosed with four grains of caffeine (260 milligrams, the approximate equivalent of a 12-ounce cup of Starbucks coffee): “Gradual rise of spirits till 4:00. Then a period of exuberance, of good feeling. Fanciful ideas rampant.”

Hollingworth found that moderate doses of caffeine stimulated his subjects’ performance on an array of tests, though some slept poorly after the highest doses. His appearance on March 27, 1911, was a high point in a four-week trial dominated by anecdotal, contradictory or sloppy testimony.

The point of the article? 100 years later and we're still asking all the same questions. Go figure.

The Human Experiment, Part 2

Earlier this month, I posted about my own efforts to deal with insomnia, and how I inadvertently threw myself into caffeine withdrawal. I'm following up here.

So to summarize my experiment on myself, I manipulated the following variables, all at once, with no control group, and no way of knowing which variable was responsible for any changes I saw.

1) I stopped all caffeine. Well, mostly. After the caffeine withdrawal headache and fatigue, I decided there was no real rationale for this, and I've been drinking half a cup of coffee most mornings. In anticipation of the crowds and a purported 1:5000 person: porta-potty ratio at Obama's Inauguration, I did not have any coffee on that morning. I've had no Diet Coke (yes, this is possible) and my efforts to completely stop chocolate have been unsuccessful. So my caffeine intake has been limited to half a cup of coffee in the morning and episodic chocolate in reasonable (mostly) quantites. No artificial sweeteners.

2) I stopped drinking alcoholic beverages.

3) Since I have trouble falling asleep, but don't have trouble with daytime sleepiness, I wondered if I've simply come to need less sleep and I tried setting my alarm significantly earlier in the mornings. I am not a morning person, and this was awful (it lasted 2 days) but perhaps because it co-incided with my caffeine withdrawal. After that, I started going to bed at least an hour later than I was used to.

4) I increased the amount of exercise I was getting...oh, at least for a while. I also tried to add on some evening exercise to manipulate my body temperature several hours before bedtime-- a few minutes until I got flushed, but not sweaty enough to need a second shower. It was going well until a few days ago when I turned into a human slug. I resume a normal exercise schedule today.

5) Stress-- I started this plan during a time when stress was low and there was a long weekend in there. I've had some stuff going on since, and I spent a night away from home and my usual routine. Sometimes, life is just what it is.

My findings:

• It is easier to give up Diet Coke than it is to abstain from Chocolate.
• It is easier to give up alcohol than it is to abstain from chocolate.
• Decaffeinated tea is as happy an event as regular coffee.
  
• My daytime energy level has not changed with less morning coffee.
  
• One can actually have mild cravings for Diet Coke.
• It's easier to go to bed later than it is to get up earlier
• It's a pain in the neck to exercise every single day
• It is notably cheaper to eat in restaurants when there is no alcohol, soda, or after dinner beverage involved (I don't like decaf coffee).

Oh, and the results: most nights, I'm falling asleep within minutes and sleeping through the night.

Sweet Dreams!

The Human Experiment

There are things to do about symptomatic distress in addition to medications and therapy. I often encourage people to make themselves their own human experiments. There are a few things we can change easily: we alter our diets, sleep, exercise, and the assorted "substances" we ingest. I sometimes suggest to people that they do 2 week trials and see if something helps. Is your life better if you stop drinking for a couple of weeks, exercise mor or less, give up food additives, decrease the carbs in your diet, cut out or add caffeine? Pick a variable, change it for a time, and see if you feel better.

That being said, I've been having some trouble sleeping. I decided I'd take my own advice and change some things. Oh, but you know, I'm an impatient sort of soul, and I decided to change a few things all at once. They didn't seem like big things: I decided to cut out all alcohol and caffeine from my diet, to set the alarm for earlier in the morning and get up and exercise in the hopes of exhausting myself. I started on a Monday, not a day of the week I typically drink alcohol anyway, and also not a day I usually have time to exercise. And caffeine, well...a cup of java in the morning, maybe two, and a Diet Coke with dinner, maybe another during the day or maybe not. And I've gone months at a time without Diet Coke. I like it, but it's not the hardest thing to give up. Have I noticed that I feel better or sleep differently without soda? No. But this time, I'm giving up coffee, too.

5:45 AM, the alarm goes off, and 4 miles later, I begin my day, without coffee. No caffeine. No chocolate. No diet coke.
6:15 AM Tuesday, and this is a day I normally exercise. Only I'm dragging, and it was an uninspired work out. By afternoon, I'm feeling really lousy. My head aches. I'm tired and fatigued, and I really can't sleep that night. It's the sleep deprivation, I think, getting up earlier than I usually do, after a night when I've had trouble falling asleep. Ugh.

By Wednesday morning, my head has ached for 2 days, and while I'm caffeine & nutrisweet free, I'm now downing Tylenol and Motrin but my head still hurts. It finally occurs to me that I'm in caffeine withdrawal. But I was never addicted! How can I be withdrawing? I look this up and realize this can last for up to 9 days. Suddenly it seems sort of ridiculous that I've changed multiple variables at once, and even worse that I've given up caffeine cold turkey.


So Caffeine Withdrawal is an official DSM psychiatric diagnosis. From the Johns Hopkins Medicine:

The researchers identified five clusters of common withdrawal symptoms: headache; fatigue or drowsiness; dysphoric mood including depression and irritability; difficulty concentrating; and flu-like symptoms of nausea, vomiting and muscle pain or stiffness. In experimental studies, 50 percent of people experienced headache and 13 percent had clinically significant distress or functional impairment -- for example, severe headache and other symptoms incompatible with working. Typically, onset of symptoms occurred 12 to 24 hours after stopping caffeine, with peak intensity between one and two days, and for a duration of two to nine days. In general, the incidence or severity of symptoms increased with increases in daily dose, but abstinence from doses as low as 100 milligrams per day, or about one small cup of coffee, also produced symptoms.

Wednesday morning, I have a half a cup of coffee. Within a half hour, my headache is gone and my energy level is normal, I feel like myself again. I go for a swim and sit in the hot whirlpool for a while, ahhhhh.....

I've learned a thing or two about being my own human experiment.

To the Max--- Life With a Little Help

I'm back from my White Christmas, back to muddy Maryland. I'm trying to find something stimulating to blog about with my brain on psychiatric vacation. Judith Warner of the New York Times has been kind enough to help with her op-ed piece "Living the Off-Label Life." She talks about a Shrink Rap favorite topic: the line between distress and illness, the use of medication (or in this case, non-meds such as coffee ...Clink....diet, etc) to help people reach some idealized potential. Ms. Warner writes:

------
What if you could just take a pill and all of a sudden remember to pay your bills on time? What if, thanks to modern neuroscience, you could, simultaneously, make New Year’s Eve plans, pay the mortgage, call the pediatrician, consolidate credit card debt and do your job — well — without forgetting dentist appointments or neglecting to pick up your children at school?

She goes on to discuss an article in Nature:

That’s why when Henry Greely, director of Stanford Law School’s Center for Law and the Biosciences, published an article, with a host of co-authors, in the science journal Nature earlier this month suggesting that we ought to rethink our gut reactions and “accept the benefits of enhancement,” he was deluged with irate responses from readers.

“There were three kinds of e-mail reactions,” he told me in a phone interview last week. “ ‘How much crack are you smoking? How much money did your friends in pharma give you? How much crack did you get from your friends in pharma?’

But Greely and his Nature co-authors suggest that such arguments are outdated and intellectually dishonest. We enhance our brain function all the time, they say — by drinking coffee, by eating nutritious food, by getting an education, even by getting a good night’s sleep. Taking brain-enhancing drugs should be viewed as just another step along that continuum, one that’s “morally equivalent” to such “other, more familiar, enhancements,” they write.
---------

Seems like something we struggle with over and over....

Scurrilous Lies

I checked my email this morning only to find a forwarded blog post that suggested I don't like chocolate. Lies! Scurrilous lies! I had to post to the blog immediately to stamp out this vicious rumor.

I was at the Chocolate Affair. I was there 45 minutes before Dinah. Dinah thinks I hardly ate any chocolate because she was late and doesn't know what I was doing while I was waiting for her. She should be glad I left some for her.

It was amazing. There was chocolate cocoa with peppermint marshmellows, flavored chocolate liquers, little tiny pancakes with elaborate chocolate toppings, chocolate truffles, chocolate cake, chocolate ice cream, chocolate flavored risotto....use your imagination and the reality was better.

I never knew it was possible to have a chocolate hangover. Trust me, it is. It's a combination of a lingering caffeine buzz with incipient chocolate cravings. This is why they only do this event once a year.

Of course, there's a certain amount of irony here. It was an elaborate affair and the creme de la creme of Baltimore society was there including our fair mayor who was "getting her chocolate on" as well as the chief state's attorney for Baltimore. There were fancy dresses and suits and spike heels and jewelry, all for the benefit of my patients. I kept thinking about my patients who wear baggy jeans and t-shirts with "DOC" stamped on them when they're released homeless. The mental culture clash was a bit jarring.

So that's the truth of the matter. I love chocolate. Don't let anyone tell you otherwise.

And Dinah looked fantastic in her tiara.

When Hummingbirds Bonk

In cycling and running there's a phenomenon known as "bonking". Bonking is when you just suddenly get overcome by exhaustion and you collapse. To be scientific about it, you 'deplete glycogen stores' and can't go on. A friend of mine tells me that this happens to hummingbirds. They can be found collapsed on the ground, exhausted, which isn't too surprising for a creature whose heart beats up to a thousand times a minute. Fortunately they can be revived with a little sugar water.

There are days when I can really identify with those little guys. On days when I see twenty-plus patients, when everyone is in crisis, when I just can't seem to find a chart (or the medication nurse can't find my order), at some point you hit the wall and bonk. It's that moment when I think to myself that I will just walk out of the facility and never come back.

Unfortunately, sugar water just doesn't do it for me.

This is what to do to revive a correctional psychiatrist in case you ever find one lying on the ground, exhausted, with a heart rate somewhat lower than a thousand beats a minute:

Administer coffee immediately, followed by judicious amounts of dark Belgian chocolate. Don't worry about checking for consciousness first, just hit the Starbucks.

If this doesn't work consider depositing a large, warm, furry and loudly purring cat on the psychiatrist's stomach. This is also a test for consciousness since those tiny sharp kneading claws are bound to get a reaction.

Once revived, deposit the psychiatrist in the middle of a large quiet forest with miles of hiking trails (trail map included). Allow time for staring up at tree branches, listening to the wind whistle, admiring large fungi and searching the stream for minnows.

Repeat, ad infinitum, until smiles return.

I suspect every psychiatrist has their own particular favorite ways to recover from the hummingbird bonk. Dinah is relaxing in a warm, sunny place and Roy seems to find comfort in buying new very large computer monitors (I'm jealous). Regardless of the recovery method, we will all find our way back to Shrink Rap eventually.

My Three Shrinks Podcast 10: Be Mine

[9] . . . [10] . . . [11] . . . [All]

---

Valentine's Day is soon upon us. Hearts, flowers, and chocolate abound. This got us three shrinks wondering about why chocolate holds such a high position in this whole love-related endeavor.
We talk about the psychopharmacology of chocolate, while we simultaneously try a taste of own pharmacocoatherapy.
Oh, and this is our TENTH PODCAST! (woo)

---

February 11, 2007:

Topics include:

• AJP: False positive drug tests on Effexor XR (venlafaxine) (positive for PCP, or phencyclidine).

• Chocolate and Mood [PubMed]: a look at chemicals in chocolate which affect mood, such as theobromine, caffeine, phenylethylamine (PEA), and anandamide.
  
• First study mentioned by Clink, on chemicals in chocolate.
• Second study, about mood modulation by food.
• Third study, about chocolate and atypical depression.
  
• Green M&Ms. Also, design your own M&Ms, even what is printed on them.
• Dogs: Don't eat the chocolate.
  
• Children of Psychiatrists (The Last Psychiatrist). Do psychiatrists have crazier children? (See Dinah's post)
  
• Suicide risk in physicians. A European study (Hawton 2001) found that female doctors, and not male doctors, had increased suicide risk. Furthermore, specialties at highest risk included anesthesiology, generalists, and psychiatrists. A meta-analysis (Schernhammer 2004) found that physicians in general were 1.4 (men) and 2.3 (women) times more likely to commit suicide than the general population.
• Questions for us? Email at mythreeshrinksATgmailDOTcom. We'll answer some starting with Podcast #11.
  

Next week: Black market price of psych meds; side effects of psychotherapy.

Last week's musical snippet was from 1983 release, Genetic Engineering, from the Dazzle Ships album by Orchestral Manoeuvres in the Dark (OMD).

---

Find show notes with links at:
http://psychiatrist-blog.blogspot.com/2007/02/my-three-shrinks-podcast-10-be-mine.html
This podcast is available on iTunes (feel free to post a review). You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

technorati tags:psychiatry, psychiatrist, psychology, mental, health, medicine, podcast, psychiatric, chocolate, psychopharmacology, theobromine, caffeine, suicide, mood, depression, valentine, valentines

Blogged with Flock

Roy: Quotes seen around the blogs

girl MD: "i've already had one cup this morning, but there's no such thing as too much coffee."

* * *

shrinkette: "I've made a rule here: 'No medical advice is given on this site.' But suppose that a commenter says: 'To taper a med, do A, B, and C.' Does that violate my rule? Should I delete the comment?"

* * *

bioethics: "Truth is an important component of the fiduciary responsibility of the physician to his or her patient. But as with the physician's prescription of a medication for treatment of a patient's illness, the maximum dose is not often the appropriate dose to prescribe, should the dose of truth administered to a patient be titrated too? "

* * *

blogborygmi: "If I were a fat pediatrician, I might be a little reluctant to counsel a fat child, myself, because, you know, little kids can't abstract like adults can."

* * *

mind hacks: "Transcranial magnetic stimulation (TMS) is a technique whereby magnetic fields are used to temporarily alter the function of the brain by inducing an electrical current in the brain tissue. ... Much weaker magnetic fields (about the strength of a loudspeaker) ... have also been used to induce unusual experiences by stimulating the temporal lobes ... A new project called Open-rTMS aims to develop this latter type of system (actually, generally not referred to as TMS in the neuroscience literature) and publish the plans and software online. They're currently looking for people to sign up to the mailing list and kick the project off, so if you're looking for a way to alter your state of consciousness with magnets, this might be your chance."

* * *

rebel doctor: "On-line poker is a dangerous and seductive mistress. I fight her allure (usually unsuccessfully) every night."

* * *

john grohol: "I have not been able to see either of these [reality TV] shows since I don’t have access to that channel, but the premise of both is disturbing. I’m also troubled by the idea that there are likely psychologists working as consultants in designing the shows and the experiments."

Roy Unleashed!

[posted by dinah]



I checked the blog yesterday was surprised to find three, count 'em, three new posts by Roy! Is he manic, I wondered? Oh, probably not...just unleashing his pent-up blogs which have been festering... I can only speculate. But this brings me to an interesting study I found, one that pertains to Roy's comments on most frequent diagnoses among psychiatric patients. A landmark 1998 study by Sille, et. al. revealed that the most common psychiatric diagnosis among bloggers is, in fact, Bipolar Disorder, accounting for 61.8% of all psychiatric diagnoses (most recent episode being a Mixed State), followed by Obsessive Compulsive Disorder, with compulsive writing being the most common symptom, followed by compulsive email checking. In a follow-up study done by Monke in 2001, it was found in a randomized, placebo-controlled, double blind study that manic bloggers were more likely to report remission of symptoms, a return to euthymia, and a decrease in compulsive blogging, when treated with a combination of Depakote, chocolate and caffeine. Interestingly enough, none of the bloggers studied responded to either Lithium or any of the novel anti-psychotic agents.

Okay, so I made it all up, but I had fun doing it!

The Starbuck Stops Here

[Posted by ClinkShrink]

The DSM criteria for caffeine intoxication includes restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility and psychomotor agitation. Regardless, the web site for one of the best coffee shops in Charm City has registered over 2.8 million hits in the past two years---that's nearly 4,000 web visitors every day. Why such a demand for such a noxious substance?

Well, duh. There is little question remaining about the addictive nature of caffeine. What remains to be addressed are the implications of caffeine addiction, or caffeinism, on legal or social policy if there is general acceptance that caffeine addiction or dependence is a mental disorder. The DSM is careful to couch it's diagnostic criteria in the following disclaimer:

The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, disability determination, and competency.

Another way of putting this would be: 'just because a diagnosis is in this book doesn't mean you can use it in your lawsuit.' This disclaimer doesn't prevent people from trying, however. Remember the Twinkie Defense? I foresee caffeine withdrawal used someday as a mitigating circumstance for a criminal offense, or perhaps as the basis for an ADA 'reasonable accomodation' claim. Hmm...perhaps my office should always be within walking distance of Starbucks. That's reasonable, right?