How About a Little Inspiration?

Anyone who knows me as a therapist knows that I believe that change is difficult, and that for the most part, people come flawed.  We seem to spend an inordinate amount of time identifying and trying to fix our flaws so that we conform to some standard of how we're supposed to be, and this leads people to feel badly about themselves and have the infamous  Low Self-Esteem.  Or to feel badly that they aren't richer, prettier, smarter, tougher, whatever.  

I think people should come to terms with who they are and say Yup, I suck at this.  And then they should not spend much time thinking about what they are bad at and they should figure out what things they like and how to grow those aspects of themselves and make those characteristics work for them so they can live a more fulfilling life.  

Obviously, there are exceptions, and I don't think people should say, "Yup I'm a sociopath and I kill people, get used to it,"  Nor do I think people should embrace their mental illness without trying to get help.

That said, and with minimal relevance to what I really want to share, I really enjoyed this TED talk by Dan Gilbert on the pursuit of happiness, and I hope you will too.  I wish I could speak like this (maybe with a little bit more air exchange).  And I stole the Seuss cartoon from Kathy's facebook page.  Enjoy.

Should State Legislators Determine Indications for Medical Treatment?

The FDA evaluates studies on medications and deems them safe enough to justify use.  They also determine the "indications" for using any particular medicine, and once that's done, physicians will often use a medication 'off label.'  That means that Medicine A was found to be safe (or relatively safe, because even over-the-counter meds can be fatal for the wrong person at the wrong time), and it works better than a placebo at treating Disease A, but some studies have found it useful for Disease B, but the FDA hasn't gotten to approving it for this yet, and perhaps never will, but docs use it for Disease B anyway.  This is very common with the SSRI's, where one has been approved for a condition, but maybe the patient isn't tolerating that one so well, so the doc uses another SSRI with a different side effect profile, even though that particular med has not been approved for that particular condition.  Just an FYI, the SSRI's are : Prozac Zoloft Paxil Luvox Celexa Lexapro.   


So the FDA says inhaled marijuana (as opposed to Marinol, a pill form of cannabis) has no medical uses and the discussion is ended.  It can't really be studied at this point, because it has no medical value so your local university can't grow or get any weed and do studies on it, because it has no medical value.  And the federal government says it's illegal.   I do believe that with 16 states disagreeing, that perhaps the FDA should reconsider this stance and repeat a study or two on inhaled cannabis for nausea induced by chemotherapy or anorexia in AIDS so that medical marijuana can be studied, monitored, grown in a pure regulated way, prescribed for a known and proven condition with some parameters like other medical interventions: 30 day supply, directions on how much and how often to smoke it (ah, the pharmacy could roll for you), reassessment so that if your doc decides to give it to you "off label" for your low back pain, and that pain is so much better but funny, you've stopped working, you lie on the couch all day playing Grand Theft Auto, and your life has virtually stopped, the doc can say, "Glad it's helped your pain, but it's put you into an apathetic, amotivational state and your life has now gone down the toilet, I'm stopping this so you can go back to work and pay the mortgage and feed those hungry children."  Or for us shrinks, "Funny, but you didn't have schizophrenia until you started smoking this stuff, let's stop it."  Obviously, if the person has become addicted (and yes, you can get addicted to weed), they'll get it illegally, but the same is true of benzos or opiates, and really medical marijuana just can't be any worse then the fiasco we've had in this country with oxycontin, especially when it gets mixed with a bit of also-legal Xanax and also-legal Vodka, and I can give you a long list of names of people who can no longer testify to this, famous and otherwise.  


So for the moment, the demand for legalized Medical Marijuana is left in the hands of our legislators.  Who better to determine medical indication, necessity, length of treatment, and methods of monitoring.  In Maryland, there was a study group led by the state's health secretary, Joshua Sharfstein.  The plan called for going slow, required training of docs to prescribe it, and required that it be distributed through academic centers.  Two legislators who are pushing bills to legalize medical marijuana called it Misguided and Heartless.


Delegate Glenn of Maryland has proposed House Bill 15, a Medical Marijuana Act.  It provides that marijuana could be used for a variety of conditions.  They include: 

(1) “DEBILITATING MEDICAL CONDITION” MEANS:
(I) A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR ITS TREATMENT THAT PRODUCES ONE OR MORE OF THE FOLLOWING:

1. CACHEXIA OR WASTING SYNDROME;
   
2. SEVERE, DEBILITATING, OR CHRONIC PAIN;
   
3. SEVERE NAUSEA;
   

4. SEIZURES, INCLUDING THOSE CHARACTERISTIC
OF EPILEPSY;
5. SEVERE AND PERSISTENT MUSCLE SPASMS, INCLUDING THOSE CHARACTERISTIC OF MULTIPLE SCLEROSIS OR CROHN’S
DISEASE;

6. AGITATION OF ALZHEIMER’S DISEASE;
   
7. ANXIETY; OR
   
8. DEPRESSION; OR
   

(2)
VIRUS (HIV);

“DEBILITATING MEDICAL CONDITION” INCLUDES:

1. (I)  CANCER;
   
2. (II)  GLAUCOMA;
   
3. (III)  POSITIVE STATUS FOR HUMAN IMMUNODEFICIENCY
   
4. (IV)  ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS);
   
5. (V)  HEPATITIS C;
   
6. (VI)  AMYOTROPHIC LATERAL SCLEROSIS;
   
7. (VII)  NAIL PATELLA;
   
8. (VIII)  POST–TRAUMATIC STRESS DISORDER;
   
9. (IX)  BIPOLAR DISORDER; OR
   
10. (X)  THE TREATMENT OF ANY OF THE ABOVE LISTED CONDITIONS. 
    
    
    On the positive side, the law does require that "compassion centers" to either grow or distribute marijuana be at least 500 feet from pre-existing schools.  Because children can't walk 600 feet?  
    
    I'm told this bill won't pass, but another one, with out the listed psychiatric indications for the use of medical marijuana, may well pass.  I might be more pro-MMJ if the stats didn't reveal that 2% of recipients in Colorado have cancer and AIDS, and that many people are prescribed marijuana by non-psychiatrists for psychiatric reasons, including insomnia.  And if medical marijuana was distributed by a pharmacy with directions on how much and how often to use it.  The one-year toke your heart out cards with the boutique flavors all as part of "wellness" don't fly so well with me.  If people want marijuana to be legal, then legalize it, but this type of legislation puts physicians in the middle as an agent.  Really, if we were talking about people smoking a little during their cancer treatments, this just wouldn't be the issue that it is.
    
    Okay, so my questions for you:
    
    1) A person gets medical marijuana for back pain or anxiety or whatever.  He gets arrested.  Should it be continued in jail?  Prison not be such a bad experience if you get to be high the whole time?
    
    2) Shrink Rap readers don't really like uninformed consent with meds.  How do we feel about giving it to agitated Alzheimers patients and how would that work?  Can you smoke in nursing homes?  Do they have to taken outside in restraints?  Agitation is not usually associated with early Alzheimers.
    
    3) Do we think it's just a little weird that a state legislator is making laws listing which medical indications a drug should be used for?  I must have missed those lectures in residency where pot is the treatment for depression, etc.   Can legislators also decide that methotrexate should be legal for the flu?  I sort of don't get it.  
    
    Okay, my rant for the day.
    

Guest Blogger SG on How the Pharmaceutical Companies Have Damaged Psychiatry

SG put a comment on our last post on The Chapter I Wish We'd Written on Bad Psychiatrists.  With permission, I'm making part of those comments their own post.  I gotta tell you, SG, we shrinks aren't so happy about these issues either.

Per SG:

I don't think the issue is so much a few bad shrinks but bad psychiatry. What I object to most is the pervasive compromising of science by pharmaceutical companies and all-out advertising.

This toxic influence is so pervasive that one comes to the forlorn conclusion that evidence-based medicine as it is currently practiced is really just a way for pharmaceutical companies to generate new revenue streams. The companies are so savvy they realized if they own the evidence through biased studies and suppressed trial data (failed studies, nasty side effects), they would have physicians eating out of their hands and prescribing their pills for whatever they wanted. I really think this dynamic is similar to state ownership of the media by totalitarian regimes.

Of course this is endemic in all of medicine, but psychiatry is uniquely vulnerable to this phenomenon because it has become so rigorously based on medical therapy (read: pills) since the DSM III ushered in the new "biologically based" model of mental health.

I refer the posters on this thread to the 1boring old man website in which a retired psychiatrist has been relentlessly examining internal emails between pharma execs, presentations by prominent psychiatrists like Madhukar Trivedi, seriously compromised studies like STAR-D, and various political infighting between powerful psychiatrists.

It's all very vertiginous and one comes away with the conclusion that the last 30 years of psychiatric "breakthroughs" are largely built on sand.
 
I think it is imperative that psychiatry look at ALL the evidence in evidence-based medicine, even if it provokes cognitive dissonance.

We must remember this about evidence-based medicine: it works on paper, but when you factor in human bias, fear, greed, and stubborn attitudes, you could have the most air-tight science (or evidence) in the world, but if it doesn't tell us what we want to hear, then the medical community automatically thinks it's flawed. How is that true evidence-based medicine?

It's time for psychiatry to come to some harsh truths and own up to them so ALL psychiatrists, even the good ones (and yes there are some good ones!) can practice at a higher standard. Even if a psychiatrist does everything right these days, I know they could do far better if they had a more honest and transparent evidence base to draw on.

Can We MAKE You Crazy?

In today's NY Times Magazine, Ethan Watters discusses cultural influences in the etiology and expression of mental illnesses in his article entitled "The Americanization of Mental Illness." Watters is not a big a big proponent of the idea that psychiatric disorders are brain-based diseases, and he points to ways that Western ideas have changed the incidence and thinking in other parts of the world. Watters writes:

Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge.

Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

Watters then goes on to ask if the medicalization of mental illness does in fact lead to destigmatization. He cites a study where college students give bigger shocks to test subjects trying to learn a new task if they believe the test subject has a mental illness caused by a biological problem rather than a childhood problem. I'll skip even thinking about this study, but why do so many studies have college students shocking each other? Shouldn't they just hit each other with baseball bats?

Watters goes on to conclude:

CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”

Displacement

Displacement is a defense mechanism that occurs when one refocuses an emotion, like anxiety or anger, onto a benign, less-threatening object than the object it is intended for. Kicking the dog is the classic example, with the assumption that it's safer to kick the dog than it is to kick the boss.

Moving is, for me, both an exciting event and a stressful one. Invariably, I deal with it by focusing my energies on worrying about something that is a bit ridiculous. When I finished med school and was leaving my life as a student to become an intern, I worried about finding enough boxes to pack in. When I finished my internship and was getting ready to move out of state and begin residency training in psychiatry, my husband pre-empted my obsession: he went out and bought boxes. (Who buys boxes?) I worried, instead, that there wouldn't be enough shelf space in my new kitchen-- I'd seen the apartment once on a whirlwind tour of apartments and couldn't remember the details. The funny part is that the kitchen we were leaving in New York City measured exactly two-feet by five-feet (yes, I measured it) and had only a single cabinet and no shelves. I'm not sure what I thought I owned that needed so much shelf space, but I arrived in town here to discover that both sides of a long kitchen were lined with shelves, cabinets, and drawers-- more than I would ever fill.

So I'm getting ready to relocate my practice. I'm moving 3 miles and I'm moving into a space that's being tailored to my needs. Oh, but I'm moving one of me into a space with 5 offices: I need some buddies. A couple of people have expressed interest in joining me, and this is exciting! Only I'm not showing any prospective sub-letters the space right now because it a construction zone, full of debris and equipment. Somehow, wandering around the space and muttering "put a door here, move a wall there, change these lights..." came pretty easily. Pick a color for the walls...well, that's where all my angst got displaced to.

Tan. I want tan walls. It's a warm color, it's neutral, it'll look nice with my red chairs. I called a decorator, she couldn't come soon enough. I advertised on a listserv for an emergency decorator, I got a few suggestions and a friend with good taste came to my rescue. She picked a carpet and a paint. The paint went on kind of yellowy. The carpet wasn't available. She picked another carpet ("Mushroom"...do I want mushroom? No one involved was asking me any more). She picked paint. Taupe. Gorgeous. It went up purple. I've been to 4 paint stores and have bought 6 sample quarts. The back of my basement door looks like a an artist's palette. The office looks like...I don't what it looks like, with variations of pinky tans and purply tans and yellowy tans all up all over the place. The property manager has taken to yelling at me "I'll come pick you a color!"
So I've got it, finally: the walls will be Shabby Chic (thank you Benjamin Moore).

What next to worry about? Well the forms, of course!

My Three Shrinks Podcast 47: Genital Retraction Syndrome

[46] . . . [47] . . . [48] . . . [All]

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Happy Thanksgiving!!!

As a big thank you to our readers (and listeners), we three shrinks got our act together and edited one of our most recently recorded podcasts and got it out there, finally. I did the editing and posting this time instead of Roy, which means that it will be less polished, more crackle-and-pop filled and less balanced volumetrically (if that's a word) than usual. So be it. After leaping over a high Garage Band learning curve I figured that was enough of a time investment to begin with and I'd figure out the more polished aspects later. But enough about the process. On to the podcast.

For podcast 47 we started out with a discussion of gender bias in civil commitment when we discussed the book (which none of us have read) entitled Mad, Bad and Sad: Women and the Mind Doctors. Clink talked about the history of civil commitment law (with a brief diversion into the "Beauty and the Beast". Don't ask.).

Then we talked about cholesterol in relationship to suicide (yes, there is one---how weird is that?). Dinah mentioned an article from the March 2008 issue of Psychiatry Cholesterol Quandaries: Relationship to Depression and the Suicidal Experience. Low cholesterol levels were associated with increased rates of suicidal ideation. Unfortunately, the article didn't mention actually what was considered a "low" cholesterol level. A number of PubMed studies supported a relationship between increased rates of low mood and hospitalization for depression in people with low cholesterol levels.

Finally, we talked about disappearing genitals. At the time the podcast was taped there was a rash of alleged "penis thefts" in the Congo; several people were accused of being sorcerers who cast spells to shrink or steal men's penises. We talked about the koro delusion (believing one's penis is disappearing) versus a cultural belief or mass hysterical phenomena of sorcerer accusations (believing that others are causing many men's penises to disappear).

After that last topic I even have the nerve to add: Please, go to iTunes and write a review.

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[Roy was here, adding usual podcast footer links...]

Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed or Feedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.