Podcast #57: A Matter of National Security

We kept this podcast a little shorter and strangely enough, we didn't ramble or argue or rant. Maybe it was a little boring?

Clink wanted to talk about a report she found online about Dr. Bruce Ivins, a researcher who was a suspect in the 2001 deadly anthrax attacks via the postal mail. Dr. Ivins died of suicide in 2008, and a group was commissioned to look at the process for obtaining security clearances, and where that process may have weaknesses. This gave Clink the opportunity to talk a little about issues that arise when psychiatrists get requests from the government for information about whether their patients pose a threat to national security.

Our links for this portion of our podcast are: A Wikipedia article about Dr. Bruce Ivins and the APA's official document called Psychiatrists’ Responses to Requests for Psychiatric Information in Federal Personnel Investigations.

Our last topic was about the management of pregnant women with opiate addictions and we discussed the use of methadone versus buprenorphine and the effects on the baby. Roy discussed an article from the New England Journal of Medicine, "Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure."

At the end of the podcast, we mentioned that we're coming up on our 5th anniversary of Shrink Rap in late April. Roy had a surprise gift for us! Mugs with the cover of book on them! This was a fun gift. And I had brought chocolate ducks. But of course we took a picture.
Thank you for listening. Please do write a review on iTunes!

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This podcast is available on iTunes 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. Send your questions and comments to: mythreeshrinks@gmail.com.

Midwife With A Knife: Infertility, Stress, and Psychotherapy

Okay, so I'm behind the times, here's a cool post from Midwife With A Knife from 2 months ago-- an interesting post on fertility, stress, and psychotherapy. Oh, and lemurs and monkeys and all kinds of critters, fertile and otherwise. I'm even stealing her lemur photos. I can't quite get the link right but it's the post called "Are you reading my blog?"

MWAK asks how to tell stress-susceptible people they may benefit from psychotherapy without making it sound like you think they are wusses (her word, isn't it great?!). What do you think?

I've never seen anyone for a primary complaint of "I can't conceive" but I face this problem regularly with pain patients. I'm left to say that some people's depression gets funneled into their body as pain or physical symptoms, and it's remarkable how treating the depression can alleviate the other symptoms. I could have sworn I once wrote a post called "You Need a Psychiatrist" about how to talk to people about getting care without sounding judgmental, but I can't seem to find it---must have been a dream.

So for tags we have pregnant pigs, bears, turtles, vultures, fish, glow in the dark cats, but no lemurs or monkeys. What kind of blog is this anyway?

FDA Drugs: March 2007

2007: Feb | Jan . . . 2006: Dec | Nov | Oct | Sep

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FDA Drugs: March 2007

• Zenvia for "Involuntary Emotional Expression Disorder". Avanir Pharm received an "approvable letter" last October for its Zenvia, which is a combination drug of dextromethorphan/quinidine (DM/Q) used to treat what is otherwise known as labile affect or pseudobulbar affect, a brain condition where one will have uncontrollable bursts of laughing or crying without truly being happy or sad. This typically occurs after a stroke or with pseudobulbar palsy or ALS. The FDA had required more data, which the company recently provided at a meeting. The DM is an NMDA antagonist, and quinidine is being used here as a P450 CYP2D6 enzyme inhibitor, which makes the drug stick around longer. The FDA asked Avanir to resubmit a new NDA for a lower, safer dose.[PubMed]


• Cephalon gets yet another Warning Letter on Provigil. The FDA dinged Cephalon again in this Feb 27 letter about inappropriate marketing claims suggesting that Provigil is effective for certain conditions when these data have not been submitted or approved by the FDA.


• Marijuana-based Drug Gathering Data. Sativex is an oral spray containing two active compounds from the cannabis sativa plant being developed for several conditions, including MS-related spasticity, AIDS-related anorexia, and neuropathic pain. Given the fact that it is directly derived from pot plants and the U.S. paranoia about marijuana, I'm sure this drug has a long, uphill battle to get approved here. [PubMed]


• Prozac Labeling Change for Infants. The labeling information for Prozac/fluoxetine now has added info on the risk of Primary Pulmonary Hypotension (PPH) in drug-exposed newborns.
  

  PRECAUTIONS-PREGNANCY-NONTERATOGENIC EFFECTS. Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). PPHN occurs in 1-2 per 1000 live births in the general population and is associated with substantial neonatal morbidity and mortality. In a retrospective case-control study of 377 women whose infants were born with PPHN and 836 women whose infants were born healthy, the risk for developing PPHN was approximately six-fold higher for infants exposed to SSRIs after the 20th week of gestation compared to infants who had not been exposed to antidepressants during pregnancy. There is currently no corroborative evidence regarding the risk for PPHN following exposure to SSRIs in pregnancy; this is the first study that has investigated the potential risk. The study did not include enough cases with exposure to individual SSRIs to determine if all SSRIs posed similar levels of PPHN risk.

  I don't know if all SSRIs will get this language. The link goes to the original NEJM article.
  


• New FDA Info Sheets on:
  

Invega/paliperidone


Keppra/levetiracetam


Trileptal/oxcarbazepine

• Permax Recalled. The FDA announced that the dopamine agonist, Permax (pergolide), has been voluntarily recalled due to concerns about damage to heart valves. Permax was used to treat Parkinson's disease and restless legs syndrome.


• Phase III Trials Started on Flurizan for Alzheimer's. This looks like a promising drug from Myriad to keep track of.
  


• Geodon Label Updated. The labeling info for Geodon (ziprasidone) was updated in the Patient Summary section, to include the black box warning about diabetes and also include the more recent indications for manic and mixed episodes of bipolar disorder.
  


• Symmetrel Label Updated. Apparently, there have been some reports of agranulocytosis (dangerous drop in White Blood Cell WBC count) with Symmetrel (amantadine), which is used as an antiviral, for Parkinsons, for pain, and probably a few other things. The labeling info now reflects this.
  


• FDA Adds Warnings on All Sleeping Pills. The FDA has asked that all makers of sedative-hypnotics, like Ambien, Sonata, and Lunesta, add warnings to their labels about (1) anaphylaxis (severe allergic reaction) and angioedema (severe facial swelling), which can occur as early as the first time the product is taken; and (2)
  complex sleep-related behaviors which may include sleep-driving, making phone calls, and preparing and eating food (while asleep). The warning affects the following 13 drugs and their manufacturers:
  

  Ambien/Ambien CR (Sanofi Aventis)
  Butisol Sodium (Medpointe Pharm HLC)
  Carbrital (Parke-Davis)
  Dalmane (Valeant Pharm)
  Doral (Questcor Pharms)
  Halcion (Pharmacia & Upjohn)
  Lunesta (Sepracor)
  Placidyl (Abbott)
  Prosom (Abbott)
  Restoril (Tyco Healthcare)
  Rozerem (Takeda)
  Seconal (Lilly)
  Sonata (King Pharmaceuticals)

Home Work

This is for our obstetrician blogger friend who wanted some help with her homework: preparing a lecture for OB/GYN residents on psychiatric issues in pregnant women.

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I'm going to ramble (I'm good at that), no references, no specifics.

What do we do about psychiatric disorders in pregnant women? This is a tough question, mainly because we know so very little, it's not unlike the issues that get put forth regarding the efficacy and safety of treatments in children: both are populations that don't get experimented on. To figure out the teratogenic effects of medications (one option in treatment) on the unborn fetus, studies are done on pregnant laboratory animals, which often tell us little about the effects on unborn people. We simply can't design studies that purposefully expose pregnant women to medications and ask Hey What Happens to those kids. What we know is incidental: someone taking the medication gets pregnant, it's reported, outcomes are followed up on. Little is known about exposure at varioius times during fetal development, and outcome is generally limited to structural birth defects and behavior in the immediate post-natal period. So there's nothing that says that a 6 week old fetus exposed to psychotropic drug X is more likely to have reading delays at age 7 or coordination problems or is less likely to fill-in-the-blank. And just to make the story more complicated, we also don't know what effects untreated maternal mental illness have on the fetus, so even if there is some risk from medications, it's looking like very sick mothers aren't good for babies, and maybe the risk of treatment with medication may be better than the risk of not medicating, but this remains speculation as these issues are only just beginning to get the attention they deserve.

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Any way you dice it, I think an obstetrician needs to refer a mentally ill pregnant patient.

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From my shrinky perspective, I believe the fetus should be exposed to a minimum number of Unnecessary medications, I think they are all Potential toxins. I tell pregnant patients that the threshold for medication is raised: I ask them to tolerate some distress for the sake of the baby, we do this anyway. We ask pregnant women to give up all the essentials: cigarettes, alcohol, otc medications, Diet Coke, street drugs, Diet Coke, coffee, hair chemicals. Perhaps we ask pregnant patients to tolerate symptoms of mild depression or anxiety or sleeplessness that we might otherwise offer medication for. The threshold for psychotherapy should also be lowered: talking is unlikely to harm the fetus, frequent sessions provide an outlet for the patient and a means to increase coping mechanisms, and systems are set in place for the therapist to do on-going evaluation and monitoring. Other support systems need to be shored up: family members often must be called upon and all available resources may be needed. A therapist may need to work with the patient on the importance of taking care of herself and accepting help from others: often a difficult thing for moms to do.

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Sometimes, issues related to coping and expected discomfort can be confused with symptoms of mental illness. A woman is sad, tired, nauseated (for Fat Doctor), not eating well, crying. Does she tell her obstetrician that she and her husband are fighting non-stop, that her co-workers are angry about her pregnancy, that the other 5 kids are overwhelming, or does she simply say "I'm depressed," a self-made diagnosis that may or may not be right and may or may not need medications?

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Sometimes, there is no escaping medication: a pregnant woman is so symptomatic that medication must be given. We don't leave patients psychotic (hallucinating or delusional) or manic, or terribly depressed; in these instances we offer medication and do our best to work with what we hope will be safe and we avoid those meds we know are not. I'll leave the lists to you, but the patient gets the best care when the psychiatrist and the obstetrician work together.

So why do I think you should refer? I'll give it to you as bullet points:

• OBs don't spend the time with patients needed to make an accurate psychiatric diagnosis and this is essential.
• OBs don't generally have a good enough handle on diagnosis and treatment of psychiatric disorders to be doing it. (And I don't catch babies).
• If the baby has a bad outcome for any reason, a defense attorney will have no problem targeting an OB who treated a psychiatric illness in an expecting mother.
• If the mother does something horrible because of untreated or wrongly-treated mental illness, this can be catastrophic.
• OB's typically stop seeing the patient 6 weeks after delivery and the patient will need on-going psychiatric care.

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When do you refer?

• If the patient appears to be having psychiatric symptoms that are endangering herself or the baby: a sad mom who isn't gaining the necessary weight due to poor appetite, one example.
• If the patient mentions suicide or harming the baby or any pre-existing children.
• If the patient says she thinks she has a psychiatric disorder or names an illness.
• If you even wonder if you should refer. Phrase it as an evaluation: I'd like you to see a psychiatrist one time just to get a handle on whether there is even a problem.

To our OB friend, I hope this helps.

Nine Months And Counting....And Counting...

I started this post as an email to Midwife With A Knife to help her with her talk about perinatal psychiatric issues. It got long enough that I decided to turn it into a blog post instead. I see Dinah is also working on her part of MWAK's homework and it's a good one. Here goes.

Last November I went to an excellent CME lecture on perinatal OCD. I thought this would be a nice change from the usual maternity-associated illnesses like post-partum depression and psychosis.

First of all, obessive-compulsive disorder is an anxiety disorder characterized by obsessions or compulsions that are time consuming or interfere with social or occupational functioning.

Obessions are anxiety-producing thoughts, impulses or images that are excessive and beyond the range of normal worry about real-life problems. Sufferers usually recognize that they are irrational, and often try to ignore or suppress them. The most common types of obsessions are contamination obsessions followed by obsessions about aggression or the need for exactness.

Compulsions are urges to perform repetitive behaviors or mental acts. They usually happen in response to obsessions and are aimed at reducing distress or preventing some unpleasant event. The most common types of compulsions are checking rituals followed by cleaning or washing. There can also be mental compulsions (repeating words or numbers, counting or reciting prayers.)

The prevalence of OCD is about 1 in 50 people (2.3% of adults). The gender ratio is 1:1 male/female. The prevalence of perinatal OCD is 0.2 to 3.7%. Eighteen percent of new cases occur during the postpartum and 6% during pregnancy. Most women with pre-existing OCD have no change in symptoms with pregnancy, but one-third may have worsening or a change in symptom presentation.

The types of obsessions in perinatal OCD are different than in non-postpartum OCD. Postpartum obsessions are more likely to involve contamination fears or fears of violence (eg. intrusive thoughts to poke the baby's "soft spot", putting the baby in the microwave) than non-postpartum OCD. Patterns of compulsions are also different---postpartum OCD is more likely to involve checking, washing and cleaning rituals. Some OCD patients have been known to call their daycare multiple times a day to neutralize their obsessions.

About half of women with post-partum depression have co-existing OCD, but the OCD is less likely to be diagnosed because of patient concealment and embarrassment. And yes, fathers can get it too.

Treatment usually involves cognitive-behavioral therapy sometimes combined with medication. For the Ob-Gyn crowd, this would be the time to refer. Dinah is writing a good post about meds in the peripartum, so I'll leave that to her.

Hope this helps.

The Good Breast

[posted by dinah]

This one doesn't get a graphic.

From the opinion section of today's New York Times, "About Breastfeeding..."

If you want to start an argument, mention breast-feeding. A two-year federally sponsored campaign caused a rumpus when it compared a mother who fails to breast-feed with a pregnant woman who rides a bucking mechanical bull at a local tavern, or, in one official's formulation, with a woman who smokes while carrying a child. Recently, a Times article on the campaign incited a new debate that kept the report in the paper's most-e-mailed list for days. While we hesitate to stir things up again, it seems as if this is one issue where the middle ground makes the most sense.

The original article, Breast Feed or Else, by Roni Robin, was published on June 13th and states:

Ample scientific evidence supports the contention that breast-fed babies are less vulnerable to acute infectious diseases, including respiratory and gastrointestinal infections, experts say. Some studies also suggest that breast-fed babies are at lower risk for sudden infant death syndrome and serious chronic diseases later in life, including asthma, diabetes, leukemia and some forms of lymphoma, according to the American Academy of Pediatrics.

Both the original article and the opinion piece it inspired discuss some practical reasons women can't breast feed: the logistics of expressing milk at work, or the mother's inability to produce enough milk to nourish her infant.

From a psychiatric standpoint, breastfeeding is a good thing; it helps with the mother's bonding to the infant while creating an environment of closeness, warmth, nourishment, and comfort-- what could be better?

Neither article, however, mentioned what happens when a mother must take medications. The trend is to not only encourage mothers to breastfeed, but to demand it, and now to create the dictate that to not breastfeed is yet one more form of (granted, not yet indictable: sorry Clink and Foo) child abuse. The issue comes up in psychiatry over and over again in the treatment of Post-partum depression. In this condition, the depressed mother is already questioning her competence, she is prone to feelings of guilt, she may be struggling with remorse and distress if there was a separation due to her psychiatric hospitalization, and she may well need to be treated with medications. The last thing she needs is to hear she's harming her infant by not breastfeeding and that her inability to do so is akin to exposing her neonate to cigarette smoke or riding any kind of bucking broncho thingamajiggy.

While one jury's still debating the precise wonders of breastfeeding, another is debating the safety of exposing neonates to psychotropic medications via breast milk. I won't go into those studies here-- most of them look at the immediate effects, or those effects that occur up to age 2 so even if it's found to be safe, the utility of these studies is limited: I want to know how the exposed infants are doing at age 20.

Maybe we will find that early exposure does good things for the infant, maybe it will protect against future episodes of mental illness in a new human being who is already at increased risk (remember, this is my rambling, there is no evidence at all anywhere that this is the case!), maybe we will some day realize that prozac should be in the water supply. In the meantime, however, I'll continue to assume that psychotropic meds might do harmful things to the developing brain. Most of the women I see have stopped nursing before they've crossed my threshold-- it's just been too much to handle in their compromised state. All of them feel guilty. And while I agree that breastfeeding is the ideal, our worlds aren't always ideal or anywhere near it, and I'm left to say that generations of people were raised on formula and people turn out as they will. Zooming asteroids, terrorists, bird flu, and all those known & unknown toxins we drink and breathe, mostly we're just doing the best that we can in a world with no guarantees.


In case I messed up the links:

post partum depression: http://www.womenshealth.gov/faq/postpartum.htm
Breast Feed or Else: http://www.nytimes.com/2006/06/13/health/13brea.html?ex=1151985600&en=4bd49310078f89a1&ei=5087%0A
About Breastfeeding from today's opinion section:http://www.nytimes.com/2006/07/02/opinion/02sun2.html

[Pic per ClinkShrink]