I've been asked this question twice this week. I think the question is more interesting for the reason why it is being asked than for the actual answer. Even after I've explained the diagnosis and what it means, discussed my treatment recommendations and the risks and benefits of treatment, even after the patient has agreed to try the treatment, they still have to ask if the medication will work.
In prison the obvious reason why someone would ask me this is because it's a prison. Inmates inherently aren't going to trust what they're told or the people treating them. When I hear this, I know that what the patient is really saying is: "Are you telling me the truth? Or are you just giving me something to placate me and get me out of your office?" At other times they are asking this because underneath it all they worry that they may never get well. By the time I see some of these guys they have already been treated by with a list of medications the length of your arm. They may be frustrated and nihilistic about trying anything new, or anything they think they've tried before. Remoralization is the key here, to remind people that they should never give up or lose the hope of getting well. Building trust is a secondary issue, one that may not get accomplished during a single incarceration. Trust is an individual issue that is built up gradually with each patient contact. It can also be fostered (or undermined) by your reputation within the facility. My patients talk to one another, sometimes because they're celling together. The trust question is usually settled before they come to my office on that basis alone; it usually is only an issue nowadays for the guys who have never met me before.
When I am sked, "Will this medication help me?" I know the best answer I can give is, "I believe it will. I know I will do my best to help you."
Monday, September 17, 2007
Will This Medication Help Me?
Sunday, September 16, 2007
My Three Shrinks Podcast 33: Inane Banter
Sorry for the delay in posting podcasts. I didn't get this posted last week due to a family emergency, but should be regular for a while now.
Podcast #34 will feature a guest speaker, Mark Komrad MD, who used to have a nationally syndicated radio call-in show about psychiatry. Be sure to check that out next week.
September 16, 2007: #33 Inane Banter
Topics include:
- Q&A from Jennifer: "In your relationships with the greater world, do you find that you are more compassionate and understanding when it comes to putting up with the foibles of people since you have a greater understanding of the brain? When you see people in traffic driving like they own the road, do you still simmer and think dark thoughts like the rest of us, or do you think, 'well there goes a person who clearly has issues of narcissism (or whatever), and I just hope he doesn't smash into anyone'? Do you find the inane banter of teenage girls less headache inducing because you know the stage is only one of a thousand they will go through on their way to the grave and Oblivion? If a really religious neighbor keeps bugging you about your lack of faith and tries to nag you into going to church with her, would you just smile and thank your stars that you are free of 'invisible friend' delusions? If any of these scenarios are true, I think I may need to go into psychiatry."
We do a decent job of answering these questions.
- American Visionary Arts Museum (AVAM). Clink discusses her observations about this Baltimore museum and some critical comments noted about the squelching of creativity by Psychiatry.
- Involuntarily medicating an "incompetent" defendant. Clink discusses a Baltimore Sun story (couldn't find link) about changes in Maryland created by "the Kelly case". It has now become harder to medicate defendants who are not competent to stand trial.
- Q&A from Emily: "Have you read the book called 'Crazy: A Father's Search Through America's Mental Health Madness' by Pete Earley? It is about the criminalization of the mentally ill. When I read it, my mind was opened to the phenomenon of mentally ill people who commit crimes while under the "influence" of their symptoms, and are punished by being imprisoned rather than getting adequate mental health care assistance.
A few questions for you:
-Do you feel that prisoners who require mental health care are able to be receive adequate assistance while locked up?
-How do you feel about mentally ill prisoners? For example, a paranoid schizophrenic who committed acts such as breaking & entering, destruction of private property, etc while hearing voices instructing him to do so, and winds up in prison rather than a psychiatric hospital. Do you treat people in similar circumstances?
-Something else that the book talks about is mentally ill people who are arrested and put in jail, then deemed incompetent to stand trial and sent to psychiatric hospitals until they can be stabilized, then sent back to the jail where they rapidly decline again for a number of reasons before they can stand trial. And the cycle goes on and on.
-So I was wondering how much of this you witness in your daily work. How often do you see people that you think should be in a psychiatric facility instead of a prison? How big of an issue do you think it is, or what do you think should be done differently?"
Clink addresses these questions, and also her contact with Pete Earley, and about another book of his, Hothouse, about Leavenworth Prison.
| Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening. |
Personality Disorder?: Chloe O'Brian from "24"
If you have watched the Fox show, 24, you know Chloe O'Brian, CTU's best analyst. Dinah and I were talking and it seems she thinks Chloe's character (played superbly by Mary Lynn Rajskub) has Schizoid Personality Disorder, while I think she has Borderline Personality Disorder. What are your thoughts?
SCHIZOID PERSONALITY DISORDER
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. neither desires nor enjoys close relationships, including being part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with another person
4. takes pleasure in few, if any, activities
5. lacks close friends or confidants other than first-degree relatives
6. appears indifferent to the praise or criticism of others
7. shows emotional coldness, detachment, or flattened affectivity
[I don't think she meets 5, 6, 7. Not sure about the rest, though the fact that she has been married reduces the strength of this formulation.]
BORDERLINE PERSONALITY DISORDER
A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, with many of the following features:
1. Frantic efforts to avoid real or imagined abandonment such as lying, stealing, temper tantrums, etc.. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, substance abuse, reckless driving, overspending, stealing, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness, worthlessness.
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights, getting mad over something small).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
[2, 6, & 8 are the characteristics that made me think of BPD.]
I'd say she has a mix of the two. In Blogs4Bauer, Bob noted: "a vote for Chloe is a vote for a knocked-up Asperger's case with borderline anti-social personality disorder with strong leaning to OCD."
In reading Guntrip's criteria in the Schizoid wikipedia article, I am tempted to agree with Dinah (but only tempted).
________________________
Dinah's Input: I decided to join in as a front page-commenter, I hope that's okay, but talk about Meaningful topics, especially now that The Sopranos are gone. Please, commenters, no spoilers--Roy is at the beginning of Season 4, I am nearing the end. I was afraid to check out the Blogs4Bauer blog. Just what I need, anyway, a new blog in my life.
Does Chloe have Asperger's : definitely.
And since Roy likes to list diagnostic criteria:
Diagnostic Criteria For 299.80 Asperger's Disorder
- marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
- failure to develop peer relationships appropriate to developmental level
- a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing, or pointing out objects of interest to other people)
- lack of social or emotional reciprocity
- encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
- apparently inflexible adherence to specific, nonfunctional routines or rituals
- stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
- persistent preoccupation with parts of objects
D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years)
E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood
F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia
So Chloe has 1-4 in the A list and 1 &2 in the B list. I haven't seen her flap and if she's preoccupied with parts of objects, I haven't gotten that far. If you ask me, schizoid and Asperger's have a fair amount of overlap and I haven't found Schizoid Personality Disorder to be a particularly useful diagnostic entity.
In terms of the criteria above for Schizoid Personality Disorder-- you don't have to have them ALL! Few people fit into Chinese Menu descriptions-- I would contend that she's mostly Schizoid. Okay, so she get ruffled and makes funny faces when she's criticized, but she scowls and moves on, Chloe doesn't break down in tears or ruminate when criticized, and many non-schizoid people would. She's a little impervious. Chloe's been married? Unfortunately trying to look this up led me to plot information about Season 5, but it seems Roy is right. I've actually assumed that a lot of the quibbling and tension between Chloe and Edgar results from their inability to address the sexual tension between them-- just my theory. Okay, so Jack's her "friend" and Chase is her "friend" but really, I think they just use her--maybe some vague fondness, but trust me, at the end of the day Jack isn't texting Chloe "Hey want to get a bite to eat." You'll note that when she gets fired in Season 4, she goes home alone, not off to a friend's. And affective flattening? Well, affective something--you aren't going to tell me, Roy, that Chloe is affectively normal.
Chloe as having borderline personality? I don't see it. I'll let our readers chime in. So she gets miffed. I don't think her relationships are all that intense or unstable. And she's chronically irritable, is that affective instability? No signs of euphoria or depression. You'll tell me if I'm wrong. And even if she does have a mild degree of one of two these features, that doesn't give you the diagnosis. OCD-type rigidity? Yup-- kind of goes with the Asperger's Diagnosis. And I also don't see the Anti-social thing.....now Jack, in the name of the greater good he can execute his own boss and a tear or two later he's back in the saddle......I hope it's okay that I jumped on Roy's post... great pic, great topic, great show.
________________________
::sigh::
Roy here. So we're gonna have all our comments within the post, huh? Okay. I agree that the affective instability is more driven by irritation with others' perceived incompetence (hmm, perhaps a touch of OCPD or NPD). [you all know, we're just having a bit of fun here; not taking the show too seriously, so please no "it's just a TV show!!" comments. tx]
But she does NOT meet criteria B1 and B2. B1 says "encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus." She is at work, so of course she has a preoccupation. There is nothing abnormal about her intensity or focus... it's her job! Lives are at stake.
B2 says "apparently inflexible adherence to specific, nonfunctional routines or rituals." Again, this is a work requirement. Her type of work requires such adherence to routines. However, she is not really so inflexible, as evidenced by her bypassing usual protocols when Jack asks her to, despite the fact that it could get her fired or in jail. She sees the bigger picture, and so tries to do "the right thing", not the correct thing.
So, I don't see any of the B criteria. And, if you look at the OCPD link above, you'd think that these criteria fit her to a T. But, it is important to remember that many of these characteristics are necessary for her work. And we really only see her in work settings, so it is hard to assess these. I think she has nearly none of the OCPD criteria. And, the only piece of Narcissistic PD criteria she meets is that of lacking empathy.
[You all can see why many of us don't focus too much on personality disorder classification. Too subjective.]
Friday, September 14, 2007
Talking About The Right Things
But this is the thing: given that my post was about patient compliance, it really wasn't about compliance with Psychotherapy, it was more about compliance with medications and behavioral suggestions. Until Gerbil chimed in, I really wasn't thinking at all about compliance with psychotherapy or resistance.
There is an obvious way a patient can be non-compliant with psychotherapy: They can simply not show up. But let's push that one aside-- and let's just say the patient shows up on time. Is it possible, then, to be non-compliant with psychotherapy, in essence, to not talk about the rightt hings? I presented my Are You My Patient? post with an edge of frustration. Is it reasonable for the therapist to get frustrated with a patient because the patient doesn't talk about the right stuff?
In a traditional psychodynamic psychotherapy patients are urged to dig deeper, to talk without censoring, to explore and breakdown defenses, to travel down that royal road to the unconscience and resolve all those conflicts while unrepressing the long-ago repressed. The treatment of trauma-related disorders often calls for the patient to talk about difficult things that have happened in the past. Clearly, there are right and wrong things to talk about?
Maybe there are things that should or shouldn't be said in psychotherapy. I rambled last year about What Patients Talk About In Psychotherapy (-- at least check out the cartoon!) and I tried to make the point that people often talk about mundane things. I would contend that it's pretty hard for patients to talk about the Wrong things in psychotherapy. Patients generally come and talk about whatever is important to them, and they usually find this helpful, even if it's not anything terribly difficult, shameful, or all too deeply hidden in their psyches. Some patients talk in very introspective and insightful ways about pretty powerful things, and then say it's no big deal, it isn't particularly helpful, and while they seem to be doing great work, nothing changes. Other patients talk about things they could easily share with a friend-- nothing all that personal or earth-shattering, and relate that it's extremely helpful and they get a lot of relief. If a patient says there's something they don't want to talk about, well...I might push a little, but mostly I respect this-- it can be addressed later or not at all. Psychotherapy, even if difficult at times, should ultimately offer relief and shouldn't be about badgering or belittling the patient. Oh, and the other thing: the relationship itself is much of what helps, and this relationship happens (in good or bad ways) regardless of what is said.
H.R. 1424 - Wellstone Mental Health & Addiction Equity Act of 2007
Here is the Congressional Budget Office's analysis of what the costs will be. Some highlights...
H.R. 1424 would prohibit group health plans and group health insurance issuers that provide
both medical and surgical benefits and mental health benefits from imposing treatment
limitations or financial requirements for coverage of mental health benefits (including
benefits for substance abuse treatment) that are different from those used for medical and
surgical benefits.
Enacting the bill would affect both federal revenues and direct spending for Medicaid,
beginning in 2008. The bill would result in higher premiums for employer-sponsored health
benefits. Higher premiums, in turn, would result in more of an employee's compensation
being received in the form of nontaxable employer-paid premiums, and less in the form of
taxable wages. As a result of this shift, federal income and payroll tax revenues would
decline. The Congressional Budget Office estimates that the proposal would reduce federal
tax revenues by $1.1 billion over the 2008-2012 period and by $3.1 billion over the 2008-
2017 period. Social Security payroll taxes, which are off-budget, would account for about
35 percent of those totals.
The bill's requirements for issuers of group health insurance would apply to managed care
plans in the Medicaid program. CBO estimates that enacting H.R. 1424 would increase
federal direct spending for Medicaid by $310 million over the 2008-2012 period and by
$820 million over the 2008-2017 period. In addition, assuming appropriation of the
necessary amounts, CBO estimates that implementing H.R. 1424 would have discretionary
costs of $20 million in 2008, $143 million over the 2008-2012 period, and $322 million over
the 2008-2017 period.
. . .
Under current law, the Mental Health Parity Act of 1996 requires a more-limited
form of parity between mental health and medical and surgical coverage. That mandate is
set to expire at the end of 2007. Thus, H.R. 1424 would both extend and expand the existing
mandate requiring mental health parity. CBO estimates that the direct costs of the private-
sector mandate in the bill would total about $1.3 billion in 2008, and would grow in later
years. That amount would significantly exceed the annual threshold established by UMRA
($131 million in 2007, adjusted for inflation) in each of the years that the mandate would be
in effect.
Their analysis does not appear to take into effect the increased tax revenue resulting from increased wages and productivity from improved mental health treatment, nor does it seem to reflect the reduction in state and federal payments for uninsured individuals resulting from folks reaching their current discriminatory maximums. This analysis seems a little incomplete, judging from the summary.
Thursday, September 13, 2007
Who's Your Mama?
You know it's a bit confabulated.....
So one of my patients happened to mention today that her son is a coach in a league one of my kids plays in. I must have known this, she must have mentioned it when I first took her history, eighteen months and two playing seasons ago. Today, at the end of the day, hours after she left and as I was writing progress notes, it suddenly hit me: her son is my kid's coach. It was this funny, disconcerting feeling.
Now the fact that a patient's son coaches my kid isn't really a big deal. Only I wish I could say that my kid is the ideal player, the coach is a wonderful coach, that I've never actually had reason to speak with the coach, or if I did, that it was a warm and rewarding experience. Let's just say that's not the case, the coach is a little weird, my kid once had an issue and I'd felt a need to intervene.
And now I can wonder, who knows what? This particular patient has no qualms about announcing her struggles with psychiatric illness. I know the son knows she has shrink, I can't imagine my name doesn't get uttered here and there-- she comes to sessions and sometimes says "Little Howie said to be sure I tell you such-and-such." Only I have a fairly common last name and like my patient, my family members all seem to have different last names (--Max has requested that I not publish his last name on the blog). I now can wonder if Coach related to me, Neurotic Mom, all the while thinking You're My Mom's Shrink. Or maybe he worried that she tells me personal things about him. Maybe we've had a whole unspoken relationship that I just missed. So, Coach Howie, if you're out there, rest assured that Mom says all nice things about you.
It's fine that I treat Coach Howie's Mom. This is the part that's disconcerting-- I realized that I relate a bit differently to different people in different places in my life. With patients and their families, I keep it pretty even and I try to remain professional (I hope). No ducks at all. Without even trying, I'm a slightly different person when I'm the doc than when I'm the mom. In my non-doc role, I talk more, I listen less, and I tell raunchier jokes. I might look to Coach Howie for wisdom or understanding. If I'm frustrated I might be more sarcastic than I'd ever be with the family member of a patient. I'd never complain to the family member of a patient, even in a non-clinical setting, that he was an idiot for not starting my kid when the kid he did start was clearly an inferior player. (--oh, I didn't really do that, but it was fun to confabulate).
Coach Howie, you have a lovely mom.
Wednesday, September 12, 2007
Nursing Bears and Jail Babies
When it gets to the point that I'm repeating myself I think I may have been a blogger too long. Roy's post on the nursing bears spurred me to do this post about a new rehabilitation program that was featured in our local paper recently. I'm commenting on this at the risk of looking like a cynical cold old coot, but at least I'm consistent. I had the same reaction that I had when writing my old post Gummy Bears and Jail Babies.
The program is called Chrysalis House Healthy Start and it's designed for nonviolent pregnant inmates. The theory is that instead of serving time in a jail or prison, the pregnant inmate gets released to a house in free society where she learns to be a parent. It was funded by a $675,000 grant and is being run by a coalition of non-profits.
One of the first two occupants mentioned in the story is a drug-addicted prostitute who was pregnant for a second time after having to give up custody of her other child, a two year old son. The program uses the services of several professionals: a nurse, two behavioral health clinicians, a social worker, day care assistants and a life skills counselor. According to the article, they are encouraged to "meditate, set life goals and raise self esteem". Apparently it also involves field trips: after the first residents moved in they all took a trip to the National Aquarium.
OK, here comes the cynical old coot part: will they teach family planning? By the time they leave the program, will they be able to spell or to read? Will they be educated? Will they have any job-seeking skills? If they actually require six professionals to be a parent while living in the house, perhaps foster care is not such a bad idea instead, at least until they can show they don't need to rely on six professionals? Why is it necessary to turn a baby into a rehabilitation tool?
The Healthy Start program is a replacement for a previous program that failed called Tamar's Children. Tamar's Children shut down in part because of concerns about the quality and nature of the therapy being given to these women. I saw nothing in the newspaper article to suggest that the new program would address this concern. If they are truly seeing a trip to an aquarium as a therapeutic intervention for bad parenting, I'd like part of my $675,000 tax money back.
Tuesday, September 11, 2007
Psychiatrist Films Bear Cubs Nursing
Sunday, September 09, 2007
Are You My Patient?
I'm actually blogging (or starting to blog) from our hotel room at the beach, waiting for the kid to wake up so we can check out and catch some final rays and junk food. It's our traditional weekend-after-Labor-Day away with the Camel Family, a final sweet kiss goodbye to summer. With many thanks to ClinkShrink for moving in with Max and the teenager who couldn't miss practice.
So Fat Doctor has up a great (aren't they all?) post about patients who check in to the hospital with abdominal pain and then refuse either the work up or the necessary intervention. There's the guy with acute appendicitis who won't allow surgery ....and if that hot appendix ruptures, the mortality rates are quite high, even I remember that. I read it and wondered, just like Fat Doctor, if you don't want treatment, why go to a hospital? Okay, okay, I'm being harsh, maybe AppyGuy is only refusing surgery and had hoped there was another option for treatment-- maybe he's taking antibiotics and this will help and maybe he won't rupture and will get better. But to refuse a non-invasive work-up? Or to die rather than have a routine procedure?So here's another good thing about being a psychiatrist: patients rarely die (and even more rarely from their psychiatric disorders) and we Never send patients out thinking there's is the Probability they will die from their psychiatric symptoms. I'm not saying we always get it right...sometimes patients hide their symptoms, sometimes they talk about being suicidal so often that we lose the ability to distinguish when it becomes imminent, but if we think the patient is in danger from their symptoms, we hospitalize them, either voluntarily or involuntarily.
I work in a private practice and in two clinics; I haven't set foot in an Emergency Room for years. It's been a really long time since I've hospitalized anyone involuntarily and I'm happy about this. While in psychiatry, there are moments when it's absolutely necessary, for the most part, I don't like making decisions for other people.
In outpatient practice, people often have very strong opinions about what kind of treatment they want when they walk through the door. It's not uncommon for me to tell people on the phone before I see them that I don't provide the treatment they're looking for and they'd be better served by someone else (--there are lots of psychiatrists in Baltimore, if someone is looking for a doc to prescribe high-dose Xanax, I'm just not it). Other people are pretty set on what kind of treatment they don't want.
Mostly, I try to work with people, I try to give them what they want or help them understand why what they want isn't the right thing to want. So Prozac helped your friend and you'd like to try that? I might think Lexapro is a better choice, and I'll tell them why, and if they still want Prozac, well, perhaps I let that choice be theirs. So Prozac helped your friend and you'd like to try that? Oh, but you have Bipolar Disorder, something totally different than your friend has, and Prozac may well destabilize you, throw you into a dangerous manic episode, shorten your cycle length, and worsen your overall prognosis: I think we should try a mood stabilizer first and only after that's on board should we even think about adding Prozac or any other antidepressant. You get the idea. And yes, I'll tell you why I asked what your favorite SSRI is soon, but in the meantime, if you haven't voted on our sidebar poll, please do.
Sometimes a patient tells me they won't take Drug X. Ever. And if I think Drug X offers the best chance of relief or recovery, I persist in telling them this. My kids can assure you that I'm very good at repeating myself to the point of nagging. Mostly, I convince people to at least try what I think might work best, but I have never, ever, said to a patient, "If you won't take Drug X, I won't treat you." That's just not what this is about.
Thinking about the Fat Doctor dilemma, there is a psychiatric correlate. Mostly I'm either able to talk patients into trying it my way, or I'm able to achieve some level of comfort while they do it their way. Every now and then I have a patient who is really suffering (or is behaving in a way that causes others to suffer) and who repeatedly foils any shot at recovery. They're miserable, and yet they refuse any treatment suggestions--either they argue with every suggestion I make, or they simply don't do it. The don't get blood levels, they won't try another medication, they won't raise the dose of the old medication or even take the old medication that worked for them the last 14 times, they won't try any behavioral changes (regular sleep hours, exercise, stop the substances, give up the boyfriend who beats you), they won't allow me to communicate with crucial significant others in their lives, they call all the shots, leave me standing there feeling helpless. And before you click on the comment button to tell us about the one or two times you didn't do what your doc suggested, that's not what I'm talking about-- I'm talking about the person who comes, pays, says they want help, but doesn't follow ANY recommendations. I'm sometimes left to point out this dynamic and say "Are you my patient?"
Friday, September 07, 2007
Suicide Rates Shoot Up in Youths
Dennis O'Brien reports in today's Baltimore Sun that the suicide rates in children and adolescents have increased since 2004, after over a decade of decreases. It was in 2004 that the US FDA decided to add black box warnings to antidepressants stating that they may increase the risk of suicide or suicidal thoughts. Many speculate that the sudden and dramatic increase is related to the 22% decrease in antidepressant prescriptions in this same population.
As noted in our review of a June 2007 AJP article in Podcast #26 (Black Box Reloaded), there was a 58% drop in the expected number of antidepressant prescriptions for kids after the black box was added, while the proportion of depressed children who remained untreated with antidepressants increased some three-fold, going from 20% to 60% (see dramatic graph). At least at last year's FDA hearing, they decided to make a more measured warning, noting that antidepressant medication treatment can be protective and reduce suicidality, as well.
O'Brien wrote:
Among people ages 10 to 24, the number of suicides jumped from 4,258 to 4,599 in 2004, the most significant rise in teen suicides in 14 years, according to a report by the Centers for Disease Control and Prevention. That reverses a 28 percent slide in suicide rates for the age group that began in 1990.We also reviewed two other articles (Simon & Savarino and Gibbons et al) about the timing of suicide and treatment in Podcast #30 (Parity Feels Like a Bird). These articles point to increased rates of suicide attempts prior to the initiation of either antidepressant or psychotherapeutic treatments.
. . .
"There's been concern that the black box would lead to a reduction in prescribing and therefore an increase in suicides, and my guess is that's what's happening," said Dr. Mark Riddle, director of child and adolescent psychiatry at the Johns Hopkins Children's Center.
Some doctors are reluctant to prescribe an antidepressant to a child if it comes with the FDA's most stringent warning label, Riddle said: "People see it as a potential feeding frenzy for the malpractice lawyers and it's just scared the clinicians off."
. . .
But other outside experts were reluctant to link the black box warnings with a one-year rise in suicides. . . "There are so many social issues that go into suicide rates and how they're reported."
The September 2007 AJP article by Gibbons et al
(a different article than the Gibbons article above) that is mentioned in the Baltimore Sun story provides data on reductions in antidepressant prescriptions by age category since 2004, clearly showing that the reductions are most pronounced in the youngest age groups and become less so with older groups. The only group with an increase in prescription rates is 60 years and older. This is the age group which the FDA has found to be most clearly protected by antidepressant treatment.The article, entitled "Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents," concludes with the following warning:
In December 2006, the FDA’s Psychopharmacologic Drugs Advisory Committee recommended that the black box warning be extended to cover young adults, and in May 2007, the FDA asked drug manufacturers to revise their labels accordingly. If the intent of the pediatric black box warning was to save lives, the warning failed, and in fact it may have had the opposite effect; more children and adolescents have committed suicide since it was introduced. If as a result of extending the black box warning to adults there is a 20% decrease in SSRI prescriptions in the general population, we predict that it will result in 3,040 more suicides (a 10% increase) in 1 year (17). If the FDA’s goal is to ensure that children and adults treated with antidepressants receive adequate follow-up care to better detect and treat emergent suicidal thoughts, the current black box warning is not a useful approach; what should be considered instead is better education and training of physicians.
Wednesday, September 05, 2007
The Reality (TV) of Jail
OK, I just saw the first episode of the new reality TV show, Jail, on WUTB last night. I understand this is a remake of the cable show Inside American Jail from Court TV but I've never seen that since I don't have cable. Anyway, this really is a show people should see. It was created by the same people who made Cops, and it's based on the same premise. The show follows sheriffs around as they process new arrestees at various large urban jails.
Last night's episode featured lots of people under the influence of drugs and/or alcohol. It showed the booking process, the intake medical screening process and the suicide prevention measures. It gave a good glimpse of the people who come to jail, why they come there and the condition they're in on arrival. It was easy to pick out the detainees with altered mental states but not nearly so easy to tell whether that change was from psychiatric problems or substance abuse. One pretrial detainee highlighted the medical problems jails deal with---he had a single tooth hanging from his upper jaw. When the officer doing medical screening asked him if he had dental problems, he burst out laughing.
The episode I saw featured three different large urban jails. All the jails were more spacious, cleaner and quieter than the ones I've been in. Maybe it was just a good time of night, but I was surprised to see their booking cells only held one or two people at a time. There was no obvious blatant profanity or shouting, but then again with the FCC fines being what they are I'm sure the networks would screen this out. I thought the show did a good job of illustrating the plight of the average new arrestee. As one first-time offender put it, "My bond is only $400 and a lot of people here have it a lot higher, but when you've got nothing it might as well be a million."
Some folks may feel a bit of guilty voyeurism watching this show, but let this pass: This show should be mandatory viewing for all people who want 'tough on crime' policies.
Tuesday, September 04, 2007
Guest Blogger Ron Pies-- Religion & Psychotherapy: Two Armed Camps or Allies of the Soul?
Hey, I made a friend on Shrink Rap!
Dr. Ron Pies is a Professor of Psychiatry at both Tufts and
-Chief of Psychiatric Times. I invited Dr. Pies to be a guest blogger, and here's what he sent: Religion did not sit well with the early psychoanalysts. Although Freud’s views 
evolved over the many years he spent analyzing religion, he generally explained religion as a kind of neurotic “compromise”: focused as it is on an all-powerful “Father-God”, religion allows us to admit our vulnerability in the world, while also giving us a feeling of superiority and control. We become “God’s children”, develop all kinds of rituals and prayers designed to gain God’s good will, and thereby secure our place in the scheme of things. [I am oversimplifying greatly—for those interested in Freud’s views on religion, I recommend the web site of Prof. Jurgen Braungardt, a philosopher and psychotherapist]. For Freud and most of the early psychoanalysts, religion was a sort of childish problem to be, well, outgrown—often through the aid of psychoanalysis. Modern-day critiques of religion—witness the spate of books by Daniel Dennett (Breaking the Spell), Sam Harris (The End of Faith ) and many others—also focus on the supposed “irrational” or extremist elements of religious faith.
There is some truth to these critiques of religion, but in many ways, they obscure as much as they illuminate. For no matter how many theories we devise as to how religion arose, or what “neurotic” needs it may serve, we will never succeed in refuting the basic claims of most conventional religions; i.e., that there is a “Superior Being” of some sort; that this Being created and guides the universe; and that we are all governed by universal and “God-given” moral principles. There are simply no scientific experiments that could conceivably refute these claims—for no matter how many failed attempts to “detect” such a Superior Being, it is always possible that the very next experiment would succeed. And even if religion first arose out of some neurotic need to keep “Big Daddy” happy and on our side, this does not disprove the existence of a Father or Mother (or any other) God. (Imagine a primitive tribe that had a “neurotic need” to believe in tiny, sub-microscopic particles—this would hardly serve as evidence against the existence of atoms!).
But there is a deeper and—from my perspective as a psychiatrist—more important sense in which the critics of religion have missed the proverbial boat. This involves their failure to distinguish what I would call pathological religiosity from the religious impulse. Think about it this way. Mr. A. is convinced not only that his religion is valid, but that it is the only “true faith”, and that everybody else is a “heretic”. Mr. A. is completely impervious to any attempts to challenge his beliefs, rituals, or religious practices. Any attempt to do so sends Mr. A. into fits of frothing rage, and violent fantasies of “avenging the slur against the One True Faith.” Furthermore, when Mr. A. violates his own religious commandments, he is thrown into deep bouts of self-hatred and depression.
Sound familiar? Mr. A’s relationship to his religion encapsulates, in my view, a certain type of fanaticism that has become all too familiar in our age. (Fanaticism, by the way, can exist in folks of any faith, or no faith at all—it is a psychological type, not a religious label). Mr. A’s religiosity is clearly at odds with most traditional goals of psychotherapy; namely, reducing excessive guilt and anger, broadening the individual’s perspective on life, and increasing the patient’s “cognitive flexibility”. Mr. A. would be one tough customer in psychotherapy!
Now consider Ms. B. She describes herself as “not a religiously observant” individual, but one who does attend religious services “when I’m feeling a little lost or alone.” Ms. B. is not sure she believes in an all-knowing, all-powerful God; however, she says that, “I feel like there is something out there greater than us—some kind of order or intelligence in the universe that I feel drawn to very strongly.” Ms. B. has undertaken psychotherapy in order to “help me figure out who I am, and where I’m headed—like, is there a purpose to life beyond just working and getting by?”
Ms. B.’s relationship to faith is clearly very different in tone and content from that of Mr. A. Indeed, Ms. B would find little difficulty relating to many traditional psychotherapists, all other things being equal. In fact, one type of psychotherapy, called Existential Therapy, would be nicely suited to the kind of exploration Ms. B. is seeking. She represents what I call the religious impulse—a yearning for something larger than ourselves, often manifest as a sense of awe, mystery, or ineffable bliss. (The word “religion” is probably derived from the Latin, ligare, meaning to “bind” or “connect”—as in feeling “connected” to some larger community, set of laws, or spiritual purpose). I believe Freud would be quite wrong in regarding Ms. B’s religious impulse as “neurotic” in any way. Her sense of wonder and awe is certainly not a feeling I would ever want to “outgrow.” On the contrary, Ms. B’s powerful attraction to some transcendent “order or intelligence” in the universe is quite like the feeling expressed by Albert Einstein—arguably the greatest scientist since Isaac Newton. Einstein said
"Try and penetrate with our limited means the secrets of nature, and you will find that, behind all the discernible concatenations, there remains something subtle, intangible and inexplicable. Veneration for this force beyond anything that we can comprehend is my religion. To that extent I am, in point of fact, religious.”1
Not only should psychotherapy be tolerant of this mature kind of religious impulse, its goals should be compatible with those of such a seeker. This is not to say that psychotherapy should be intolerant of more conventional or orthodox forms of faith; it is just to say that, in so far as the religious impulse veers over into pathological religiosity, its difficulties with traditional psychotherapy will multiply.
In my book, The Ethics of the Sages, I try to show how several different religious faiths hold views compatible with those of cognitive-behavioral therapy (CBT). For example, in the Jewish tradition, we are instructed, “…do not consider yourself wicked.”
[Pirke Avot 2:18]. The rabbis believed that, while we could certainly judge our individual acts as “wicked”, we should not entirely condemn our very being. (Hence, the modern-day expression, “Hate the sin, not the sinner.”). All this is quite compatible with a type of CBT developed by Dr. Albert Ellis, known as Rational Emotive Behavioral Therapy (REBT). Ellis (who died just recently) argued that, “If human beings have any intrinsic worth or value, they have it by virtue of their mere existence, their being, rather than because of anything they do to “earn” it...You are “good” or “deserving” just because you are…” 2
Similarly, in another portion of the Talmud [Pirkei Avot 2:21], we are told, “...it is not up to you to complete the task, but you are not free to desist from it...” This teaching is part of a powerful "anti-perfectionism" in Judaism. It tells us, in effect, “Don’t condemn yourself if you don’t finish everything successfully—but don’t just give up on it, either.” This is quite consonant with the position taken by Ellis and Harper: “People who lead a lazy, passive existence...are almost always (consciously or unconsciously) defending themselves against some irrational fear, especially the great fear of failure. Viewing failure with horror, they avoid certain activities that they would really like to engage in...” (A Guide to Rational Living, p. 174).
There are many such fruitful intersections between psychotherapy and various religious traditions. The values of psychotherapy—and let us be clear, there are such values—may never coincide completely with those of traditional religion; but neither do psychotherapists and the religiously faithful need to be adversaries. Though they proceed from different premises and may seek different goals, psychotherapy and religion may yet be “allies of the soul.”
Albert Einstein, Response to atheist, Alfred Kerr (1927), quoted in The Diary of a Cosmopolitan (1971)
Ellis A, Harper RA: A Guide to Rational Living; No. Hollywood, Wilshire Book Co., 1971, p. 89
Monday, September 03, 2007
How to Raise Teenagers: I Must Have Slept Through That Lecture
Those of you who are regular readers may recall that in addition to being a psychiatrist, writer, and podcasting blogger, I am also the mother of two teenagers. It's okay, no surprises here, after all I went to medical school and I'm a psychiatrist which means I'm an expert in human behavior, those teenage years being just part of the developmental process. I know exactly what to do and say to assure that I have wonderful, happy, mentally healthy, well-adjusted, and successful children who glide through life glitch-free and openly share with me any of the little bumps they might encounter along the journey.
And now let me tell you about this little bridge I have for sale, it's a great bargain.
And let me tell you what they teach you about raising children in Medical School and Psychiatry Residency Training Programs. They don't teach you anything, at all, ever, about normal developmental adolescent behavior. Somewhere along the line I learned that babies develop a social smile between 5 and 8 weeks of age and they should be fed whole milk until age 2. Either the information stopped there, or I blocked everything else out.
Pediatrics rotations in medical school take place on an inpatient medical unit. I saw children with leukemia, babies with failure to thrive, kids with acute abdomens, and inevitably half of morning rounds went like this: "Bed A suffered burns on her right arm when mom's coffee spilled on her, Bed B has burns on his left leg from dad's spilled tea...." I did learn that parents should be very careful about hot beverages, hot bath water, and space heaters (--there was a major burn unit in the hospital where I studied). We had lectures on diarrhea while we sat around a table eating cookies. Not once did anyone tell me that it's completely normal for formerly articulate, intelligent boys to suddenly stop speaking and merely grunt for years at a time. Nor was there a course that mentioned how it's impossible for the mother of a teenage girl to dress right...or even breathe right. Honestly, I thought my own mother--who handled my obnoxious teenage years with grace-- embarrassed me because she was embarrassing. It didn't occur to me until I had teenagers of my own that it had more to do with me than with her.
Three months on an inpatient child psychiatry unit, with shifts in the pediatric ER, didn't help. I met kids who were completely out of control, chronic runaways, children who'd been violent in their group homes. In the ER I saw suicidal teenagers and had no where to place them --try finding an inpatient bed for an uninsured suicidal teen who's parent says they've had it won't take them back. Not only did I not learn a thing about normal adolescent development, but I saw the worst case scenarios of children who'd had lives that were tragically devastated at young ages, already paragons of loss, chaos, and upheaval. It wasn't a setting filled with hope; it takes a lot for a child to end up in an inpatient unit in an inner city teaching hospital.
Okay, so teenagers, this is the thing I'm figuring out: It's a stage, it's its own distinct thing, and being a psychiatrist, I have this tendency to look at my teenager's behaviors and extrapolate them to adulthood. I'm just getting it that a lot of normal teenage behavior looks surprisingly like impending disaster. Nothing about being a doctor helps with this, most of what I've learned being a psychiatrist makes it hard to keep things in perspective, especially when living with a teenage boy.
I'm not much for How-To-Raise-'Em books. Mostly, I thought we were doing fine by gut, but lately I've decided we could use a little help. I bought some books, I even read them, and I thought I'd share my thoughts about these books with you.
This was my favorite:
Get Out of My Life...but first could you drive me and Cheryl to the mall?
by Anthony E. Wolf, PhD.
This book was laugh-out-loud funny with descriptions that resonated so strongly I was left to ask how this guy knew my kid.
"What happens is that teenage boys develop terminal lethargy. They seem to catch a lengthy case of sleeping sickness. They appear to do nothing. If the normal speed of human activity is one hundred rpm's, teenage boys seem to go at around six."
You mean that's normal??? Why didn't anyone tell me? What a relief! And the list continued. I won't say I agreed with every thing Dr. Wolf says-- he sounds more willing to tolerate certain behaviors than I would ever be, but overall this was a quick read and did more for cuing me into Why I Shouldn't worry, What I Can't Control, and Why I need to Let Go, more than psychiatry ever has. Relief: yes. Sadly, I'm left knowing that my children are pushing me away because they are growing up and doing all the things they should be doing, and while it's always been easy to rejoice in their milestones, these stages entail a bit of quiet grief as I come to terms with the fact that my children will never have the relationship they had with me when they were little.
I Wanna Be Sedated, edited by Faith Conlon and Gail Hudson, is a collection of 30 essays
by professional writers all on parenting teenagers. Okay, I admit it, I bought the book because the title was irresistible and at the moment I was surfing for books about raising teenagers, I really did want to be sedated. Some of these stories were hysterical-- we had both our kids read "How To Lie To Your Parents" by David Carkeet. "Mom? Everything's Okay, but..." by Linda Rue Quinn was funny even though neither of my children have actually set any part of our house on fire. The stories varied: funny, poignant, sad, even boring, but for the most part it was a compelling read. There were no parenting tips, it really was just the sharing of stories, and a reminder that teenagers, while in many ways alike in their stages, differ greatly in how easy or hard they can be to raise and what kind of people they actually are. The honesty of the writers was brutal at moments, at many points I was simply thankful not to share their problems, at other points I felt I'd found a kindred spirit. I smiled at Stephen J. Lyon's essay, "Commuting With Rose." He writes, "Anyway, as a parent of a teenager, you are always off balance--grasping at straws, parenting books, or a bottle of Zoloft. So you ten to stay with any small success. Sociologist love to rattle off statistics about how many minutes per day fathers spend with their children, always discounting the power of silent communication and the value of mere presence, along with the all-important fatherly stare and raised eyebrows. And they rarely speak of how little or erratically a teenager wants to relate with any parent." Finally, I looked at Staying Connected to Your Teenager by Michael Riera, Ph.D. This is a more conventional How-To book and I had a harder time staying with it. In the first chapter, he suggests trying to talk to your teenager after midnight, and for a while, I'd try to stay awake that long. I made smores one night with my son and he recited to me the Shakespeare he'd had to memorize for school--it was definitely worth staying awake for and not a conversation that ever would have been had at a more civilized hour. Otherwise, though, it felt like the author had all the answers and I think my challenge has been to make peace with the fact that there probably are no real answers.
Sunday, September 02, 2007
My Three Shrinks Podcast 32: Doctor Anonymous on Depression Overdiagnosis
Today's podcast features a guest, Doctor Anonymous, who joined us via Skype. DrA is a midwest US primary care physician who blogs about medicine and health care. We've been trying to get him on for a while, but call schedules and such just didn't align. We both had Skype set up, I added Call Recorder (which allows you to easily record both sides of the conversation, each on a different channel), and it went off without a hitch.
DrIzzy from Michigan added a complimentary iTunes review (thank you), but he commented on our sound levels, which we agree are sometimes subpar. He points out that, since we have made the podcasting "big time" (LOL), we should get us some grown-up sound equipment. Now we are using a single Snowball microphone with the high-gain patch (mentioned in Podcast #3), which is sometimes doesn't pick up Clink and Dinah as well. So, we are thinking about getting a mixer and some lapel condenser mics. Let us know if any of you have suggestions about this. I'd like to add a couple Google ads on the sidebar to help pay for it; Dinah is equivocal. Let us know what you think. (Oh, the bird in the background is Monkey, my parakeet.)
Oh, and I see that DrA has started a call-in show! Check out the first one here.
-Roy
September 2, 2007: #32 Doctor Anonymous on Depression Overdiagnosis
Topics include:
- DrA on Skype (not a soundboard). Dinah relished the memory of Podcast #24. Check out DrA's blog, doctoranonymous.blogspot.com.
- Is Depression Overdiagnosed? We discuss two point-counterpoint pieces in the August 18 2007 issue of BMJ (British Medical Journal). The YES piece is written by Gordon Parker, who believes there is a trend to turn "sadness" into a medical condition: "The ease of assigning a diagnosis of clinical depression, even of major depression, has rebounded on psychiatry, blunting clarification of causes and treatment specificity."
The NO piece is written by Ian Hickie, who argues that despite the benefits of increased rates of diagnosis, many people with depression continue to go unrecognized, untreated, and impaired: "The increased rate of diagnosis has had other benefits, including reduced stigma, removal of structural impediments to employment and health benefits, increased access to life insurance, improved physical health outcomes, reduced secondary alcohol and drug misuse, and wider public understanding of the risks and benefits of coming forward for care."
Find online comments on these articles at BMJ's website here.
- Further discussion about the symptoms of major depression, subsyndromal depression, dysthymia, substance abuse, the influence of the pharmaceutical industry, depression screening, access-to-care problems, inpatient bed capacity problems, per capita psychiatrists and psychologists, stigma about mental illness, primary care management of depression, emergency evaluations.
- We digress into hot McDonald's coffee, Twinkies, and chocolate.
| Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening. |
Saturday, September 01, 2007
Google Ads
What we'd like to get is a mixing board and 4 quality condenser mics (~$500). Anyway, as of Sept 25 we've made $12.99 (wooo!). We've heard from one reader that an ad was served that went to an off-shore, drugs w/o a prescription site.
Google allows us to block ads from certain website, so if you find an an objectionable ad, please copy the url (right-click on the ad's link) and let us know the URL in a comment on this post. (Note, the url will look ugly, like http://pagead2.googlesyndication.com/pagead/iclk?sa=l&ai=BiNocrOP5RtarLZ6ca53TtcoCwqi0If7pm4ICwI23AcCaDBABGAEgiqPPBigCOABQqLXpyAJgyc6SiYikhBCyAR5wc3ljaGlhdHJpc3QtYmxvZy5ibG9nc3BvdC5jb226AQoxMjB4MjQwX2FzyAEB2gEmaHR0cDovL3BzeWNoaWF0cmlzdC1ibG9nLmJsb2dzcG90LmNvbS-oAwGwA5KVoAbIAwfoA4AF6AO1A-gDhgX1AwgAAAD1AwAAIAA&num=1&adurl=http://www.the_road-back.org/weight_-_loss.htm&client=ca-pub-1457668036852312&clkt=-1&nm=6
), but that's okay... just paste it in and we'll block it.)
Thanks!
May I also point out Prochaska's stages of change model? It's a common misconception that people go directly from one stage to the next, from precontemplation through maintenance. More often, it's not linear at all--they flit back and forth among the stages. So it's entirely possible that someone would decide "hey, it's time to get help," but by they time they actually make it to the office, they're back in denial that they even need the help in the first place. And besides, isn't resistance the best therapy fodder there is?