U.S. Suicides Peak on Wednesdays

In the recent issue of Soc Psychiat Epidemiol, authors Augustine Kposowa and Stephanie D'Auria from the University of California review U.S. death certificate data from 2000-2004, and find that suicides are twice as likely to occur on a Wednesday than on a Sunday. No clear reasons why, but it is tempting to speculate.

They also replicated previous findings that Spring and Summer are more deadly than Autumn and Winter, whites are at higher risk than minorities, and that men are three times more likely to die of suicide than women.

I looked up the origin of the word Wednesday (from Woden's Day). Woden was an Anglo-Saxon god, thought to be the entity responsible for carrying off the deceased's soul to the next plane. (See also Dead Like Me).

The full-text article is available as open access here.

Shrink Rap: Grand Rounds is Up on Pharmamotion

When Dr Guzman is not handling H1N1 in Argentina, he tries to get out the occasional Grand Rounds, and this is it. Some good links to posts on nurses, first-year residents (it IS July, you know), the Lantus-cancer issue, and our health care "system."

The High Price of Sanity: What Antipsychotics Cost

When I was in medical school, there were these medications that were used to treat hallucinations and delusions (what we psychiatrists call "psychosis") and sometimes extreme agitation. They were the neuroleptics, and they worked: medicines like thorazine, and haldol, and mellaril, and navane. Oh, and like prolixin, too. They worked, but they came with a horrible stigma and lousy side effects. Some people tolerated them with no problems, some people even preferred how they felt when they were on them, but a lot of people found them to be pretty awful. Some made patients very tired -- this is why they are also referred to as major tranquilizers. Others were less sedating, but they made people very stiff: a side effect called Parkinsonism because they chemically gave people a temporary state similar to Parkinsons' Disease. You can sometimes look at someone and know they are on medication, and this is never good. And sometimes they caused a permanent, irreversible movement disorder called Tardive Dyskinesia. Okay, so people really don't like taking these medications, and sometimes they can be fine-tuned with other medications to halt the side effects, but they come with a price.

By the time I was a resident, the new generation of antipsychotics had come along. Risperdal, Zyprexa, Geodon, Abilify, Seroquel, Invega, the list marches on. These medications also worked and people didn't mind taking them (...okay, some people didn't mind taking them). They are also used for mood stabilization, to calm agitated states, for mania, as augmentation for depression, and sometimes for sleep. They aren't addictive, they aren't as stigmatized, and the immediate side effects aren't so troublesome. It's much easier to get patients to consider taking them and my experience is that in the short run, they help a lot of people feel better and function better. The down side has been that in some people they cause weight gain, diabetes, and hypercholesterolemia/hyperlipidemia. We don't seem to know who will have these problems (clearly, not every one does) and sometimes people are so sick without them that we're stuck fixing one disease while contributing to, or causing, another, and that needs treatment, too. And did I mention that these medications cost a fortune. If that's not enough, we have to order regular blood tests to monitor for the problems they cause, and patients may need more and expensive medications to treat the conditions the medicines cause.

So how much does it cost to stay sane? The state of Maryland, apparently, spends $80 million a year for atypical antipsychotics (these newer medications) for patients with Medicaid, and I suppose for uninsured patients in the hospital. This doesn't count the patients who self-pay, or have private insurance, or who get samples from their doctor, or who have Medicare. So the cost of keeping my state sane is pretty high. So far, only one of these medications, risperidone, is available in a generic.

Okay, so I price-shopped. I called some pharmacies, and here's the price for 30 pills. Remember, some people take higher doses-- I priced middle-range doses-- and some patients take several pills a day:

DRUG	Walgreens	CVS	Sam’s Club	Independent
Risperidone (Risperdal brand), 3mg	$339	$385	$292	$295
Risperidone (generic), 3mg	$170	$203	$150	$  46
Quetiapine (Seroquel brand), 25mg	$  85	$103	$  82	$  97
Quetiapine (Seroquel brand), 200mg	$265	$324	$262	$262
Haloperidol (Haldol brand), 5mg	$  10	$  11	$    4	$  28
Aripiprazole (Abilify brand), 10 mg	$449	$542	$440	$450

Hmmm, so there's a $3/pill differential for Abilify, depending on where you get it?
Oh, and I wondered about the generic risperidone--- $203 at CVS and $46.50 at a local independent pharmacy? I asked the pharmacist to check it twice, and then I called a second mom & pop pharmacy, and their price was just under $40. If you pay cash, it's worth shopping around. Are these the prices your insurance company pays? I doubt it-- they negotiate deals and have formularies. I asked how much the state pays for the medications for a patient with Medicaid, and none of the pharmacists I asked could tell me...one said it was top secret. Okay.

One note on Haldol, the older generation medication-- I'm not sure if the $28 price was for generic or name brand, the others were all for the generic.

Dr. Carlat Wants To Talk About The DSM-V

Dr. Daniel Carlat has his own psychiatry blog and he wants to talk about what's going to happen with the new Diagnostic and Statistical Manual (DSM-V). Funny they call it a statistical manual when there are no statistics (there are diagnoses!).

I'm sending you over there to join the discussion:

http://carlatpsychiatry.blogspot.com/

Mental Health and MLB

Roy asked me to post about this article, by Shirley Wang,
from the Wall Street Journal:
Professional Baseball Faces Loaded Problem: Mental Health

The article starts by talking about the fact that there are three Major League Baseball players on the Disabled List (the D-L) for anxiety. It goes on to talk about 'butterflies' and golfers' 'yips.' It names some professional athletes who've suffered from other mental health issues, and there is talk of pitchers who suddenly couldn't throw. The players, apparently, have access to a counselor.

What don't I like about the article? Somehow, I read it and had the flavor that these players are disabled by anxiety from the stress of their profession and the performance demands...the article ends with a psychologist being quoted as saying that anxiety is normal.

My best guess...and I don't know these players and have never examined them....is that there is more to it than stage fright, or the pressure of the biz. When you're getting paid what these guys get, I don't think they let you bow out and go on the D-L because you're job's too much and you get butterflies in front of the crowd. By the time you're on the D-L, the mental health issue is probably quite disabling, and not the normal or expectable anxiety that goes along with jitters and yips. And I can't imagine that professional sportsmen are any less vulnerable than the rest of the population to mental health issues.

Clutter Free Reality TV and My Fantasies.

Patients have been talking about a TV show I'd never heard of: Clean House.
It's a reality TV show where they come in and help the clutter bugs get rid of their stuff. I've never watched it (obviously). This is entertainment? My patients say they watch it then go throw some of their stuff out. Entertaining and therapeutic. It's funny (as in kind-of-ironic, not ha ha), but people spend a lot of time in therapy talking about their clutter and the piles of paper they can't part with. I suggest bonfires, but hey.

So I started thinking about this whole reality TV show concept, and the fact that I'm writing about psychotherapy (now done with 2500 words of What Is Psychotherapy). I had this fantasy about having a real life therapy podcast. Roy once talked about how there was bound to be a reality therapy TV show. Couldn't I do a start-to-finish psychotherapy podcast and put it on iTunes? I've got the microphones, and I could probably get Roy to teach me how to use all these gadgets. It might be interesting, it might be something people could use to teach (Gosh, that therapist says dumb things!) or it could be really boring. How does one logistically recruit a patient for such thing? Is it ethical (hmmm...) to offer free psychotherapy in exchange for allowing it to be broadcast on the internet? Could anyone relax and be themselves? What if it got up close and personal and the patient wanted out? Obviously, you stop, but then what becomes of the therapy? Funny, they didn't deal with these issues in medical school.

Okay, it's not happening. It was just a fantasy. I'm going to clean out my closet now. For real.

When the Shrink Needs a Shrink.

Somehow I missed this one, and Meg was kind enough to send it along.

Last week's New York Times had a piece by Elissa Ely on psychiatrists who need someone to talk to. I started reading it and immediately thought, oh, this is why we have friends, why we get together for lunch, why I have Camel and Roy and ClinkShrink! But as I read on, I realized that the issue raised was more than about having friends. It's about how awkward it gets as a psychiatrist ages, when s/he knows all the players in town, when s/he needs someone outside his circle to talk to about the more personal things. Therapy, after all, is not simply a substitute for friendship. Dr. Ely asks:

But no amount of wisdom prevents personal frailty. You are never too old for your own problems. Yet when you are the professional others go to, where do you bring your sorrows and secret pain?

She goes on to write:

Often, though, the situation is not straightforward, and medication is not the problem. Life is. Maybe we are overcome, maybe ashamed, maybe despairing. Self-revelation — the nakedness necessary in therapy — is hard when you have been a model to others.

“In my situation, it would be difficult to find someone,” Dr. Dan Buie, a beloved senior analyst in Boston, told me. It is not that psychiatrists aren’t waiting in wing chairs all over the city. It is that so many of them are former students and former patients. One generation of psychiatrists grows the next through teaching and treatment.

Surrendering that professional identity to become a patient reverses a kind of natural order. “You can’t be a simple patient,” Dr. Buie said. “Anyone I’d go to, I’ve known.” To avoid it, some travel to other cities for therapy (probably passing colleagues in trains heading in the other direction).

Dr. Ely goes on to talk about how some psychiatrists may have a preference for therapists who are older and wiser, that there is comfort to seeing someone who's been there before and who may have gained insights. Is this true for everyone? When I started at this, nearly all my patients were older than I am, and still, many people I see have children my age. They aren't psychiatrists, though.

I liked the piece. I've just started on the psychotherapy section for our book, and I'm struggling.
I've been working on the concept that some people seek care for insight and education (as opposed to for treatment of symptoms) and it's not easy forming my ideas.

Advertising Works

On the Maryland Psychiatric Society's listserv I recently heard about a newly available (in the US) SNRI, Savella (milnacipran). It came out for fibromyalgia earlier this year but is used for depression in other countries. First I heard it was available. Who knew?

Then, I pick up the June issue of the Psychiatric Times. I usually let this languish in a pile, still wrapped in plastic, for a few months, and then summarily discard it, unread, once it breaks my "3 months rule". (If a throw-away mag/journal is more than 3 months old, toss it.)

I flip through it and discover -- only because of the advertisements -- several other new drugs I am unaware of. Where have I been that I've not been clued in? Twitter #fail!

So here are the other things.

• Fanapt (iloperidone) was approved, for treating schizophrenia. Vanda makes it.
• You can get 225mg of Effexor XR in a *single tablet*! But it's not "Effexor," it's actually a generic brand called Venlafaxine Extended Release (yes, that is the actual brand name). And it's a tablet, not a capsule. Made be Upstate Pharma. Who knew?
• There's also a new brand of bupropion (aka Wellbutrin) out there that puts an extended release formulation of the maximum dose (450mg) all in one pill. I heard about that one in an email from Sanofi, about this new formulation called Azplenzin (though you have to order 522mg to get 450mg). This one's so new, a Google search turns up only 3 hits.

So, I'm just saying that the marketing works to get something new noticed. The more important part is doing the research to determine if it is something that may help you or your patient.

Watch Real-time "Memories" Forming

This is pretty cool. Hopkins neuroscience researcher, Dr. Richard Huganir, and his postdoc, Da-Ting Lin, created a fancy microscope that allows one to easily visualize synaptic memory activity (specifically, insertion of AMPA receptors) as green flashes in the video. Find out more here.

Technology and Boundaries

I'm working on a way to make this post about psychiatry. Sort of getting there.
In today's NY Times Magazine, Peggy Orenstein notes in "The Way We Live Now--The Overextended Family," that she doesn't want to Skype videochat with her parents. Too much intrusion, there need to be some boundaries. Orenstein likes sending digital pictures, she doesn't like email. And somehow, she's aware that while she's not sure she wants to videochat with her folks, she recognizes that she might want to chat with her kids.

To Skype or not to Skype, that is the question. But answering it invokes a larger conundrum: how to perform triage on the communication technologies that seem to multiply like Tribbles — instant messaging, texting, cellphones, softphones, iChat, Facebook, MySpace, Twitter; how to distinguish among those that will truly enhance intimacy, those that result in T.M.I. and those that, though pitching greater connectedness, in fact further disconnect us from the people we love.

She goes on to write:

Video chat, while obviously cheaper, would seem to have the same skewed ratio: too much access, too little control. But that’s speaking from the standpoint of a daughter. My perspective shifts significantly — as it does on so many subjects — when I mull this one over as a mother. It’s one thing to consider how much about me my parents have a right to know; it’s another to contemplate how much about my daughter I have a right to know — or even want to know.

I suppose the article caught my attention because I have a couple of those teenager people. One goes to college a half a country away, and when I suggested we videochat, I was told he doesn't do that. He'll email, he'll talk (actually, it's more grunting), and the most reliable form of communication is the text message, but he's not interested in IM-ing me, videochatting, or being my friend on Facebook. He doesn't follow me on twitter, and somehow I doubt he reads Shrink Rap.

So the psychiatry tie in? Oh, Roy would feel no need to look for one. This time, I'll let it go.

Please Don't Curse At the Shrink Rappers.

We try to have fun with this, but we're 3 real live psychiatrists and we all take our work very seriously. Lately, we've been getting a lot of insulting and offense comments in response to our posts. We're fine with opinions that differ from ours-- but please, no obscenities.

Good News: Bigger May Be Better!

From the New York Times, an article that made my day: Excess Pounds, But Not Too Many, May Lead to Longer Life.

The report, published online last week in the journal Obesity, found that overall, people who were overweight but not obese — defined as a body mass index of 25 to 29.9 — were actually less likely to die than people of normal weight, defined as a B.M.I. of 18.5 to 24.9.

By contrast, people who were underweight, with a B.M.I. under 18.5, were more likely to die than those of average weight. Their risk of dying was 73 percent higher than that of normal weight people, while the risk of dying for those who were overweight was 17 percent lower than for people of normal weight.

The finding adds to a simmering scientific controversy over the optimal weight for adults. In 2007, scientists at the Centers for Disease Control and Prevention and the National Cancer Institute reported that overweight adults were less likely than normal weight adults to die from a variety of diseases, including infections and lung disease.