Sunday, September 30, 2007

Ain't It Romantic?


I have a nasty little secret to confess. Here it is:

I like opera.

Yes, it's true. I may listen to KMFDM, Pig, Nine Inch Nails and Rammstein while working out, but in my spare time I've been known to watch Tosca, Nabucco and Carmen. This weekend I saw Aida at the New York Metropolitan Opera.

This blog post was inspired by Act III, where the Egyptian general Radames meets his lover, the slave girl Aida, down by the Nile. He's betrothed to marry the Pharoah's daughter the next day, and Aida fears he's coming to tell her he'll never see her again. She stands by the riverside bemoaning the loss of her love, and declares that if she loses him she will throw herself into the river and drown her sorrows permanently.

This is standard opera fare---in the end the hero and heroine both end up dead---but the thing that intrigued me was a story that was told to me by the lawyer sitting next to me. Apparently he was at a performance of Macbeth in which an audience member jumped to his death from a balcony seat during intermission. After an extended intermission (the performance was also being broadcast) the show was ultimately cancelled while police investigated to determine if the death was a suicide or a murder. After a little bit of googling I quickly found the New York Times story about the incident here, as well as a bit about the man who died here.

Hearing about this man's death put the opera into a new light for me. It got me thinking about culture in general and about the romanticization (if that's a word) of suicide. From Anna Karenina and her train to Romeo and Juliet and their poison, we've got people "proving" their love by killing themselves. The wedding ring and the gun are inextricably juxtaposed in drama and in real life. When my patients talk about their girlfriends and I hear the phrase, "I love her to death," I cringe inwardly and want to blurt, "Please don't."

Saturday, September 29, 2007

JCP: Family Intervention Overcomes Poop-out

Your taking an antidepressant for major depression, but after a year or two it seems to wear off; what some call SSRI Poop-out. A recent article in the Journal of Clinical Psychiatry finds that a family intervention approach to this problem is more effective than increasing the dose of the antidepressant.

Can anyone educate us about the "McMaster model"?


Family Intervention Approach to Loss of Clinical Effect During Long-Term Antidepressant Treatment: A Pilot Study


Background: The return of depressive symptoms during maintenance antidepressant treatment is a common phenomenon, but has attracted very limited research attention. The aims of this investigation were to explore the feasibility of a family intervention approach to loss of clinical effect during long-term antidepressant therapy and to compare this approach with dose increase.

Method: Twenty outpatients with recurrent major depressive disorder (diagnosed using Research Diagnostic Criteria, i.e., patients were at their third or greater episode of major depressive disorder, with the immediately preceding episode being no more than 2.5 years before the onset of the episode which led to antidepressant treatment) who lived with a partner and relapsed while taking antidepressant drugs were randomly assigned to (1) family intervention approach according to the McMaster Model and maintenance of the antidepressant drug at the same dosage or (2) dose increase and clinical management. A 1-year follow-up was performed. The study was conducted from January 2002 to December 2004.

Results: Seven of 10 patients responded to an increased dosage; all but 1 relapsed again on that dosage during follow-up. Seven of 10 patients responded to family intervention, but only 1 relapsed during follow-up. The difference in relapse was significant (p < .05). Conclusions: The data suggest that application of a family intervention approach is feasible when there is a loss of clinical effect during long-term antidepressant treatment, and this approach may carry long-term benefits. The results need to be confirmed by large-scale controlled studies but should alert the physician to explore the psychosocial correlates of loss of clinical effect.

(J Clin Psychiatry 2007;68:1348-1351)

Thursday, September 27, 2007

My Three Shrinks Podcast 34: Guest Mark Komrad, MD

[33] . . . [34] . . . [35] . . . [All]

This week we have a special guest, Dr. Mark Komrad, who is an old hat at discussing psychiatric issues on broadcast media. Mark had a live, two-hour, coast-to-coast, nationally syndicated talk radio show for about 5 years. He also had a regular gig on Channel 2 with Rudy Miller, and continues to be a regular guest on NPR. Mark is the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger in July, when he posted on Ethics and Continuing Education for the Psychiatrist. (And Monkey the parakeet joins in.)



September 26, 2007: #34 Guest Mark Komrad, MD


Topics include:
  • Prison Tattoo Database. Clink informs us about Maryland's tattoo database.
    Dr. Komrad talks about Match.com's inclusion of tattoos in their matching database. We also talk a bit about the psychology of getting tattoos, in general.



  • Q&A: I am a second-year medical student in Canada who is considering psychiatry. I have a few questions that hopefully you haven't already addressed elsewhere.

    Firstly, do you get many negative responses from other medical professionals and the general public for being psychiatrists. If so, how do you deal with it?

    Secondly, can you discuss some of the differences you know of in practicing psychiatry in Canada versus the US?

  • Dr. Komrad discusses how he got into Psychiatry, and the images of Psychiatrists in the movies and in Hollywood. (Mentions Irving Goffman here.) Mark points out that only 3% of Americans have even been to a psychiatrist, and so most people learn about what Psychiatry is about from movies. Movies and shows discussed include The Sopranos, Dark Shadows, Beauty and the Beast, Prince of Tides... more on Podcast #35.

  • Check out NAMI's Ask-the-Doctor column that Mark writes, also his website at komradmd.com.

  • [Edit] Correction: Somewhere on the podcast, Dinah discusses a movie she incorrectly refers to as Reign Over Me. She meant to say The Departed.







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.

Wednesday, September 26, 2007

The Co$t of Being Depressed


Okay, I've truly lost it. I've just spent the last half hour on the phone calling a couple of pharmacies to find out the cost of antidepressants, all for Shrink Rap. You see, as a doctor, I've never learned what this stuff costs. I know vaguely that the older stuff is cheap, and the latest greatest is expensive, sometimes really expensive. I actually started my research yesterday. I thought I'd compare the prices at a local independent boutique pharmacist in a ritzy neighborhood where home delivery is offered, to a chain, to Walmart or Sams Club with the assumption that Walmart would be the cheapest--though really, I'm not sure of this. My quest was limited, however. By the time I really sat down to do this, it was so late I was limited to 24-hour pharmacies, so no Walmart in the comparison.

With my gratitude to the pharmacists who humored me, here's what I found.

The local independent pharmacy informed me that "our system doesn't allow us to look it up without a prescription." Huh? I asked again several times, they couldn't tell me what a medication cost. Okay....

CVS-- a large chain store-- I got a pleasant sales person on the phone.
Similarly at Walgreens. Pharmacists are generally nice people, I've found.
So all prices are for
30 pills, I aimed at the usual antidepressant doses. A little bit of confusion around Elavil (amitryptiline), one of the older tricyclic antidepressants which I just about never use, but it's cheap. I asked about a 100mg dose and CVS told me it came as 75 mg while Walgreens said they had it as 100mg. I only asked for a few prices at Walgreens, mostly to see if there was variation (there was). Zoloft, Lexapro, and Trazodone are scored pills, so if you take half the listed dose, this will last you two months. Many people, however, are on 200 mg of zoloft, and since the largest pill is the 100mg tablet, double the price for high doses. These are the cash prices, in US dollars, and I called pharmacies in Maryland. I tried to set this up as a table spreadsheet, but blogger ate that format.

Paxil, 20 mg...................... 125.99
generic Paxil 20 mg............ 48.95
generic Prozac, 20 mg ........19.19 .............29.99 (Walgreens)
Zoloft, 100 mg ....................140.99
generic Zoloft, 100mg ......... 45.19
Celexa, 40mg .......................122.99
generic Celexa, 40mg............ 33.69
Cymbalta, 60mg .................. 149.99........... 142.99 (Walgreens)
Nortryptiltine, generic, 75mg.. 31.69
Lexapro, 20 mg ..................... 106.99......... 105.99( Walgreens)
Elavil, 75mg ............................53.59
generic Elavil, 75mg................ 10.99,,,,,,,,,,, 12.39 (walgreens)
Trazodone, 150mg ,,,,,,,,,,,,,,,,,,, 23.19
Wellbutrin XL, 300mg............ 215.99
generic Wellbutrin XL, 300mg... 149.99....... 139.99 (Walgreens)



[from Roy]
Don't forget about Walmart's $4 list. You can buy 30 pills of any of these for $4, whether you have insurance or not. In the hospital, we frequently choose meds for uninsured pts based on this list (eg, Prozac 20 mg = $4/mo. Elavil, Paxil, Trazodone and Doxepin are other choices for antidepressants.)

Monday, September 24, 2007

How to Select an Antidepressant: Part 2


Dinah posted about How Psychiatrists Select Antidepressants, which was a very thoughtful and concise description of the factors we take into consideration. Supremacy Claus commented on Dinah's pragmatic, plain-speaking distillation (talk about plain-speaking pragmatism, check out this legal eagle's excellent blog). Dr Smak (another great blog... she and Dinah should go shoe-shopping together) was surprised to find no mysterious revelations, and "The" Shrink (a great new psychiatrist blog... welcome!) felt doctor preference was a missing element.

I started a comment, but it got so long and non-plain-speaking (sorry, S. Claus) that I moved it here.

Shrink, not so sure about the physician preference part (or maybe I am atypical... ha). I don't have a "favorite" or fall back antidepressant, as I find that when I apply Dinah's list (which is quite comprehensive and a good list), I am usually left with one or a couple drugs, and can still find a reason to pick one over the other (eg, cost). I feel I am quite familiar with the zillions (ok, maybe it's only 15 or 20) and ready to pick whichever seems best.

I do think Dinah's #4, 5, and 6 should be expanded on, and #4 should be split into 2 separate sections (I'm a splitter)... #4a being Other Medical Issues (eg, Seizure -x-> Wellbutrin; Psoriasis -x-> Lithium; Hypertension -x-> Effexor; etc) and #4b being Drug Interactions.

Drug Interactions is a whole 'nother post, and is a BIG factor for me when prescribing. Many of my pts are on multiple meds, so it becomes really important to think about this. Prozac and Paxil, for example, are famous for 2D6 interactions, so I avoid it when folks are on drugs which are solely metabolized by that enzyme. Luvox is a great hs antidepressant, but will muck with 1A2-metabolized drugs. Serzone and 3A4 drugs (though, haven't seen Serzone in years now... too bad, was a great drug to have around, esp if you knew how to use it... great for blocking SSRI-induced sexual side effects).

#5: Target Sx - When I think thru these, I think in terms of receptors (may be a tomato-tomahto thing here). I hear "no appetite" and think "I want histamine antagonism"; I hear "can't concentrate" and think "dopamine agonism"; I hear "no energy" and think "norepinephrine".

#6: Side Effect Profile - This is the one I spend the most time on with a pt. For any given side effect that is either desireable (sleepy, energizing, stimulates appetite, reduces appetite, etc) or undesireable (weight gain, wt loss, sexual, rash, seizure, nausea, etc), I have a pecking order in my head of drugs and their propensity to cause -- or not cause -- the particular side effect (other term is "adverse reaction", though they are only "adverse" when undesireable). The above 3 sections are where a better understanding of psychopharmacogenetics would come in handy.

The above may be where Dr Smak noted the perceived "secret way" in which shrinks pick 'em. What may be different in the way in which psychiatrists and PCPs select antidepressants is just in the way these thought processes get all merged together, or maybe thought about in an explicit way (my receptor-tomahto approach) or an implicit or nonverbal way (Dinah's best guess-tomato approach).

This "gut feeling" about which drug to use is merely the end result of a massive probability calculation which is automatically performed in the brain, based on all the above input about which side effects or target symptoms should take precedence for that specific pt, which drugs are more or less likely to deliver them based on receptor and metabolic profiles and based on literature and personal experience, in addition to the other factors like likelihood for compliance and affordability, all boiled down to a single "I think you should try Effexor". Much of that calculation is not conscious, and I think Dinah belies the complexity under the surface by simply (but honestly) stating "my best guess".

Sunday, September 23, 2007

How A Shrink Picks An Anti-Depressant

[Part Two of this post is here]

Midwife With A Knife wants to know how a psychiatrist chooses a medication for an SSRI-naive patient. Wow, I'd already started that post when she asked.

So a patient comes for treatment. His symptoms meet criteria for Major Depression, no question here, and he wants medication to help his condition. This is his first visit to see me.

Prozac Paxil Zoloft Lexapro Celexa Luvox Effexor Cymbalta Lamictal
Wellbutrin Remeron Serzone Pamelor Elavil Nardil Parnate Emsam Trazodone

I probably missed a few.

So how does a shrink decide what medicine to begin?

1) Past history of response. If the patient says, Oh, yeah, six years ago I felt this way, I took Paxil for six months and that helped a lot and I didn't have any side effects, then Paxil it is.
The path changes if the story is that the medication didn't work or had side effects.

2) Family history of response. This is the patient's first episode, but mom swears by Wellbutrin, it's helped her when nothing else would. This would be a good first choice.

3) Patient preference. He's here because his best friend took Celexa and became a new and wonderful person. I have no idea what friend's diagnosis is or why Celexa was chosen for friend, but if there isn't a contra-indication, then I might as well honor a patient's wishes and there's some power to believing something will help. Similarly, if patient reports that Celexa caused best friend to commit outrageous acts of horror and he wants anything but Celexa, I pick something else.

4) Other Medical Issues. I don't start with meds that interact with what the patient's already on. I don't pick meds that might exacerbate an existing medical condition. Wellbutrin is contra-indicated in patients with seizure disorders, eating disorders, or a history of CNS lesions, so I don't start with it in these patients. I save the risky stuff for after we've been at it a while, and then only with a fair amount of discussion about possible risks compared to possible benefits.

5) My Best Guess at What Will Help the Target Symptoms. Patient is tired and unmotivated...Wellbutrin is reportedly a bit energizing, so maybe that's what I use. Patient also has a lot of OCD symptoms, I might go with an SSRI. If someone has a concurrent pain syndrome, Cymbalta or a TCA might be my first choice.

6) My Best Guess at the Side Effect Profile, for better or for worse. Really, this is a guess. I actually hate this issue because patients often worry about side effects they never get, but okay, if someone is agitated, I might start something I think of as being more calming. If someone says they'll die if they gain a single pound, I pick something more weight neutral.

7) The Patient's Financial Concerns and What I have Samples of. This is only a consideration if the patient is uninsured and paying cash for the meds, but this is not a trivial thing. After that, I move to What's Cheapest that will work and won't cause intolerable side effects. If the patient has been on something and had good success, then loses their insurance, I might try something cheaper in the same class of meds, but I wouldn't recommend a switch from say a working SSRI to a cheap Tricylic-- it's not worth the risk.

Can I say a word about Weight Gain as a side effect? Some patients refuse any medication that's been associated with this. But clearly, and I'm probably repeating myself at this point, there are people who don't gain weight on medicines that are said to cause weight gain, just like there are people who don't get better with anti-anythings. People respond to meds differently. My suggestion to those who are concerned they'll gain weight-- if there's some reason to believe a medicine might help, it may be worth a try. Buy a scale. Get weighed before starting the medication. Get weighed every 2-3 days after starting it. If you gain 5 pounds (1 or 2 or 3 can be variations in fluid retention or scale flakiness), Then it's worth worrying about weight gain and addressing whether it makes sense to continue.

We've been at this blog so long, I've lost track of what I've said already, what I've thought about saying, what I want to say.

Saturday, September 22, 2007

What's Your Favorite SSRI?


I like polls....something about asking questions and thinking about the answers. It started on our sidebar with Who Are You? Then, What Do You Want To Read About on Shrink Rap? Then, for lack of anything more creative to ask, What's Your Favorite Color? One day it seemed like the question should be more psychiatric to fit the Shrink Rap theme, so with little thought, I changed it to What's Your Favorite SSRI? Only I suddenly found myself tracking the answers. I didn't ask, purposely, things that might give the question some perspective: like what are you basing your answer on-- the comparison of results of your 732 patients, all of whom have been on every SSRI, or your own experience taking them--which may or may not include a comparative factor. I see lots of people who better on the first SSRI they take, swear by that med, and there's no reason to go further. Some patients are clear that one works for them while another doesn't. Tried my wife's Zoloft and it just isn't Prozac (the names have been changed to protect the innocent).

SSRI's wandered into the psychiatric scene at the start of my training, so I've watched the evolution. First let me tell you my totally random, not-particularly scientific but observational thoughts on each of the SSRI's on the poll. Then you can tell me what you think in the comment section (or Roy & Clink can hi-jack the post and add their profound thoughts if they so wish).
Prozac: It wasn't around when I was a med student, so I saw glimpses of the world before and after. This medicine clearly changed some people's lives in dramatic ways. It's easy to use-- at first the smallest pill was 20 mg and that was the therapeutic dose (though soon we were zooming it up for OCD patients). Fewer side effects than TCAs, not all that hassle with EKGs and blood levels and therapeutic windows and pretty dramatic toxicities. I worked on the inpatient units during it's earliest days where sexual side effects weren't such a big deal. Not that they weren't a big deal, but the patients would get better and go home and then they'd be a big deal, but the outpatient docs were the ones to hear about it. For the people they worked for, Prozac was a good medicine, and it opened up some people's lives.

Zoloft: It's selling point was a shorter half life, fewer side effects, less agitation, and if you don't tolerate it, it's out of your system sooner than Prozac. At first, I didn't think it worked as well-- it didn't seem to have the life-changing benefits of Zoloft. I started asking other people I worked with: Have you seen patients have great responses with Zoloft? This was an informal poll. A few said yes. A few said, "I've seen people have great responses with Prozac." It became a kind of self-fulfilling prophesy for a bit there-- I used Prozac more so of course I saw more responses to Prozac. Oh, it's been decades: I've seen a lot of patients have great responses to Zoloft, and because of the shorter half-life issue, I prescribe it a lot. Oh, the other good/bad thing about Zoloft-- the big dose range. The FDA max is 200 mg. I've seen it used up to 300mg and that patient had no side effects (at all) and the OCD experts apparently go even higher off label. While most people seem to need 100-200 mg for a good response, some people feel better on 25mg, and so for them it's nice to have the option of very low dosing. The bad is that for those who need the whole 200mg, well, it can take a while to get there.

Paxil: This was definitely good stuff, seemed to be well-tolerated, work well, my best guess was that it was more calming, or at least less agitation producing than Prozac, I've prescribed a fair amount of this stuff and still have patients on it who do very well. Time--- two bad things I've seen: a few patients complain of weight gain. I had one patient, certainly the outlier, who gained a huge amount of weight. I would have taken her off the medicine, but she didn't want to stop it. She'd been a skinny kid, she didn't like being the skinny kid, while she didn't like being so much heavier, I was shrink number 3, she'd been on lots of medicines, had lots of diagnoses, her life was a wreck. I'd stopped everything, started 10 mg of paxil, her life was better than ever, and she'd rather be heavy and happy. The years went by, it started to bother her that she was so heavy, eventually changed to Serzone, dropped a lot of the weight, and last I saw her, was still well. Oh, but then the really bad: some people had withdrawal syndrome. Most didn't. But of those who did, well there have been a few where it lingered, where the patient had this very disconcerting and distressing sense of being off balance. I still use Paxil, it still helps people, but before I start it, I tell people there is this risk, and I never just stop it, there's always a slow taper, pill breaking, and every other day dosing when it's time to come off. This helps, and I'd say it's been a while since I've heard about a withdrawal syndrome, but really, the numbers I'm dealing with are too low to be relevant.

Luvox: I've only used this a handful of times. Seems like an SSRI. It's hype is it's indication for OCD. It seems to be the least used SSRI and the poll thingy wouldn't let me have all of them as choices, so this one got dropped. By all means, write in with your Luvox experiences.

Celexa: I've worked in clinics where I get to see other people's prescribing habits, and I worked in a clinic with a doc who liked using Celexa in very high, over-the-FDA-recommended, doses. Seems like it works and is well tolerated. I have a few people on it, mostly they came to me on it. I tend to forget it exists.

Lexapro: Like the others, it seems like a good medicine. Well tolerated, and it works when it works and doesn't work when it doesn't. Same side effect profile as the others, people don't complain much about it. This was our voter's favorite and I wonder if it's because it's the newest that it's what lots of people get prescribed. I think there are now a few of people out there on Lexapro because I've thought "It's the favorite of our readers."

And the poll results, of 105 respondents:

Prozac
16 (15%)
Zoloft
25 (23%)
Celexa
16 (15%)
Paxil
14 (13%)
Lexapro
34 (32%)

Tuesday, September 18, 2007

The Questions You Asked

As I go through my day, I often think about the things people write in the comment section of our posts. Often we get questions, sometimes we forget to respond, sometimes I simply forget they are there, sometimes we save them for the Podcast, and sometimes, well, they are too out there to even begin to address.

I'm going to take a moment here to backtrack and talk about some stuff that's been asked...doing it as a post instead of in the comment sections.


Flash recently visited an old post and asked:

A third year med student also considering psychiatry. I have liked many different things in all of my rotations but I keep coming back to psych. I just had a daughter and suddenly lifestyle is very important. Have psychiatrists on this blog found that they could have controllable hours/live decently/pay back loans with psych? I would love to work part-time when I complete residency, but is this even possible?...Can I retain my fun-loving self if I become a psychiatrist? Obviously I am serious, sincere and compassionate in my patient encounters. I wouldn't be considering psych if I was otherwise. But could psych drag me down?


Hi Flash and thanks for visiting. In terms of money and lifestyle: many issues here. We're all so old-- back in our day loans had to be paid off in 10 years. Now, I hear residents talk about their quarter million dollar school debts (no, I'm not kidding) that go on for 30 years. Mortgage number two, essentially. I work part-time and psychiatry is particularly amenable to part-time work and controlled hours. Employed spouses help. Lottery tickets are good. I don't know any starving shrinks, but the ones I know who are the sole support for their families do work long hours. Rich dead relatives can be useful as well. If you're heavily in debt, if your spouse is a school-teacher, if you have a fondness for vacation homes, Versace bags, and large boats, don't be a psychiatrist. You can retain your fun-loving self. Psych could drag you down, but not as much as a lot of other medical specialties. I do know a psychiatrist who got through school working as a professional clown.

And Lily wrote in one of her comments:

My psychiatrist never seems hopeful. I don't get it. I think all of the three of you are too good to be true.


Are we too good to be true? I've been thinking about that. ClinkShrink and Roy are definitely as good, if not better, in real life than they are on the blog. How can a guy who names his bird "Monkey" be bad? And someone who loves cats and devotes herself to society's criminals? SuperClinkShrink not only runs zillions of 9 minute miles, cares for thousands of downtrodden criminals a year, but she stays with my dog and my kids when I'm away.

Me? I think I'm better on the blog. In real life, I'm just a shrink with a strange sense of humor and a blog. More often then not, I click (not clink) with patients, occasionally someone credits me with saying something that really helps-- usually something that makes them feel understood or vindicated -- and often people credit me with writing prescriptions that help them feel a whole lot better. Hopeful? I am kind of hopeful and excited at the beginning of someone's treatment. If it's gone on a while and the patient is getting discouraged and the meds aren't working, I keep plugging away, but the excitement wanes. When we're talking years.....well, in terms of hopefulness, I readjust the goals, at least in my own head. Here and there, someone pushes my buttons and I think I do all the things all the other shrinks out there do. My strengths: I return phone calls, I'm really good at that, and being a psychiatrist who does psychotherapy as well as prescribes medications reasonably competently (I hope) has become a niche market-- all those folks doing 10 minute med checks make me look really good.

And for the final question in the comment section:
When is pizza?


In my personal experience, there is never a bad time for pizza. Pizza is best in New York City (the greasy stuff at Penn Station is particularly fabulous). I don't like many toppings and pepperoni is totally out, destroys the stuff if you ask me. Happy to try the latest greatest Baltimore's best as soon as I shake this cold. Please send chicken soup.

This Post Is A Lie

Everything I'm about to say in this post never took place. I'm making it all up. I'm putting up this hypothetical story because it could happen someday, or maybe it already has happened but I just don't know it. Anyway, I'd like your thoughts.

Here's the story:

I'm sitting in my prison clinic and I hear inmates sitting out in the hall talking. One of the inmates happens to be my patient but he doesn't know I can hear him. He is bragging that the first time he met me he "told Dr. Clink all kinds of stuff" and got put on meds. He added that when he gets out of prison he will be "set" because he'll have "a check for life". He doesn't mind taking meds because the pills he gets are "good stuff that helps me rest" and that what he doesn't take he trades away.

Curious, I pull his chart and look up his intake history which I completed two months before. When I saw Inmate X then I noted that his hygiene seemed a bit poor but he was calm and polite. He was slow to answer questions and at times seemed distracted as though listening to internal stimuli. He was evasive about questions regarding his past psychiatric history and refused to elaborate upon prior symptoms or treatment beyond acknowledging one hospitalization in his late teens (he's now in his mid-20's). He didn't remember the name of the hospital and couldn't or wouldn't tell me why he was there. He was not suicidal. His speech was sparse, and although not overtly thought-disordered his questions at times were a bit 'off the mark' and tangential. He acknowledged feeling "paranoid" around other inmates but no clear delusions were elicted. The rest of his mental status examination was unremarkable.

Concerned about possible psychosis I start him on risperdal. At followup visits he reports medication compliance but gives no additional information other than that found in the intake history. No new or additional apparent symptoms are seen at followup.

So here are my questions, which I'm particularly interested in having our psychiatrist readers address: Does this patient truly have a psychotic disorder or have I misdiagnosed him? What would you do to differentiate psychosis from malingering? To differentiate malingering from "faking good" (or bragging) in an inmate with a real psychotic disorder? What do you do when the social worker comes to you to fill out entitlement papers on this inmate who has announced his intention to defraud social security?

Thanks in advance for your thoughts. I await your ideas.

Monday, September 17, 2007

Will This Medication Help Me?


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."

Sunday, September 16, 2007

My Three Shrinks Podcast 33: Inane Banter


[32] . . . [33] . . . [34] . . . [All]

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

A. Qualitative impairment in social interaction, as manifested by at least two of the following:
  1. 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
  2. failure to develop peer relationships appropriate to developmental level
  3. 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)
  4. lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
  1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
  2. apparently inflexible adherence to specific, nonfunctional routines or rituals
  3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
  4. persistent preoccupation with parts of objects
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

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


So my post from a few days ago-- Are You My Patient? -- inspired a lot of thought-provoking ideas, and thanks to everyone for the comments. I wrote about patients who come to treatment, and then reject all suggestions, thereby leaving the doc feeling a bit helpless.
To be honest here, I've really only felt held-hostage by this situation a couple of times-- most people who don't like my ideas simply stop coming. And the very few times I've actually pointed out to a patient "Look, you're suffering and then you won't do anything I suggest, you won't even try the medications I recommend....yada yada yada..." Well, once I've confronted them, for the most part, they've made an effort.

Gerbil wrote in with a comment that really got me thinking. She said...

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?

So who's this Prochaska character and what Stages of Change?-- Follow the links, I looked it up and I was pleased that a reader made me learn something new.
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

This is really cool! A psychiatrist friend shot this video of two bear cubs nursing in Alaska. Just adorable.

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 Fa
t 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.
. . .
"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."
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.

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.