Wednesday, September 17, 2008

Psychiatry Stuff in the New York Times.


Has anyone seen my co-bloggers? I think they've vanished.


I'm still here. Life feels a little weird lately-- my oldest teen, the one who makes all the noise-- went away to college a few weeks ago, and younger teen started at a new school. Things feel a little off-kilter, like there's an odd void. It's more peaceful, and college kid sounds very happy. It's all good, just a little unsettling, and I feel like I need to figure myself out all over again.


With that as an aside, two interesting articles in the New York Times:


In The Bipolar Kid, Jennifer Egan explores the increase in the number of children diagnosed with bipolar disorder, the struggles their families face, the maze of treatments and medications these families explore, and how little we know about this disorder. As a parent, I found it a sad read. As a psychiatrist, well, there's this awareness that some people have stories of really horrendous childhood behaviors and grow up to be just fine. Egan writes:



Most clinicians say they believe that there will eventually be clear “biological markers” of bipolar disorder: ways to see and measure the disease as we can seizures, cancer or hypertension. Scientists are working to identify the genes (there appear to be many) involved in creating a predisposition for bipolar disorder. Brain imaging, still in its infancy, can already detect broad differences of size, shape and function among different brains. The hope is to know early on who is at risk so their condition can be diagnosed and treated as early as possible. Mental illness wreaks brutal damage on a life, crippling decision-making, competence and self-esteem to the point where digging out from under years of it can be next to impossible. And there is also a biological theory for why going untreated might worsen a bipolar person’s long-term prognosis. Epilepsy researchers have found that by electrically triggering seizures in the brains of animals, they can prompt spontaneous seizures, a phenomenon known as “kindling.” Simply having seizures — even artificially generated ones — seems to alter the brain in such a way that it develops an organic seizure disorder. Some scientists say that a kindling process may happen with mania, too — that simply experiencing a manic episode could make it more likely that a particular brain will continue to do so. They say this explains why, once a person has had a manic episode, there is a 90 percent chance that he will have another.


And our former guest blogger, Dr. Ronald Pies, had a short piece in Tuesday's NYTimes: Redefining Depression as Sadness. Dr. Pies talks about the difficulties psychiatrists face in differentiating bereavement from normal sadness, the risks of under-diagnosis and the implications of over-diagnosis. He writes:


Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.

Should I give him a diagnosis of clinical
depression? Or is my patient merely experiencing what the 14th-century monk Thomas à Kempis called “the proper sorrows of the soul”? The answer is more complicated than some critics of psychiatric diagnosis think.


My quicky take on his partial vignette, without my usual 2hour psychiatric evaluation, is that it's unusual for someone to seek psychiatric treatment for the first time because of a recent loss-- people generally cry on the shoulders of their friends, talk to their religious leaders, grieve and don't consider this unusual. The subset of people who present to a psychiatrist maybe having a more severe response, or another concern. With the little we know, it sounds to me like this patient has an Adjustment Disorder with Depressed Mood (is it okay if venture a guess based on on a few sentences?) and the patient should be seen often for psychotherapy. I'd give him medications if: 1) he has a history of depression and this looks like a recurrence 2) he's suicidal or unable to function/work 3) he's really insists that he needs a medication and he's intolerably miserable 4) he got no relief after a few weeks of therapy. Oh, and actually, if any of those things were going on, I'd call it Major Depression and not Adjustment Disorder. I just thought I'd stick in my unrequested opinion here, sort of silly given how little we know, but the issue of understandable reactions versus psychiatric illness is one we like talking about here at Shrink Rap.