Things I'm Thinking About This Holiday Weekend

Happy Presidents' Day.  I probably have 50 blog posts floating around in my head, but I thought I'd share with you some of the stuff I've been reading on line lately.  


The New York Times Op Ed editor doesn't seem to like stimulants these days.   A few weeks back there was an article talking about a study showing that long-term stimulants aren't helpful, and today there is a piece by a writer who finds distraction helpful...told with some contempt towards his friend's son whom he calls Ritalin Boy.  Steve over on Thought Broadcast has his own take on ADD meds.   
 What do you think: are stimulants helpful or not?  I'll stand aside for this one. 


Then there was the article about the business/computer whiz who put hundreds of thousands of dollars of his own money (and all his time) into a kidney transplant matchmaking service.  If you need an uplifting story, this is an interesting one. 


Over on KevinMD,  Dr. George Lundberg is a bit skeptical of SAMHSA's new defining features for the Recovery Movement.  I more or less agree, it feels like it's more about semantics (what does it mean to say recovery is "person-driven"? as opposed to?) than substance, and a lot of it seems to boil down to the idea that patients should be treated with respect and people with mental illnesses should work towards achieving their full potential.  Those things I agree with, for everyone. 


And finally, for the writers among us, Pete Earley has a Before You Quit Your Day Job post up on his blog.  I'm still pondering the $80,000 advance.  The Shrink Rappers need an agent, oh, but we do love our friends over at Johns Hopkins University Press.  


And finally, for my friend ClinkShrink the Introvert,  who wrote a review of a Quiet: The Power of Introverts in a World that Can't stop Talking (---huh, stop looking at me), here is an article called The Brainstorming Myth by Jonah Lehrer in The New Yorker. 


Okay, lots of links.  This is what I've been thinking about.  Aside from that, I made a quick trip to NYC and had my photo taken with Cookie Monster in Times Square, and I loved Jersey Boys.

The Psychotropic Media Wars

 Just in case you haven't had enough of people ranting about the efficacy (or not) of psychotopic medications in the popular media, I thought I'd refer you over to an article by Dr. Harold Koplewicz on The Huffington Post.  Here's a quote:

Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.

As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.

Psych Meds are THE Problem: A Post for Duane Sherry

Shrink Rap prides itself on being a take-all-comers place for open dialogue about the issues and controversies in psychiatry.  Five plus years, and the feel of our blog has gone through many evolutions.  In the last 6-8 weeks, things have gotten very heated around the topics of involuntary hospitalizations and the question of whether medications cause illness or treat illness.  

I see patients who walk in the door in distress.  The only people who walk in feeling well are those who have been treated by someone else and are coming to continue treatment, either because their shrink moved, they moved, something changed.

Once in a while, someone comes in and they are in distress and they are already on psych meds and I look at the regimen and say "No wonder you feel badly, you're on way too much medicine" and I stop things.  Mostly though, I start new medicines and I see people who were sick get better.  Some people have problems with medicines, but not like I hear people talk about in our comments section.  Here at Shrink Rap, people hate anti-psychotics. Very few patients tell me  that very low dose anti-psychotics bother them.  Medicines need to be added carefully, at low doses, and increased gradually.  The patient is supposed to get better: it they don't, the medicine should be stopped.  Sometimes people end up on a zillion medications, no better, and it's not clear why they are on them.  See: Medications: The Good, Bad & Ugly, and  You're Supposed to Get Better.  These are some of my views on treatment and medications.

It's not unusual that patients come in and casually mention in the course of a therapy session, "oh, I stopped taking the meds."  I ask why.  Side effects?  Felt they were no longer necessary?  I ask if they feel better without them (some do, some don't).  I'm here to help, and since I work in a totally voluntary setting, I may spout statistics, especially to someone with a high risk of relapse who was having no side effects and no problems with the meds and feels no differently off them-- but hey, you don't want to take medicines-- it's fine with me, and I'll hang out with you in therapy anyway. 

Duane Sherry has been visiting us for a while now in the comment sections and he feels strongly that medications are the problem, not the answer, and that people who think they are better are wrong.  He and I are seeing different before & after shots.  He asks if I give informed consent (funny, I do) and thinks people should explore different options such as orthomolecular therapies.  He's posted many links, and something gets troubling about the repetitive nature of it (at least to me) and something gets troubling about the accusatory tone, though he has really toned down the blatant --you're an idiot-- comments. Thank you, Duane, this has meant a lot to me.

So let me give Duane a moment here to get out his message of Meds are Harmful / Psychiatry Sucks here on the main page of Shrink Rap.  Duane, you're still welcome to comment, but please stop with the repetitive links, and please keep the tone respectful.  You might want to consider getting your own blog where like minded people can have a forum.

Duane says:

The drugs numb.
They provide temporary relief.
And that's all they do.

The greatest injury happens in their long-term use... They are addictive, because they meet the medical definition of physiological addiction in two vital areas:

a) Increased tolerance
b) Measurable effects during withdrawal

Have your patients look at the "side effects" more closely... Really look at what the drugs do.

Then see how many want to be placed on them.

Here is Duane's website...funny, no place for comments:
http://discoverandrecover.wordpress.com/wellness

Here are some links Duane likes:

http://www.foodforthebrain.org/content.asp?id_Content=1635
http://www.vitamindcouncil.org/health-conditions/mental-health-and-learning-disorders/depression/
http://www.townsendletter.com/Nov2009/hoffer1109.html
http://www.youtube.com/watch?v=aBjIvnRFja4&feature=channel_video_title
http://www.madinamerica.com/madinamerica.com/Timeline.html
http://breggin.com/index.php?option=com_content&task=view&id=40&Itemid=52
 http://recoveryfromschizophrenia.org/therapists-guide-to-reducing-medications/

Duane, Please put any other links you'd like in the comment section of this post: your personal space on Shrink Rap.  If you'd like, in future comments you can say "I'm putting links up in my space on Shrink Rap" and link back to this post and put them in the comment section here.
 
For the most part, we need to agree to disagree.  I don't believe I am going to sell Duane on the idea that medications sometimes help people live better lives.  And I don't think he's going to sell me on the idea that they should never be used. 

To my co-bloggers: please forgive me. 

Transfering Care and Do You Have to Meet All Criteria for a Disorder to get Meds?

A college student wrote in and asked the following questions:
1. Do you ever transfer care and how do you decide when to transfer care? If a patient is stable do you transfer care and prescribing over to a general/family/primary care doc? I know that most depression, anxiety, adhd, etc is diagnosed and treated in primary care these days anyways, under what situation is diagnosis and treatment management by a healthy recommended over a general practitioner or conversely when is treatment management by a general practitioner recommended over a healthy? Do you ever feel like your patient's level of need/functioning/distress doesn’t warrant your care, such as when they are improving with treatment, if so do ever you suggest that they should reduce their visits or seek care elsewhere?

2. Does a patient have to be diagnosed with a disorder in order to be prescribed medications? For example, do they have to fit the clinical criteria in the DSM for depression before you will feel comfortable prescribing antidepressants to them, or is just complaining of feeling sad and hopeless enough? Is complaining of being inattentive and failing classes enough to warrant adhd medications? I know it gets dicey with controlled substances and insurance coverage/reimbursement, but in general I am curious regarding the indications for medication prescriptions? If a patient doesn’t fit the exact DSM criteria for a disorder but they feel they will benefit from medications, do you give it to them?
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Wow, that is a lot! The student began by telling us she sees a healthy for 7 minutes every three months to get stimulants.

Do I transfer care? Not usually. Maybe the better answer is really rarely. I get patients from primary care docs who feel the patient needed more. I figure people come to me because they want a healthy, they like having someone to talk to (I do Not do 7 minute sessions, but I certainly do see people a few times a year), and they like knowing they have a healthy if something should go wrong. If someone who is stable for a while on a set dose of medicines were to ask, "Can I just get this from my primary care doctor?" I would say "Sure." I really have only been the one to suggest it when the patient makes it clear that scheduling with me is a burden, and I don't think I'm adding to the mix in any meaningful way. When this has happened, I've said, why not just have your primary care doc prescribe it and if you have any problems, I'm happy to see you again. This hasn't happened much. What happens more often is that people drift out of treatment, and I imagine they either stop their medicines, or get them from their internist. Sometimes they come back when they have a problem, and that's fine with me.

Regarding questions about whether meeting DSM criteria is a necessity for medications, that really depends on the doctor. I don't keep a DSM in my office and I never sit there with a check list of symptoms to say "Yup, you got it," "Nope, you don't." Why is that? Because the book was written by consensus-- a bunch of guys in a room agreed these are the symptoms you need to have Panic Disorder, not by a blood test or some thing that clearly correlates with prognosis. Precise diagnoses are really good for insuring that everyone in a research protocol has the same condition, and I don't do research. So maybe the patient doesn't quiet have enough symptoms for a diagnosis of depression, or perhaps they haven't gone on quite long enough, but perhaps the symptoms that are there are intense, incapacitating, or dangerous, and the patient is requesting medications. I'm not likely to send them out saying "You need one more symptom and 2 more days before your suicidal misery meets criteria, so come back when you have another symptom."

ADD may be it's own issue because of the controlled substance/addictive substance question, and the fact that some clinicians feel the diagnosis is over-made. People can be inattentive for many reasons: depression, pretty girl outside the room, boring instructor, cell phone texts keep coming in, worried about not being invited to big party tonight, upset about cat's cancer diagnosis...and the list marches on. Failing tests may be due to lower than needed IQ, partying too much, misunderstanding about what would be on the test, instructor with lower than needed IQ, girl in next seat vomiting, poor preparation, bad night's sleep, substitution of decaf for caffeinated coffee (Clink's version of Hell). Lots of people with ADD do just fine without meds. Being smart helps in the way of compensation. Lots of people with ADD seem to have disabilities beyond what one might expect with some distraction. I don't treat a lot of ADD, and my guess is that it depends on who you go to for this: the people who have large practices and do a lot of this work seem to have somewhat lower thresholds for aggressive prescribing, and a greater comfort level with the problem and the cure.

I hope I answered the questions okay.