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I had the notion that I would slowly attack the pile of articles that I had amassed over the last 7 months and be able to comment about them fairly easily in this blog. I did not consider the possibility, or rather the actuality that there would be additional articles demanding my attention as well.

And so it is with Mind Over Meds — How I Decided My Psychiatry Patients Needed More From Me Than Prescriptions, a recent article from the Sunday New York Times magazine section. I have so many reactions, it is hard to organize them in a coherent fashion. But, I will try.I will have to leave my pile of other articles for another time. This article is written by a psychiatrist, self defined as a psychopharmacologist, who comes to realize that focusing on medications only, may not be in the best service of the patient! Duh, is all I have to say. Actually, I have a lot more to say on the subject than that.

I trained as a psychiatrist before the coming of Prozac and most of the other newer and fairly effective medications that are used in 2010. In the early 80’s when medications did not seem to work as well, one was left with having to sit with the patient and talk to them to try and help them get better. I went to a psychiatric training program, University of Colorado Health Sciences Center, that focused on teaching psychodynamic psychotherapy, but also incorporated medications or psychopharmacolgy into the treatment as an intrinsic part of the whole. It was in the early days of the rise of the primacy of medications in psychiatric treatment, even if way before Prozac. My training taught me how to talk with patients and how to listen to what they were trying to tell me.

There is no question that medications can cure or treat certain psychiatric symptoms. I still remember working with a very suicidal patient years ago, when medications could just not relieve his depression or  suicidal thinking. We spent session after session developing a checklist of things to do for distraction when he became suicidal. But, we could talk til doomsday and never really impact the depression or the suicidal thinking. Along came the new SSRIs and guess what?  The new class of antidepressants not only eliminated the depression, but completely wiped away the suicidal thoughts as if they had never been there.  Without a trace! As a psychiatrist, and as a psychotherapist, the results were incredibly powerful — medications had a life changing potential.

But just as similarly, the person who comes in who may have some trouble with sleep, motivation and sadness, may not quite benefit from an antidepressant, and instead, need some time in psychotherapy to sort out what in their life may be causing her to feel out of sorts, and what might they want to about it. Providing medications and psychotherapy, in this instance, I can assess whether the psychotherapy is allowing the complaints to remit, or whether a medication needs to be added.

Dr. Carlat indicates in this article that it is easy to learn  the science: the criteria, diagnostic categories, differential diagnosis and match it all up with medications. He recognizes that learning psychotherapy is another story. It is not my purpose in this article to review the pressures he touches on in this article that have pushed the psychiatrist to become a psychopharmacologist. However, I strongly feel that medications and psychotherapy are just two of the  tools found in my tool bag that are used to help a person when the situation warrants. Just like the washing machine repairman, who needs the very large pliers and belt to remove the drum when it is not working (and only that tool will work for to fix this problem), the psychiatrist should be able to apply their art and know what is called for in the situation: medication, psychotherapy, both, or even neither.  Patient sessions can be 15, 30 or 45 minutes to tailor the appointment to the need of the patient. It does not have to be “one size fits all” and say “over the course of 15 or 20 minutes, this is about all I can offer” ! (exclamation point is mine)

It alarms me that I get referrals for treatment where the patient or referring party comments on the fact that they can’t find a psychiatrist who provides both medications and psychotherapy in a combined treatment. Dr. Carlat relies on studies and statistics to back up his conclusions. While that approach may be helpful to the general public (e.g. only 29% of psychiatrists provided psychotherapy in addition to medications in 2004, or that it is more cost effective and decreases the number of sessions when the psychiatrist does both the medications and psychotherapy), it all seems so far removed from my everyday reality. Ultimately I feel that it is the patient that suffers.

After reading this article, I really feel like a not-quite-extinct-yet-prehistoric-animal, or perhaps a lonely voice from the wilderness. Thankfully, Dr. Carlat adds his voice to the mix that there is value and benefit for a psychiatrist to be able to prescribe medications and perform psychotherapy. I am very worried that the coming changes in healthcare, which have yet to unfold, will not support this benefit and push more of us to have to provide medications only.

for further thoughts on this subject, see my entry “What is a Psychiatrist ?” on the home page of my website:www.abetterstateofmind.com

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I have seen a lot of patients with traumatic brain injuries. So when I saw this article, I thought, oh no, not another brain scan to come on the market. As it is, SPECT scans and PET scans are still somewhat controversial in regard to the definitive diagnosis of brain injury. I was very much surprised to read in New Test for Brain Injury on Horizon that the reference is to a blood test that would be able to detect proteins released in to the blood stream produced by an injured brain. Wow! This blood test would operate on the same model as proteins released by an injured heart muscle in the hours after a myocardial infarction (heart attack). This simple blood test revolutionized the detection and treatment of heart attacks, and if this brain injury blood test bears out in clinical trials, should save lives, direct treatment, and lessen injuries that until now, may be overlooked or incorrectly treated. The Department of Defense will be conducting the trials, and look for FDA approval as they hope for a blood test that they can “carry onto the battlefield”.

I have worked with a tremendous number of people who have the history and clinical symptoms of a traumatic brain injury or a carbon monoxide exposure, but have no “objective” test to document and verify their condition. Here’s to hoping that perhaps this blood test can one day be used to help out in all these situations.

A Look at Head Trauma

  • About 1.7 million people annually in the U.S. suffer a traumatic brain injury. Some can lead to long-term difficulties in functioning.
  • Most common causes among civilians are falls, car crashes and assaults. Blasts can cause brain injuries in soldiers.
  • About 75% of brain injuries are concussions or “mild” brain injuries.
  • 52,000 people in U.S. die from brain injuries annually, and 275,000 are hospitalized.
  • Most commonly affected age groups are children up to 4 years old, and teens 15 to 19.
  • More than 3 million Americans have long-term need for help in daily tasks because of brain injury.

Sources: U.S. Centers for Disease Control and Prevention; Brain Injury Association of America; WSJ interviews.

There has been some amount of controversy about adults being newly diagnosed and then treated for Attention Deficit Disorder, when it is a disorder that is “supposed” to be present from childhood. Mind Games –Attention Deficit Disorder Isn’t for Kids. Why Adults are now being Diagnosed Too was an article that tries to explain it, and does only a fair job of doing so.

Needless to say, there is much apparent uncertainty in the general public already with the diagnosis and medication treatment of children and teenagers of ADHD, and now many college campuses are filled with stories of Adderall or Ritalin for sale for student usage before finals. However, in the mental health community, the criteria for ADD/ADHD (the H, for hyperactivity can be a separate part of the disorder) is well established in the DSM – IV and does a fairly good job at identifying the spectrum of symptoms found whether for children or adults: forgetfulness, lack of focus, tuning others out, lack of organization, difficulty with planning, hyperactivity or impulsivity.

Adults sometimes get diagnosed when one of their children gets a diagnosis of ADD, as it very often runs in families and can be manifested in one or both parents (“So that is why I always seem to have trouble with….”). Some adults may find that they never could really focus, and never thought about ADD, and still others had adopted a variety of coping methods to deal with their difficulties, and find that their system no longer works like it used to (increased demands at work or home, juggling more things, emotional stress). The screening test that the WSJ includes doesn’t work well for me because it includes too many questions about emotional up and downs that could be due to many problems other than ADHD (anxiety, bipolar, depression). I prefer the diagnostic criteria provided by DSM- IV and find them pretty reliable. I would echo the article in that medications tailored to the individual, behavioral treatment, and an ADD coach can truly make a difference in the person’s life.

I often find the Wall Street Journal medical articles informative, even for me, and very accurate. In this instance, I was very disappointed by the whole thing.

It has been more than many months since I last posted something on this blog. Alas, time commitments have not allowed me the time I wanted to do this in the manner that I wanted. So, I stacked the articles that I was interested in reviewing, and even took them with me in on one car trip, hoping that I would finally get to them. I never did.

My stack is pretty high. The articles may be old, but the ideas in them are not. So, starting today, while waiting for the Fourth of July holiday festivities amidst the pouring rain and furious hail, I am going to read an article from that pile. I begin in a random fashion, simply with whatever article has indiscriminately landed on the top, mixed and remixed like a deck of cards in Las Vegas, as I shuffled the stack over the last 6 months.

New Findings Boost Theory that Infection Causes Schizophrenia from March 2010 was an article that I pulled because it is fascinating to me that an illness like schizophrenia, around with us for a very long time, etiology never really determined and now accepted to be mediated by some brain chemical imbalance often thought to be dopamine, could actually be caused by an infection. Infection?!

Actually, what was most fascinating to me from everything in this article, was that if toxoplasma parasite should  infect a rat (it normally infects cats), it should normally end there, with the rat and toxoplasma parasite unable to reproduce and complete its lifecycle. But, toxoplasma renders the rat “crazed” so that it becomes attracted to cat urine, gets nabbed and devoured by the cat, allowing the toxoplasma parasite to gain entry to the cat bloodstream where it thrives and reproduces. This evolutionary adjustment to ensure its survival in the cat is caused by excess dopamine production in the rat caused by the toxoplasma parasite. Now isn’t that something?

The author indicates that perhaps 30% of all schizophrenia could  probably be eliminated by infection control (toxoplasmosis, influenza, peri-conceptional genital-reproductive infections), but obviously there must be a complicated interplay between environment and susceptible genes or else schizophrenia would be a lot more prevalent than it is. No question that what we see is the symptom, which is the end result of a myriad of factors, and only time will tell whether etiology is really important in the final treatment of the illness/syndrome/symptom. In the meantime, schizophrenia prevention is certainly worth the time and effort, and I guess it is important to keep in mind that nothing may be what it appears!

It is that time of the year when things get hectic and there is not enough time to get things done. So, I went to a cabin several weeks ago, to get away from it all, and slow things down. And while I was there, outside of Rocky Mountain National Park, I read an article in the Denver Post that blurs the boundary between reality and science fiction. Robotic Hand in Mind’s Grasptells of a fascinating experiment where the electrodes of a robot hand are simply inserted into the nerves of a man who had previously lost his arm. This is more fantastic than the real experiment conducted with stroke victims who are able to regain function of a paralyzed limb by tying back the good or functioning limb. Talk about mind over matter! Or is this how the borgs first got started?

Now that it is December, and the shortest days of the year are quickly upon us, Seasonal Affective Disorder, or SAD, can be a common encounter. “Bright Ideas for Winter Blues” is a fairly good review article on the state of current thinking regarding SAD, and its treatments. It gives a solid overview of the issues involved with light therapy and the kinds that actually work. It refers the reader to www.cet.org (Center for Environmental Therapy) and has a questionnaire to determine what time of day the light therapy would maximize your wakefulness depending on your own individual circadian rhythm and when your brain probably secretes melatonin.

I actually went to the site and took the test to see when would be ideal for me— 6:15 am, and I am hardly a morning person! It would have to be way better than coffee, at that time of the morning! And maybe the idea is if it can get you to wake at that time of the day, you can do anything! But the article does mention that in addition to lights, antidepressants, natural sunlight, and exercise can often help as well. They throw in Vitamin D, which seems to be this decade’s cause of all the world’s problems, but they admit there is really no good data to support it as a treatment for SAD. CBT or Cognitive Behavioral Therapy is mentioned as treatment for maladaptive thought patterns that come about due to the depression, and actually helped a fair number of people. It was better at preventing a recurrence the following winter than anything else, which I was very surprised about. I left out the other treatments that really provide little benefit, from my point of view, but you can read the article to see what they come up with.

I still feel there is nothing better than a week on a sunny beach in the Caribbean during midwinter, if you can get away, or a ski trip with blue sky and sun reflecting on the bright white snow, providing you can get out of bed and have the energy to travel!

So in trying to join the new millennium, I decided to give this blog a go many months ago. Alas, my schedule did not allow for much time to consider this enterprise other than saying, “Sure! How hard could it be?” Fast forward almost a year later and well, here it is. This is meant simply to be a place to put observations about life and work in the psychiatric field, mixed in with comments about interesting articles I have stumbled on. It’s a way to laugh at life, and not take oneself so seriously. And, it’s food for thought. Mine and/or yours. I am sure it will evolve, as everything seems to do.

I get most of my medical information these days from The Wall Street Journal. A lot of interesting and relevant sort of stuff. Tuesday, November 17, 2009, Personal Journal had 2 “opposite end of the spectrum” entries. The first, “When Mr. Clean Meets Ms. Messy” is a laugh, sobering though it is, about the nature of relationships, and the passive-aggressive stances some people get into when centered around clutter and cleanliness. Talk about being unable to change a person! Not to mention the feeling of helplessness about a partner that is mis-matched on the other end of the messiness spectrum. Although it may give additional work to my colleagues, it seems more to be a ticking time bomb. It is hard to imagine living like that.

The other, “A Key to Unlocking Memories” is more scientific in nature about the effects of music on memory. Listening to oldies, sing-alongs with old standards that everyone seems to know often, can help a person’s memory, even Alzheimer’s patients that have trouble remembering their spouses. Think back to the craze of Mozart music before taking tests, and you may remember (if you recently listened to music) that IQ scores are raised as well test performances. The Institute for Music and Neurologic Function is trying to get playlists for Alzheimer’s patients identified so relatives can download them onto ipods and play them for “therapy”. Music also has a tremendous effect on mood and has been claimed to “soothe the savage beast”. Take my job away? I dunno. We all can point to certain songs that evoke powerful memories or strong feelings. It’s something to think about—this complicated and engmatic brain of ours. No wonder so many people sing in the shower, or in the car!

So, either a family member or a doctor (or perhaps even yourself) has indicated you should see a psychiatrist to get psychotherapy or an evaluation for medication. It seems like a fate worse than death, or the last stop on a slow train bound to nowhere. Actually, it is neither, but what should you expect?

A psychiatric consultation is a primarily a conversation between you and the psychiatrist to figure out what might be wrong and to come up with a “treatment plan” to correct the problem. Since establishing the correct diagnosis will lead to the proper treatment, the conversation begins with what is presently wrong — Why do you come to the psychiatrist’s office today when you could be anywhere else on the earth? And, what complaints do you have?

Other pertinent information will be asked about, including: family history, prior psychiatric history (if any), and if you have ever been tried on any kinds of psychiatric medications before. A review of comprehensive psychiatric symptoms will occur next, to fill in details about common psychiatric disorders like panic, insomnia, anxiety or depression and to get a sense of your present level of functioning. Questions will also be asked to get some information about what kind of person you are, and about your interests and background. Often, the above takes close to an hour to complete.

All the information is used to reach a tentative diagnosis and then used to discuss the initial components of treatment: psychotherapy and/or medication . Occasionally, blood work may be obtained to rule out other overlapping medical problems such as low thyroid, or anemia.

It may not be reasonable to expect a person to have to decide their course of action at the conclusion of the first session if they are uncertain, want to do research, want to discuss it with family members or need time for further consideration. The decision regarding treatment can be discussed then, or at our next appointnent. Pros, cons, benefits and side effects of medication treatment under consideration are reviewed.

Medication therapy is also compared to the obvious choice of doing nothing. If medication treatment is begun, a follow up appointment is scheduled approximately 2 weeks after the initial appointment to assess the early benefits of the medication prescribed and to make whatever adjustments are necessary. It is never assumed that anyone, by the mere fact of walking into a psychiatrist’s office, will have to take medication, never mind for the for the rest of their life. The length of time needed for medication treatment is determined by a number of factors, particularly, how long have the symptoms been present?

When the agreed upon length of time on medications has passed, and the original complaints are resolved, the medication will be tapered and discontinued to see if meds are no longer needed to keep the symptoms treated. Your condition and symptoms will be closely monitored and followed regardless of the diagnosis or treatment pursued. Each person’s treatment is individualized a reasonable amount of time between appointments to allow for adequate practice of certain psychotherapeutic techniques or enough time for a medication to begin to work.

Office visits are scheduled for different lengths of time, to allow for adequate observation, communication, assessment, exchange and decision making. During that time, no question, concern or problem is ever too minor or unimportant to be discussed as treatment. Treatment is an active collaboration and evolving decision making process between two persons.

Contact Dr. Dworetsky