All Opinion pieces are written by Dr. Sederer

Contents:

- Pope Francis and People With Mental Disorders

- Philip Seymour Hoffman and America’s Most Neglected Disease

- Population Health: Transforming Health Care to Improve Our Health

- How Great Leaders Inspire Action

- The Best News for Baby Boomers in a Long Time

- A Third Strike Against Big Pharma

- Addiction: The Equal Opportunity Threat to Life

- The Cost of Not Caring for People with a Serious Mental Illness (written with Dr. Henry Chung)

- Wartime PTSD: What Works and How to Care for a Loved One (written with Dr. Sandro Galea)

- The Trauma that will Succeed the Tornadoes

- Traumatic Stress Disorder

- Readying for a Radiological Disaster

- Bipolar Disorder: what a family (or friend) might see and what a family can do

- Things you want to know about psychiatric medications but didn’t know who (or how) to ask

- The Painted Bird: stigma and mental illness

- Biomarkers for Depression: promise or prime time?

- A Stroke of Insight

- Children’s Mental Health After the Shooting in Newtown, CT (with Dr. Eva Alisic)

- “Where Have All The Flowers Gone?”: Thoughts After the Newtown Massacre

- Mental Health and Hurricane Sandy: What can we expect, what can we do?

- A Safe Place To Be Smart: The Bronx High School of Science

- Mental Health and Hurricane Sandy: What Can We Expect, What Can We Do?

- Doctors Make Mistakes

- The ‘War’ On Drugs

- Addiction: Help you can get beyond 12 Step and conventional Western medications

- The Enemy is Apathy

- “Random” Acts of Violence Are Not So Random

- Addiction: America’s Most Neglected Disease

- Comparing psychiatric and general medical medications: what does the evidence say?

- Trauma and Adversity in Childhood: History need not be destiny

- The DSM-5: Will It Work in Clinical Practice?

- Mysterious Illness at the LeRoy School: Understanding Conversion Disorders

- Casinos for Kids

- Sleepwalking Is For Real

- Screening our Youth for What Ails Them

-Prescription Drug Abuse -The New Killer on the Block

- The American Psychiatric Association’s New Bible: The DSM-5 – The Changes Ahead (Second of two parts)

- Rapid Cycling Bipolar Disorder: in the Office and on ‘The Street’

- Raising the Hope Ceiling

- The American Psychiatric Association’s New Bible: The DSM-5: Making it Happen (Part I of a Two Part Series)

- What does suicide prevention have to do with improving health care?

- ‘Dying with your rights on’: mental illness, civil rights and saving lives

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Pope Francis and People with Mental Disorders

Two weeks after he had been elected pope, on Holy Thursday, Francis knelt on his knees and washed and kissed the feet of 12 imprisoned juvenile delinquents, two being Muslim and two being women. This was yet another remarkable departure for Time Magazine’s “Person of the Year” since the Papal convention has been a reenactment of what Jesus did with the apostles but with 12 priests at a ceremony held at St. Peter’s or another grand Roman church. When one of the youth asked why, Pope Francis answered: “Things from the heart don’t have an explanation.”

This also was the man, a Jesuit scholar, who at 76 replied to a query about gay priests with five words that rocked the world: “Who am I to judge?” This was the man who leaped into his Papacy by turning away from the Church’s long standing disapproval of being gay by offering, in effect, the Gospel message “He who is without sin among you, let him be the first to throw a stone…” (John 8:7). Pope Francis opened his arms and that of the Catholic Church to people regardless of their faith, gender, sexual preferences or past behaviors. This man, this new Pope, welcomed everyone; he was relentlessly positive and compared the Church to a field hospital during war, which when faced with “a seriously injured person…you have to heal his wounds.”

The Pope’s message, which I take as a Jew, is non-sectarian. As a psychiatrist, I think his message resonates with what is becoming a prevailing ethos of good mental health care – a belief that everyone has promise, can recover and rebuild from life’s misfortunes, and should be able to have what we all want, namely the warmth of relationships, the safety of home, the experience of community, and the dignity of being able to contribute to society.

Stigma against people with mental disorders has been around even longer than the Catholic Church. Blame for being ill or behaving oddly has accompanied that stigma. As a young doctor I was taught to forecast to young people with a serious mental illness (and their families), like schizophrenia, bipolar disorder or post-traumatic conditions, that they never could achieve lasting relationships or success in a career. It was a message to those ill that they should resign themselves to a bleak life and a fate that could not be countered. It was, as well, a clinical stance that, ironically, kept good clinicians from providing what may be more important than anything else – fostering hope and helping to heal the wounds of illness.

Francis’ message is clear: as people and institutions we need to be welcoming (not judging); not defer to the dogma of powerful, hierarchical authorities (“Excessive centralization…complicates”, he said); serve those in need (the wounded); and practice what we preach. This is more and more the lesson taking off in my field as well, where a powerful concept of recovery is spreading. Recovery means sustaining hope, inclusion, finding strengths, building resilience, and valuing, most of all, the patient’s needs and wishes first and not the convenience of practitioners or organizations, nor the mandates of received teachings or hallowed theories. Recovery does not deny illness; that would not help either. Recovery is about making a life despite limitations, which seems to have far greater application than just to those with mental and addictive disorders.

Few people have the extraordinary privilege, and responsibility, of occupying the world’s stage. The new Pope has riveted the attention not just of 1.2 billion Catholics, globally. He is speaking to us all.  He has gotten our attention. The leadership he is exercising in his Papacy dares not to miss so rare and important an opportunity. The reception he is getting, not just from Catholics, speaks to how much his message is one we have been waiting to hear.

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Copyright Dr. Lloyd Sederer

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Philip Seymour Hoffman and America’s Most Neglected Disease             

Life is short, and tragically shorter if you lose your battle with addiction. As did Philip Seymour Hoffman – an actor whose stunning portrayals of a wide range of troubled characters vividly lingers in the minds of countless movie goers. He reportedly was found with a syringe in his arm and packets of presumably what is heroin scattered about his West Village apartment.

Addiction is a disease. Addiction is not recreational drug use. It is characterized by compulsive drug and/or alcohol use despite clear harm to relationships, work and physical health. When addiction advances we see physical dependence on the substance where the body experiences withdrawal when blood levels drop. Like other diseases, addiction makes no distinctions between gender, race, ethnicity or socioeconomic status.

Addiction is the leading cause of preventable death in the U.S.A. CASAColumbia, a renowned policy center on addiction, reports that of the approximately 2.5 million deaths (2009) in the U.S., nearly 600,000 deaths were attributable to tobacco, alcohol or other drugs. The costs of addiction to government (not to mention families, businesses and communities) exceed $468 billion annually (http://www.casacolumbia.org/addiction-research/reports/addiction-medicine).

Addiction in this country remarkably escapes our attention despite its huge prevalence. “40 million Americans age 12 and over meet the clinical criteria for addiction involving nicotine, alcohol or other drugs. That is more than the number of people with heart conditions, diabetes or cancer. Meanwhile, another 80 million Americans fall into the category of risky substance users, defined as those who are not addicted, but use tobacco, alcohol and other drugs in ways that threaten public health and safety” (CASAColumbia).

Yet, and this may be even more difficult to believe, only one in 10 people with any form of addiction report receiving any treatment — at all. Past-year illicit drug use treatment (age 12 or older) was 15% and past year alcohol use treatment (also age 12 or older) was 8% (http://store.samhsa.gov/shin/content//SMA13-4796/SMA13-4796National.pdf).

Mr. Hoffman’s loss to his family, his friends, his professional community and his admirers cannot be expressed with statistics. Instead, his loss tells us story of a life abruptly cut short by addiction during his peak of creativity. It is a reminder to us all how lethal a substance use disorder can be.

There are many paths for recovery from addiction. Help is available {1-800-662-HELP (4357) or 1-800-273-TALK (8255)} .

No one size fits all. For some, 12-step programs are lifesaving. Some people may be suited for a program calling for abstinence while others may benefit from what is called “harm reduction”, a path that starts with reducing use (and danger) and can build from there. Recent years have seen the introduction of medications that aid people in remaining substance free (called medication assisted treatment, or MAT); these are often best coupled with 12-step or counseling programs. We all, not just addicts, need to surround ourselves with people who support our wellbeing while assiduously avoiding people who want to exploit and otherwise take advantage of us. A variety of non-Western activities (like yoga and meditation) as well as nutrition and exercise aid in recovery.

Addiction is America’s most neglected disease. Every day we lose people to its lethal outcomes. May Mr. Hoffman’s epitaph include a reminder of how far we have yet to go to save others from so tragic a fate.

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Population Health:

Transforming Health Care to Improve Our Health

 

As the debate about improving health in the United States wages on, it turns out that only 10% of our health status and longevity, experts declare, derives from health care.

The two graphics on Determinants of Health and the CDC Health Impact Pyramid can be viewed at:

http://www.huffingtonpost.com/lloyd-i-sederer-md/health-care_b_4455582.html

<a href=”http://images.huffingtonpost.com/2013-12-15-DeterminantsofHealthPieChart.gif”><img alt=”2013-12-15-DeterminantsofHealthPieChart.gif” src=”http://images.huffingtonpost.com/2013-12-15-DeterminantsofHealthPieChart-thumb.gif&#8221; width=”433″ height=”420″ /></a>

DETERMINANTS OF HEALTH (1)

What Makes Us Sick?

As the Determinants of Health pie chart reveals, it is our behaviors, our habits (like excessive and poor eating, more than moderate drinking, smoking, physical inactivity, high salt and processed food intake), that drive the lion’s share (40%!) of our ill health and early demise. It is also mental health conditions that often disable people and keep them from effectively managing their illnesses (2). While 30% of our health may be attributable to our genes, we now recognize through the science of epigenetics that genes are turned on or off by their exposure to our environment and what we do and don’t do – which helps to explain the rapidly growing rates of certain illnesses in this country.

Understanding the determinants of health is more than academic because of what it means to the quality of our lives and because the USA spends $ 2.7 TRILLION annually on health care services (18% of the GNP). Yet, this vast sum of money appears to influence only 10% of the health outcomes we achieve. Citizens of the USA may live longer than we did two decades ago, but we suffer from higher rates of morbidity (where functioning is limited by disease) and death when compared with 34 other developed nations (3). While we greatly outspend other countries for health care we have far too little health to show for it.

Of course, we want a top notch emergency room to go to if we have chest pain. We want skilled surgeons to operate on our vital organs and joints to sustain life, relieve pain and enhance mobility. We want (and need) scientifically proven disease management programs to slow the progression of the chronic diseases (like diabetes, heart disease, asthma, depression) that afflict our lives.

But it is population health, a growing movement in health policy and practices, which considers the wellbeing of a group of people and offers an approach that extends beyond the 10% of determinants managed by medical care delivered at hospitals, emergency rooms and even doctors’ offices. Population health extends to the 90% of factors that make us sick.

What can be done?

Going beyond the pie chart of determinants of health leads us to the pyramid of factors that can improve our health.

This graphic, courtesy of the CDC and work by Dr. Thomas Frieden, depicts a graded approach of the actions a society can take to impact its health. But no level of the pyramid is meant to be primary or exclusive. The more levels affected the better we will mitigate disability and death.

<a href=”http://images.huffingtonpost.com/2013-12-15-CDCFreidenPyramid.jpg”><img alt=”2013-12-15-CDCFreidenPyramid.jpg” src=”http://images.huffingtonpost.com/2013-12-15-CDCFreidenPyramid-thumb.jpg&#8221; width=”400″ height=”302″ /></a>

Achieving success on any level of intervention in the pyramid depends upon partnerships among public health proponents, medical centers, business entities, communities and citizens.

Stable and safe housing, even without health care, can stabilize chronic disease and reduce unnecessary emergency room and hospital care. Smoke free environments can reduce respiratory illnesses and cancer. Early detection of cancer, colon and breast cancers for example, allows for earlier intervention and reduces death. Early detection in primary care or community settings of hypertension, diabetes, high cholesterol and depression improves lives and saves money. Self-care with diet, exercise and stress management are at the heart of healthy communities and nations.

Is Population Health Possible?

What makes us think that population health can be achieved?  The natural act of self-interest may answer that question. We are far more apt to do something if it is shown to be in our self-interest or the interest of those we care about – and when it is built into the routines of medical care and our lives.

We now have inescapable evidence that illness is bad for business. We know that illness produces absenteeism, presenteeism (showing up but being unproductive), and greater rates of disability. We also know that wellness (“…a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” – The World Health Organization) increases worker (from the factory floor to the corner office) productivity and is associated with higher corporate earnings (so says IBM).

We know that 1% of patients in a large group of people account for ~ 20% of medical costs; that 5% of patients account for 50% of costs; and that 10% of patients account for 75% of costs. But if only 10% of their health is determined by the provision of health care we are talking about a tiny fraction of what can reduce costs.

Enter population health: unless we change behaviors and the environments people live and work in there will be limited impact on the economic burden a society and a community face. In other words, we can’t afford to still primarily focus on medical care.

We also have a sea change underway in the financing of healthcare. Buyers of health care (Federal and state governments and large employers in the private sector – the vast predominance of the purchasers of medical services) are now putting in place payments that will reduce reimbursing medical providers for doing more and instead incentivize them to economically contain the health costs of their subscribers. When health plans and medical practices are put at financial risk for not managing to a fixed budget  or, even better, create arrangements where savings are shared by purchasers and providers together, the marketplace can add its muscle to achieving health.  Penalties like not paying for inpatient readmissions within 30 days also drive better health. They force hospitals to be partners with communities and with patients (and families) since what happens after a hospital stay usually has little to do with what happened in the hospital and everything to do with follow-up care and the attention patients give to their health.

Privacy concerns notwithstanding, we also are seeing an explosion in information technology – the nervous system of health care. We are positioned to place a cortex, an IT cortex, to inform and help improve the health of patients and populations. Information need not stop at the grounds of a hospital. Patients, primary care clinicians and medical practices can (and are doing so in demonstrations underway) be linked to information about what consumers buy in the supermarket, the fitness they pursue with pedometers and in clubs, and their smoking and drinking habits. If Netflix and Amazon can know so much about you and influence what you buy and do, so can health IT. What’s more, insurance premiums paid by subscribers may come to reward, or not, those whose habits are less costly to society. Using information to shape public behaviors may be called the “nanny state” but it is also a way by which individuals can take control of their health while businesses as well as state and municipal governments save money and lives.

Who is leading the way?

I recently attended a meeting, a Population Health Summit, in New York City, hosted by the NYS Department of Health with the support of the NYS Health Foundation, the NYC Department of Health and Mental Hygiene, hospital associations, NYS county governments, community health care providers, researchers, global and local companies, universities, and the NY Academy of Medicine. We met at the headquarters of the NY Academy of Sciences.

Attendees were there to advance the cause of population health: to assert the evidence for it and to provide examples of what can and is being done. The message throughout the day was that it is possible to reduce illness and death, improve quality of lives and “bend” the curve of (if not diminish) budget breaking health care costs by attending to more than the 10% that has dominated our health care heretofore.

To do so, however, requires unprecedented collaboration among the varied groups assembled – who need proof that they can achieve results consistent with their respective interests. Hospitals have had to fill beds and do complex procedures to remain financially viable. Governments have had to regulate to try to control costs and quality. Businesses, large and small, have struggled with the growing burden of health insurance costs and have done what they need to do to limit them. Researchers have had little opportunity – or support – to move from controlled, university settings into the barrio, the supermarket aisle, domestic dysfunction and damaging human habit disorders.

Among the prominent public health experts at the Summit were Drs. Tom Frieden (head of the CDC), Nirav Shah (NYS Health Commissioner) and Tom Farley (NYC Health Commissioner). Their message to the diverse interests in attendance was that population health can be financially sustainable and can get NYS (and this country) out of the global cellar of rates of morbidity and mortality.

But experts, government officials and corporate buyers cannot succeed without individuals and families coming to believe that their interests will be served, their lives improved and their personal budgets spared by taking their health seriously. Changing habits is among the most daunting of endeavors for any of us. But we now have behavioral interventions like Motivational Interviewing (4) and Screening and Brief Intervention and Referral for Treatment – SBIRT (5). We have smart phone apps (and other technologies) for monitoring and managing just about everything human from the food we ingest to the moods we have. Peer influences are helping to reduce smoking and excessive sugary drinks. Insurance incentives to live healthy can add leverage for prevention and self-care. No single intervention works here either but when bundled together people do change.

Population Health

Population health will not be achieved by a few missionaries. But it can be led by a confederation of public health advocates, organized medicine, government, independent businesses, and patients and families. What seems out of reach is possible when so many players are on the same team.

As individuals, we can benefit from new medicines and more frequent MRIs, surgery or other procedures. In fact, we have an amazing health care system in this country that does just that for those who have good medical insurance. We don’t want to lose that capability; we want to add to health care the needed attention to the 90% of determinants that impact our health, our longevity and our pocketbooks.

To paraphrase President John F. Kennedy, changing the public’s health will not be easy – it will be hard. Those gathered at this Summit on Population Health were there for the sake of our generation and the generations to come. Let’s wish them well and lend our collective support for they surely will need it.

References:

  1. McGinnis, JM, Williams-Russo, P, Knickman, JR: The case for more active policy attention to health promotion. Health Affairs, 2002;21:78-93
  2. Sederer, LI, Chung, H: The cost of not caring for people with serious mental illness, The Huffington Post, July 16, 2013, http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_3605777.html
  3. US Burden of Disease Collaborators. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors [published online July 10, 2013]. JAMA. doi:10.1001/jama.2013.13805
  4.  Miller WR, Rollnick S. Motivational interviewing: preparing people for change. 2nd ed. New York (NY): Guilford Press; 2002.
  5. Bernstein, SL, D’Onofriodoi, G: A Promising Approach For Emergency Departments To Care For Patients With Substance Use And Behavioral Disorders, Health Affairs, 32, no.12 (2013):2122-2128 (10.1377/hlthaff.2013.0664)

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Originally published on December 16, 2013, in the Huffington Post. Copyright Dr. Lloyd Sederer.

http://www.huffingtonpost.com/lloyd-i-sederer-md/health-care_b_4455582.html

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Why? How Great Leaders Inspire Action – Comments on a TEDx Talk by Simon Sinek

Simon Sinek’s TEDx talk has gained over 13 million viewers yet what he has to say is nothing new. But it is clear and punchy and makes it all sound so easy. Can anyone can be a Steve Jobs, a Martin Luther King, an Orville or Wilbur Wright. Can anyone can sell products beyond belief, gather legions of followers or master powered manned flight. What’s the secret? Sinek seems to know.

Sinek’s message is that people buy products or enter movements on the basis of ‘why’, not on the basis of what is being done. He paints Apple not as a computer company but rather closer to a revolution meant to change the status quo; we are drawn to Apple because we too want to be first, creative and iconoclastic. We follow Dr. King because he speaks to what we believe; we march for ourselves, our beliefs, not his: he says “I have a dream…not I have a plan”. And the Wrights? Well they wanted not to just fly; they wanted to change the course of history (by introducing manned flight).

Sinek even tosses in a bit of neuroscience pointing out that while the “outside” layer of our brain, the neocortex”, is rational that it is our “inner” limbic brain, feeling and instinctual, that compels our actions.

What I learned from this TEDx talk was how critical it is to start an organization’s message with its purpose, its mission, its humanity, and its values. I knew about how important those are, but maybe had not quite been converted to the necessity of painting those in neon at the front of every media communication and social conversation.

I did not need to learn, but I was nicely reminded, that in the end we all do what serves us – whether our aims be noble, altruistic, material or self-serving. It is a very good thing when virtue finds a cause or a leader of a cause. I suppose that is what Margaret Mead meant when she said “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” I suppose that is what Gandhi meant when he inverted the change message to say “Be the change that you wish to see in the world.” But, of course, it is a very bad thing when evil finds a leader who can change hearts, not just minds; history is replete with tyrants like Hitler, Stalin, and even Jim Jones (cult leader of the Jonestown, South Africa, massacre).

But I do think Sinek needs a bit more neuroscience instruction since instinct has not always been a friend. Without a neocortex, a thinking brain, we would not have law, some measure of equality and civilization.

Sinek’s talk, however, is indeed worth the 18 minutes he entertainingly delivers. Not only to help sell more iPads, sneakers, and alcoholic beverages; not only to engage others in our mission, whatever might that be. But because we are too often programmed to start with “the what and the how” – the service or product and the way it does its thing – and omit the greater value of it all.

In fact, starting with the purpose, the why, could very well disclose the essence of something. It could reveal whether something or someone deserves to be bought or followed. It might demand that whatever is offered demonstrate, in its small, vast or unique way, that it could elevate our society and make the world a better place. Or not.

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Originally published in the Huffington Post on December 6, 2013

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The best news for baby boomers in a long time!

Jeffrey Kluger, in the Science/Longevity Section of TIME Magazine (9.23.2013), delivers an intelligent and clear message: getting old does not mean that creativity goes out window! Bless him – I say for my cohort of people born over 60 years ago.

How can we explain such luminaries as Frank Lloyd Wright, Picasso, Grandma Moses, Igor Stravinsky, Chef Paul Bocuse, Goya, Goethe, Warren Buffet, even the comedian George Burns, and so many others whose creative genius flourished in their 70s, 80s and into their 90s?

The myth that brain cells stop regenerating has now been disproven. Cortical cells do grow and repair some of what age destroys. Studies also now indicate that myelination, a process that begins in childhood and allows brain nerve fibers to perform more reliably and keep neural circuits running well, continues into the 6th and 7th decades of the human brain. Biology, in other words, helps explain why there is good news for baby boomers.

But there is more. While we gray hairs may not be able to do a Rubik cube as fast as millenials, we have – by dint of need – compensated by using both the left and right brains in unison. Younger peoples’ brains tend to compartmentalize these brain hemispheres whereas when we get older the walls between them diminish and allow for verbal and non-verbal, logical and spatial, reasoning and feeling to more fully intermix and generate works that can surprise even those who produce them!

Finally, there is something to the empty nest, to no more car pools, fewer day to day demands (ill health of course notwithstanding), and more time to do what we want rather than what we need to do. It is hard to paint, write, design or create in any medium if your mind is cluttered with the mundane and the exigent.

This is heartening news for those whose bodies are surely aging but whose brains may still be able to pay some dividends. We can imagine that at least three factors conspire to allow for what has been called “cognitive reserve” – the capacity to draw from our mental gas tank when we need to.

The first appears to be innate brain reserve. This means being born with more neurons and better synapses to connect them. We can think of this as better hardware. It helps to start with more cells and better wiring.

The second is how our development enhances the workings of the brain. This is closer to software capability. Higher education and more cerebral occupations are associated with greater brain resilience and capacity for repair after loss from cortical injury or cell death. It has been hard to tease out whether this is merely a function of innate brain reserve leading to more education and life stimulation but because our brain is dynamic it probably plays an independent role of its own.

The third factor is how well we maintain the ‘machine’, the way we take care of our brains. Here is where lifestyle makes a difference. Aerobic exercise, for example, helps to enhance brain functioning. So too does a variety of mental games, second and third language development, and healthy eating (and not doing the brain harm with excesses of alcohol and other substances that can be neurotoxic). Conversely, depression and other mental disorders jam the machine and need to be detected and effectively treated, as do other medical conditions that impair cerebral blood flow and metabolism (like diabetes and cardiovascular diseases).

I have wondered how I still have the wherewithal to be writing articles like this on nights and weekends, as someone born before the baby boom and with a real day job and a few other things to do. Well, turns out that I may just be among the many with reserve that has been built up and maintained – like a vintage car that likes to accelerate and feel the rush.

I want to thank Yaakov Stern, PhD, a Professor of Clinical Neuropsychology at Columbia Psychiatry and the NYS Psychiatric Institute, for his teachings on this subject.

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 Originally published in the Huffington Post on September 16, 2013.

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 A Third Strike Against Big Pharma

The U.S. Attorney General has just announced that Johnson & Johnson (J & J), a household name and one of the world’s largest pharmaceutical companies, has agreed to pay $2.2 billion for false advertising, principally for its antipsychotic medication Risperdal (risperidone is its generic name). J & J’s knockoff drug, Invega (which is what risperidone becomes in the body after ingestion), was also implicated.

This is the third settlement in recent years. Pfizer and GlaxoSmithKline (GSK) also paid out hefty settlements for similar illegal actions.

Risperdal has been FDA approved for many years for treating psychotic symptoms such as hallucinations and delusions. But J & J employed false marketing to doctors and kickbacks to pharmacies to promote its non-FDA use in the elderly, children and people with developmental disabilities (such as mental retardation). Treating dementia in elderly patients; controlling disruptive behaviors in children; and managing a variety of non-psychotic problems in people with developmental disorders are not FDA-approved indications for Risperdal — yet these were what the company’s marketing staff promoted.

Risperdal has had multibillion dollar annual sales for J & J for many years, making it one of the company’s valuable products. The settlement by J & J included payments for the improper marketing to doctors to promote prescribing of these drugs, kickbacks to pharmacy suppliers tied to sales and forfeited profits.

But these illegal practices are not new. The incentives to promote wide use of this drug, and many other agents, despite limited FDA approval, are huge. That means either the government or consumers, namely patients and families, are necessary checks against improper drug company practices.

What can government do?

Court cases are after the fact. While they may have some deterrent effect the damage has already been done.

In New York State, where I work as medical director of a state agency, we have implemented two ongoing methods of improving prescribing practices and promoting patient safety.

The first is a checklist that doctors and prescribing nurses at the NYS Office of Mental Health must regularly complete on patients receiving antipsychotic agents. In 2010, after reports of cardiac complications of antipsychotic medications in the elderly as well as inescapable evidence of the health risks of these drugs in patients of all ages, we introduced and still use a checklist called SHAPEMEDs (“Is Your Doctor Using A Checklist?”). It does not tell the clinician what to do, but engages him or her in critical thinking about his or her practices.

SHAPEMEDs (an acronym) asks eight questions about each patient:

1. Are you currently prescribing antipsychotic medications for this patient?

2. What is the patient’s primary psychiatric diagnosis?

3. Please list each of the antipsychotic medications the patient is being prescribed.

4. Please list the primary targeted symptoms or behaviors for which these antipsychotic medications are being used.

5. Is the patient currently experiencing any of the following side effects or health issues? (A list then appears to chose from.)

6. Is adherence to antipsychotic medications a problem?

7. Has the preference of the patient and the patient’s parent or guardian been a strong consideration in the choice of antipsychotic medication?

8. Is the current antipsychotic medication regimen expensive (a table with drug costs relative to one another then appears).

a) For the patient or the patient’s family: e.g., insurance copays, out-of-pocket costs?

b) To the health-care system as a whole: e.g., Medicaid, OMH, DOCS, other payers?

The second is a NYS government database on medications and other treatments that patients have received in the past five years. OMH calls this data system PSYCKES (another acronym, you can Google if you wish). We have built in a number of quality monitors that include flagging instances of polypharmacy (the use of multiple medications of the same class, such as antipsychotics), as well as medications known to increase health risks, especially for diabetes and heart disease. PSYCKES is being progressively made available to clinicians and hospitals beyond OMH-operated facilities throughout the state.

Both SHAPEMEDs and PSYCKES are government created and implemented quality monitoring and improvement tools. They foster prudent prescribing practices in the interest of patients — and their caregiving families and loved ones.

What can patients and families do?

Some time ago, I asked in a HuffPost blog, “Can You Trust Your Psychiatrist?” That question arises again in light of the J & J case.

More than ever, patients and families must be vocal advocates for their interests. In my recent book, A Family Guide to Mental Health Care (Norton, 2013), I write about the questions that recipients of medications should ask of the prescribing clinician. Some of these are: Why did you select the medication you did? What symptoms do you think this will help, and by when? What are the risks as well as benefits? What alternatives exist? What does it cost? When will we next review this treatment plan? What are the risks of no treatment?

Given the rush and complexity of medical services, the known risks of all treatments, and the influence on prescribers that the J & J case and other cases reveal, there are just too many ways that care can go awry. It is thus essential — it may not feel fair or right — but it is essential that patients and families become informed and vocal advocates for their care.

Good doctors know that patients (and families) need to represent their self-interests. Good doctors welcome good questions — they ask questions when they are patients! Keep that in mind when you gather your courage to ask them. You can reasonably expect clear and understandable answers in everyday English. That is what is meant by “patient-centered care.”

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This article originally appeared in the Huffington Post  on 11/05/2013.

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Addiction – The Equal Opportunity Threat to Life

Addiction spares no one because of age, gender, race, privilege or social status. In a pair of interviews in Glamour Magazine (September 2013) and The Today Show (http://www.huffingtonpost.com/2013/08/07/christina-huffington-today-cocaine-arianna-huffington_n_3719062.html) Christina Huffington, the 24 year old daughter of the editor-in-chief of The Huffington Post and prominent spokesperson, Arianna Huffington, told the all too familiar story of the progression of the disease of addiction until she was living on the knife’s edge of life.

Addiction is a disease. Addiction is not recreational drug use, or risky behaviors (like adolescent binge drinking or buying drugs on the street). It is characterized by alcohol and/or drug abuse (compulsive use despite clear harm to relationships, work and physical health) and dependence (where the body experiences withdrawal when blood levels of a substance drop).

Addiction is the leading cause of preventable death in the USA, which is why, in addition to its being blind to who you are, it is the equal opportunity threat to life. Of the ~ 2.5 million deaths in 2009 in the USA, near to 600,000 deaths were attributable to tobacco, alcohol or other drugs. The costs of addiction to government, (not to mention families, businesses and communities, exceed $468 billion, annually. Yet, and this may be even more difficult to believe, only one in ten people with addiction report receiving any treatment – at all (http://www.huffingtonpost.com/lloyd-i-sederer-md/casa-addiction-report_b_1622978.html).

For Christina Huffington, her road to addiction began at age 12, with surreptitious use of alcohol. By the time she began boarding at an eastern prep school, she was drinking compulsively and showing, in her words, binge eating – another compulsive behavior that led to admission to a eating disorder program and return to LA, and being closer to home. Then, at age 16, came that moment that people with addiction so frequently describe: that experience of using a substance and feeling like they had never before, a feeling that seemed to demand repeating, and repeating, and repeating.

Cocaine became her ‘drug of choice’, an expression in the addiction community that portrays the one drug that an addict prefers more than any other. She denied having a problem (another feature of the disease early on) and stopped after she was caught at home. But she did not stop being an addict, she stopped using – for the moment. She worked hard at school, getting into Yale, and was clean for three years until she took the next snort. It was if not a moment had passed; she was again as compulsive, and secretive, a user as she had been. That feature of going from zero to sixty right away is also characteristic of the disease of addiction. Everything else gives way to using. She developed tolerance (where increasing doses are needed to get the same high) and a host of physical problems from her daily drug abuse. She got scared and told her mother. That is the first step in recovery: admitting you have a problem.

The next step was rehab, the beginning of a journey in recovery where it is not the drug a person faces but who they are, and what it is about them they use the drug to bear or run from. Rehab also begins a process of turning to others for support, and not only to stay sober – though that is essential. Many people in recovery, though not all, follow the 12-Step approach familiar to many from AA, NA (Narcotics Anonymous), and Alanon. Rehab begins a process of learning to live a drug-free life, one where love, work and purpose serve as the natural highs we all need. For sure, the first time in rehab is not the one that works for many people. It can take a number of tries at being clean and sober, at living a life of recovery, before the process takes hold. Experienced clinicians know not to give up hope even though it can be very hard to predict when recovery will really kick in; people with addiction, and their families, need to know this as well to stay the course, to not abandon hope, to persist and be there when a person wants to try again.

What we don’t want to see or admit we do not confront. Within a family and within our culture tackling addiction starts with detecting it. Simple screening tests for alcohol, drugs and tobacco exist and can be made standard practice throughout medical care (and in educational and counseling settings). SBIRT – Screening, Brief Intervention and Referral for Treatment – is a recognized, proven and even reimbursed medical procedure that awaits general use despite the consequences we suffer from not using it.

There are many paths for people to take to addiction recovery. No one size fits all. For some, 12-Step programs are life saving. Others benefit from medications that aid in remaining drug free (called medication assisted treatment, or MAT) coupled with psychotherapy. We all, not just addicts, need to surround ourselves with people who want to support our wellbeing, and assiduously avoid people who want to exploit and otherwise take advantage of us.

Addiction is America’s most neglected disease. Bravo to Christina Huffington and her family for speaking out, for baring their struggle, and for offering hope to so many others.

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Originally published in the Huffington Post/AOL on August 9, 2013.

 Dr. Sederer’s new book for families who have a member with a mental illness, The Family Guide to Mental Health Care, published by WW Norton, is now available, as is his even newer book (with Jay Neugeboren and Michael Friedman), The Diagnostic Manual of Mishegas. 

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The cost of not caring for people with serious mental illness

Lloyd I. Sederer, MD

Henry Chung, MD

The Kaiser Health Plan of Northern California, usually touted for excellence, recently was hit with a $ 4 million fine by the state’s Department of Managed Health Care. Reportedly, the HMO did not provide mental health services comparable to that for physical illnesses for some of their more seriously ill patients, perhaps akin to not providing care for patients with heart disease who require cardiac rehab or patients with severe respiratory diseases that need more intensive and specialized treatments than usual office based practices.

The population of people needing mental health services is like a pool with a shallow and a deep end, as Dr. Michael Hogan (who led the last Presidential Commission on Mental Health) described. The shallow end of the pool is comprised of the people who will annually suffer from common conditions like depression, anxiety disorders (including PTSD), and alcohol and drug problems. This population is large and typically seeks care (if they do at all) in primary care and general medical settings, delivery sites where Kaiser has shown innovation for integrated health and mental health treatment services.

But there is also a deep end of the pool – people with bipolar illness, schizophrenia, suicidal states, eating disorders, borderline personality and other serious and persistent mental disorders. While this group may be fewer in number their conditions require more comprehensive care, over time, like chronic physical diseases.

Quality care for the shallow end of the population pool can be delivered in primary care settings by embedding screening, medically proven treatment paths, care managers and psychiatric consultation – with repeatedly proven good results. Kaiser has focused on this population in order to not just treat their mental conditions but to contain their medical costs when diabetes, asthma, heart disease, hypertension do not improve because depression or problem drinking gets in the way. Integrated health and mental health care is often brief and effective.

But when a health plan, especially with its own delivery system, as Kaiser has, carries the responsibility for a population of people, working or poor, young or old, healthy or sick, they can’t pick and choose. They can’t say we do this and not that or possibly try to refer their high need patients to public sector services that we all know are over-extended trying to serve those covered by Medicaid, a primary payer for the poor, or who have no health insurance at all. The deep end population has to be served wherever and whenever they appear, carpe diem, since they are often wary of doctors and hospitals, sometimes because of how their illness impairs their thinking, sometimes because of how they are treated, or not.

When ill people in the deep end of the pool are unrecognized or untreated they don’t simply go away. They show up in emergency rooms and on general hospital wards with out of control diabetes, heart attacks, pneumonia, trauma, and states of intoxication. That costs a lot of money. They are at high risk for homelessness and inhabit expensive community shelters. Their non-violent crimes get them arrested and confined to jails and prisons where some 400,000 inmates with mental conditions now reside in this country. These people drain government coffers when their illnesses progress and they come to depend on food stamps, welfare and disability payments.

Ironically, treatments for serious and persistent mental disorders are as effective as treatments for chronic physical conditions – when patients’ illnesses are properly detected and diagnosed, and when they are made welcome, kept in care and delivered proven interventions. There is no need to eschew the deep end of the pool because of misinformation that nothing will help; quite the contrary.

Responsible and good medical care does not confine itself to the shallow end of the pool. Restricting access and limiting services for those with serious and persistent disorders, mental or physical, abrogates a professional ethos to care for the patient and, over time, costs health care and communities far more money. A lot more than four million dollars.

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 Dr. Sederer is Adjunct Professor at the Columbia/Mailman School of Public Health and author of The Family Guide to Mental Health Care (WW Norton, 2013).

 Dr. Chung is Vice President and Chief Medical Officer of Montefiore Care Management at Montefiore Medical Center

The opinions offered here are those of the authors not their respective organizations.

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Wartime PTSD: What Works and How to Care for a Loved One

Lloyd I. Sederer, MD and Sandro Galea, MD, DrPH

June is PTSD Awareness Month, so declares the Veterans Administration. Hundreds of thousands of war returnees from Iraq and Afghanistan have or will develop post-traumatic stress disorder. It is a condition that induces suffering in veterans – and their families who can be repeatedly separated from their loved one, live with more limited resources as a member is gone, and emotionally contend with anxiety about the possible injury or death of their soldier.

The risk of developing PTSD is increased when military personnel experience combat, are wounded, witness death, are taken captive or tortured, handle remains, or are sexually harassed or assaulted. The most stressful of combat experiences include exposure to unpredictable attacks, including IEDs, sniper fire, and rocket-propelled grenades. Longer and multiple deployments as well as greater time away from base camp add to a soldier’s likelihood of developing PTSD.

The Institute of Medicine/National Academy of Sciences (http://www.iom.edu/Reports/2012/Treatment-for-Posttraumatic-Stress-Disorder-in-Military-and-Veteran-Populations-Initial-Assessment.aspx) issued “Treatment for PTSD in Military and Veteran Populations (Initial Assessment)” after reviewing Department of Defense and VA data on prevention, screening, diagnosis, treatment and rehabilitation of PTSD. Its aim was to inform and direct future efforts to more effectively respond to a condition that profoundly impacts soldiers, families, and our communities.

What Might PTSD Look Like in Your Family?

Your loved one was exposed to a life-threatening or horrific event, which may have happened in recent months or perhaps happened in the past—even years ago. Your soldier becomes inward, isolated, and preoccupied, with difficulty concentrating on and completing tasks. He or she has changed profoundly, leaving you confused and even afraid. Some will startle very easily, at something as minor as the sound of a door closing or a telephone ringing. Some will be highly vigilant, as if a sniper were on a rooftop nearby. If you can get the person to talk about what is happening, he or she will describe feeling scared, numb, or both. Images of the trauma erupt into the person’s conscious mind, sometimes without a clear trigger. Sleep is terribly restless and full of anxious dreams. Alcohol and drug abuse is very common, and if a person smokes cigarettes he or she will smoke a lot more. Suicidal thoughts are common. (In fact, the number of completed suicides among veterans of Iraq and Afghanistan now far exceeds the deaths suffered in combat.) A well-validated screening tool is the PTSD Checklist, a version of which exists for military personnel, and can be accessed on the web to help in identifying this condition.

Treatment of PTSD

We have much to learn about what are the most effective treatments for PTSD, for which individuals and at what point in the course of their illness. A principle that applies to PTSD, as it does to every serious medical illness, is that early detection and early intervention can help slow the progression of the disease. Another principle is that comprehensive treatment is essential: interventions are often best when they combine medications, therapy, ongoing self care (exercise, nutrition, yoga and meditation), supportive friends and families, and control the use of alcohol and non-prescribed drugs. Still another principle is that treatment be continuous – because interrupted treatment allows illness to gain the upper hand producing relapse (falling ill during an episode of illness) or recurrence (falling ill after recovery).

Studies indicate that the therapy treatments that work for PTSD are exposure therapy, cognitive behavioral therapy (CBT), anxiety management programs, and EMDR (eye movement and desensitization reprocessing – a new finding given its unclear results in the past). It is critical to detect depressive illness and substance use disorder, highly common co-occurring conditions to PTSD, because unless these are recognized and treated a soldier cannot recover from the primary traumatic disorder.

Medication treatment has proven less clear, especially for the commonly used selective serotonin uptake inhibitors and serotonin reuptake inhibitors (SSRIs and SNRIs). Studies of US veterans have yet to show conclusive efficacy, though there is considerable debate about this finding because of more sanguine findings with veterans in other countries. Findings about other antidepressant medications like tricyclics and monoamine oxidase inhibitors have been even less conclusive.

Complementary and Alternative Medicine (CAM) treatments show promise and include herbal compounds, yoga (especially breathing techniques), acupuncture, and meditative techniques. But here too the evidence is at best preliminary and contested.

What Can You Do?

It is not enough for doctors to ask ‘why are you here?” Patients and families often wonder how will I be able to tell if the treatment is working?” So doctors need to ask their patients and their families “what do you want to achieve?” If you are not asked, come prepared to say what that is. Establishing clear goals for treatment is a simple and practical way of determining if the treatment is working. In addition, the use of standardized questionnaires, simple check lists that quantify symptoms and functioning, like PTSD and depression scales, are also good ways of monitoring if a person is responding to treatment. While mental health disorders have yet to have blood tests these paper and pencil scales are as reliable in determining treatment response as are blood sugar, hemoglobin A1c levels and lipid profiles.

Psychiatric conditions, including PTSD, depression and substance use, often have the additional vexing problem where those affected fight against receiving the care that can make a difference. Sometimes it is the illness itself that blinds a person from knowing they are ill. Stigma, shame, hopelessness that anything can help, bad experiences with care, not wanting to be a burden, and fear of unemployability as a result of mental illness (especially in uniformed personnel jobs like police, fire, and EMTs) all conspire to deter a person with PTSD from getting care. Sometimes this is the greatest problem a family will face.

Families will need to be clear about what they see in the person affected, validate their experiences with each other and ally together, listen to understand why the veteran is behaving as he or she is, and carefully use their leverage to help their loved one act, ultimately, in his or her interest. Families can learn how to best help their loved one but they generally cannot do so without the support and coaching of others.

What We Can Do Now for Veterans and Their Families

The IOM report urges that PTSD screening be carried out at least once a year in primary care settings. Standardized screening is an important way to rise above a “don’t ask, don’t tell” policy of medical evasion by doctors and patients.

Families need to be an ongoing part of the treatment of war returnees with mental health conditions. While consent is always needed it helps to create family involvement as an expectation of good treatment, not tack it on after the fact. The family may prove not only the best early warning system of danger but also can be the greatest asset a person with an illness may have.

We must measure the quality and outcomes of treatment programs to insure that they are consistently providing the evidence based practices (such as they are) and are producing results. We can evaluate program performance to determine patient retention in treatment so they have a chance at recovery.

We must also seek innovative and alternative treatments that may prove not only effective but more palatable to soldiers, their families, and even are less costly than conventional interventions.

What Lies Ahead

The IOM has also called for observing clinical services and practices on military bases as well as ongoing assessment of new and emerging treatments and practices. It speaks to an ongoing need – and commitment – to help veterans and their families recover from the “invisible” yet profoundly evident consequences of war on the minds and souls of combatants.

The fight ahead is not only to ‘wage war for peace’, to paraphrase The Carter Center, it is also for the peace of mind of those individuals (and their families) who served and are serving in Iraq and Afghanistan.

This article first appeared in the Huffington Post/AOL on June 11, 2013.

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The Trauma That Will Succeed The Tornadoes

The debris is all too visible from the tornadoes that visited catastrophe on Oklahoma this past week. Lives were lost, property irrevocably destroyed and neighborhoods razed.  The tornado might as well have been a load of thousand pound bombs from above looking at the destruction it rained. The damage, however, will not stop there.

This natural yet preternaturally awesome storm now leaves in its wake another form of disruption – insidious and internal to those who witnessed or were impacted by its force. This is the stress response that is first acute, lasting for days or weeks, and for some post-traumatic when symptoms will not abate or return as a repeat psychic storm after laying dormant for months or longer. We know these as acute and post-traumatic stress disorders.

After rescue efforts are exhausted the recovery phase of a disaster begins, what might traumatic disorders look like in you or a loved one in the aftermath of the destruction?

 What Might Acute Stress Disorder Look Like to You?

After the tornado, a person is deeply shaken and may not be able to stop thinking about the event. He or she may have difficulty sleeping and may be “jumpy” or irritable. Taking care of everyday business is hard and spending time with others feels a burden. The disaster survivor person may smoke or drink more and withdraw from others.

Sometimes a person will experience dissociation (where someone feels and appears very distant or shut off from what is going on), or re-experience the event, and feel intense anxiety and want to avoid going out and participating in everyday life; these symptoms can impair functioning at school or work, and within the family. For the diagnosis of an acute stress disorder (ASD) to be made, the condition must come on within 4 weeks of the trauma and last more than a couple of days. If significant symptoms persist for longer than a month, it’s likely that the ASD has progressed to PTSD.

What Might PTSD Look Like to You?

The life-threatening or horrific event happened in recent months or may have happened in the past—even years ago. But with some trigger, another storm or personal challenge, a person begins to change: they turn inward, become isolated and preoccupied, and have difficulty concentrating and completing tasks. Someone you know well seems different, not in a small way, leaving you confused and concerned. Some people will startle very easily, at something as minor as the sound of a door closing or a telephone ringing. Some will be highly vigilant, as if another storm was on the horizon. If a survivor can talk about what he or she is feeling they might describe feeling scared, numb, or both. Images of the disaster, or its aftermath, can erupt into a person’s mind, sometimes without a clear trigger. Sleep can be terribly restless and full of anxious dreams. Alcohol and drug abuse is very common, and if a person smokes cigarettes he or she will smoke a lot more. Suicidal thoughts may occur, paradoxically in a person who has lived through a life threatening event.

PTSD symptoms must persist for over a month for the diagnosis to be made. Unlike ASD, PTSD may appear after a month or, as mentioned, sit dormant, only to arise months or years later, typically after some destabilizing event or illness. PTSD that arises well after the event is referred to as delayed-onset PTSD. Along with alcohol or drug abuse, the presence of other mental disorders (like depression or bipolar disorder) is a powerful risk factor for the development of PTSD after a traumatic experience. These factors also forecast that treatment will be more challenging.

The risk of developing ASD and PTSD can be mitigated by protective factors (such as supportive families and communities as well as faith) and resilience. Most people are resilient and with time will rebuild their lives, physically as well as emotionally. But for those who will not – those at risk to develop a mental disorder after a tornado, or any natural or human-made disaster, the principles of early identification and early mental health intervention will be as necessary a salve as the restoration of their property and community.

Additional information:

Galea, S., Brewin, C. R., Gruber, M., Jones, R. T., King, D. W., King, L. A., et al. (2007). Exposure to hurricane-related stressors and mental illness after Hurricane Katrina. Archives of General Psychiatry, 64, 1427-1434.

Galea, S., Nandi, A., & Vlahov, D. (2005). The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Reviews, 27, 78-91.

Norris FH, Tracy M, Galea S. Looking for resilience: Understanding the longitudinal trajectories of responses to stress. Social Science and Medicine. 2009;68(12):2190-2198. PMID: 19403217. URL: http://dx.doi.org/10.1016/j.socscimed.2009.03.043

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Originally published in The Huffington Post/AOL on May 28, 2013

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Traumatic Stress Disorder

A person who has undergone a trauma is someone who has experienced, witnessed, or was confronted with an event involving actual or threatened death (or serious injury) to self or others.

At the time of the trauma, that person felt intense fear, helplessness, or horror. However, people’s responses to these situations are varied: Not everyone exposed to a severe traumatic event will develop acute stress disorder (ASD) or posttraumatic stress disorder (PTSD).

ASD always comes on soon after the traumatic event, while PTSD emerges after a month or lies dormant for months or even years before symptoms occur. PTSD is the more persistent and severe response to trauma, and ASD always precedes it. This means that detection of ASD provides opportunities for early intervention to stop the progression to PTSD. Military forces and disaster-response teams around the world are searching for the best interventions to do so.

What kinds of events may cause ASD or PTSD? A traumatic event as one that threatens the life of (or causes serious injury to) a person or other people around that person. These include:

  • Natural disasters, such as earthquakes, tsunamis, hurricanes, fires, floods, and tornadoes
  • Manmade disasters, like terrorist attacks or arson
  • War, particularly instances involving atrocities or horrific deaths of fellow soldiers or civilians
  • Crime, including torture (all too common among refugees), rape, and physical or sexual abuse

As we see in the news, three young women have been rescued after 10 years of what must have been horrific and persistent abuses. They have been exposed to the types of stresses that foster traumatic conditions.

What Might Acute Stress Disorder Look Like?

A clear and major stress has happened to someone. He or she survived a serious accident, was directly exposed to a horrific natural disaster, or was assaulted. The person is deeply shaken and can’t stop thinking about the event. He or she may have difficulty sleeping and may be “jumpy” or irritable. Taking care of everyday business is hard and socializing is no longer fun. The person may smoke or drink more and withdraw from others.

Symptoms include dissociation (where someone feels and appears very distant or shut off from what is going on), re-experiencing the event, anxiety and arousal, avoidance, and emotional distress; these symptoms impair functioning at school or work, and within the family. For the diagnosis to be made, the condition must come on within 4 weeks of the trauma and last more than a couple of days. If significant symptoms persist for longer than a month, it’s likely that the ASD has progressed to PTSD.

What Might PTSD Look Like?

A person was exposed to a life-threatening or horrific event, which may have happened in recent months or may have happened in the past—even years ago. You see that person become inward, isolated, and preoccupied, with difficulty concentrating on and completing tasks. Some people will startle very easily, at something as minor as the sound of a door closing or a telephone ringing. Some will be highly vigilant, as if a sniper were on a rooftop nearby. If you can get the person to talk about what is happening, he or she will describe feeling scared, numb, or both. Images of the trauma erupt into the person’s conscious mind, sometimes without a clear trigger. Sleep is terribly restless and full of anxious dreams. Alcohol and drug abuse is very common, and if a person smokes cigarettes he or she will smoke a lot more. Suicidal thoughts are common. PTSD symptoms must persist for over a month for the diagnosis to be made.

A well-validated screening tool is the PTSD Checklist (a civilian version can be found at http://www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf).

A version also exists for military personnel.

What can be done?

Good care for a person with a traumatic disorder includes:

  • Reducing the severity of symptoms using effective treatments like crisis counseling, medications, and therapy;
  • Preventing or lessening trauma-worsening, co-occurring disorders by early identification and treatment of these conditions—the most common being depression and alcohol and substance use;
  • Enhancing functioning in adults and promote normal development in children and adolescents by aiding and guiding individuals to return to daily routines and resume functioning as soon as possible;
  • Striving to prevent relapse by understanding triggers of trauma and acquiring skills to manage them; and critically but very hard to achieve;

and perhaps the most important and most challenging:

  • Helping a person search for meaning and reparative beliefs about the traumatic event to try to put the horrific experience into perspective and master the potentially disabling reactions to it.

Trauma is ubiquitous in our world. Sometimes, however, its magnitude is so profound or persistent that while recovery is possible a person’s life is forever changed.

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Originally published in the Huffington Post/AOL on May 8, 2013

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Readying for a Radiological Disaster: Preparing for Dirty Bombs, Nuclear Disaster and Other Radiological Emergencies

I recently attended a conference on Preparing for Dirty Bombs, Nuclear Disaster and Other Radiological Emergencies. Scary stuff. A subject that is about the last thing we want to consider – yet in the ‘new normal’ it has become inescapable.

Disaster, especially terrorism, notwithstanding its horrific initial impact on lives and property takes its greatest toll, over time, by destabilizing the emotional – and thus economic – fabric of a community, state or nation.

NYS Congressman Chris Gibson, MPA, PhD, a retired Marine Colonel, opened the meeting appreciating that mental health and mental illnesses are not ‘static’; in other words, how we respond individually and collectively will influence the trajectory of human distress and disorder. He understood that those people who learn to turn and face a challenge, a danger, will suffer less and be more successful, over time. Mental health professionals understand this as overcoming avoidance, a natural, even instinctual, response that may transiently reduce anxiety but offers no lasting mastery.

Experts on radiological events, often armed with chilling photos of nuclear disasters, as well as our Federal government now assert that an IND (Improvised Nuclear Device) could be assembled using contraband uranium by rogue dictators or organized terror groups. An IND can fit in a car or van and have the destructive capability of the Hiroshima and Nagasaki bombs. Beyond the incomprehensible horror of the blast, or the contamination dispersed by winds or other natural means, the footprint of the psychological terror unleashed would extend well beyond the boundaries of a bomb. The emotional blast from a nuclear event has no definable limits.

How people react determines more than anything the outcomes of a disaster. Radiation is a terribly feared hazard, sharing top billing with biological weapons of destruction. The particular evil of radiation, and how it spawns such intense alarm and dread, is that it is invisible, silent and odorless. We have almost no ways to know the danger (unless we have Geiger Counters). Moreover, psychogenic symptoms, like rash, fatigue and gastrointestinal problems, are common and confound understanding who has been truly exposed. Perhaps worst of all is that we are apt to turn away from, or against, our fellow human beings (including emergency workers) as well as places and products from the disaster zone because they represent potential dangers to our health.

Disaster experts have learned from too many such events that trustworthy information, promptly delivered, is the most effective ‘anxiolytic’ (remedy for anxiety). Responsible officials can, and must, impart information about what is known, what is not known, and dispel misinformation to build trust and assist a fearful public.

What survivors of a nuclear event will need to know, god forbid that should happen, is what to do to avoid harm. The main message is “Go Inside, Stay Inside, and Stay Tuned.” Remarkably, we just witnessed this message in Boston for a very different threat: the city was told “Go Inside, Stay Inside, and Stay Tuned.” – also known as “Shelter in Place.”

From every disaster, including 9/11, Katrina, Hurricane Sandy, Boston, Texas, and the massacres that have darkened the lives of families in Newtown, Aurora, Columbine, Virginia Tech and too many other sites, we know that people are resilient. We also know that people are ‘pro-social’, namely they tend to turn to each other – both to help and to seek help. We all need encouragement and support to heal.

Now is the time to build a stockpile of information, messages and communication plans about what to do, how, and by whom. Now is also the time to identify and train a core group of people who can carry the message and “just in time’ train others, for when the next disaster strikes. This is called readiness. Not preparing, not building readiness, exposes our communities and potential victims and responders to its disturbing alternative, a lack of critical knowledge about how to respond. Readiness is how to help protect the public from not taking the self protective actions that can keep immediate disaster from becoming sustained catastrophe.

I didn’t sleep well the night after the conference. I suspect others who attended did not as well. But I felt better knowing that Federal, State and community based organizations were taking Congressman Gibson’s words to heart and turning toward the challenge, with eyes wide open and minds restless to build readiness.

Published in the Huffington Post/AOL on May 7, 2013

Reprinted in Columbia/Mailman School of Public Health 2×2, May 8, 2013

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Bipolar Disorder: what a family (or friend) might see and what a family can do

Nearly 1% of people suffer from bipolar disorder (sometimes referred to as “manic depression”). Bipolar disorder is a mental illness major mood swings of mania (Bipolar I) or hypomania (a less intense form of mania called Bipolar II) and depression.

We see in the press that Catherine Zeta Jones has admitted herself to a hospital for treatment of what has been identified as Bipolar II: this form of bipolar disorder can produce considerable distress as well as difficulty meeting life’s demands – but without (yet) resulting in a full blown manic attack.

People with bipolar disorder, I or II, with good treatment, self- care and supportive family and friends can – and do – live full and productive lives. Without effective treatment, bipolar disorder can have a devastating effect on the person and their family, relationships and work.

What Might Bipolar Disorder Look Like to Family or Friends?

Because bipolar disorder involves both depressive and manic states, either mood problem can herald the recurrence of the condition. But I will focus here about what you might see during an emerging manic or hypomanic episode. In fact, mania typically progresses from excitement to hypomania and, if not controlled, can escalate to mania. So what you will see first is probably hypomania.

Over the course of days to weeks, your family member or friend starts sleeping less and less. He or she seems to have rather unlimited energy and is full of ideas. At first, the person may be funny and pleasant to be around, but soon that mood will become more irritable and unstable. Your loved one may start drinking more or using drugs secretly – a very common problem in people with bipolar conditions. If the person was on medication for bipolar disorder, he or she has probably stopped taking it (causing the problem to come back) or will want to discontinue because it can dim the feeling of excitement, a very desirable, though problematic, feeling for someone with this illness.

Money may be missing from where you keep it or from your bank account. Bad judgment is common during a hypomania, or in a full manic state: Your loved one may spend money recklessly and engage in risky behaviors, including casual (and unprotected sex), gambling, driving at high speeds, and frequenting neighborhoods and settings where no good is known to happen. Your loved one may accuse you of being boring, oppressive, or ruining his or her life or hopes. As time goes by and if the illness is not treated, the excitement mounts and a person will be unable to get anything done; behaviors can become progressively more threatening to the safety and wellbeing of the family. Commonsense talk seems to go when you try to reason with the person who is now ill.

What Can You Do?

Faced with mounting evidence of serious problems and a family’s efforts at reasoning defied, with worry and love driving them, a family may want to push harder, insist that their loved one faces facts – does something! Tempers can escalate and each side digs in more deeply.

The first thing you can do is what not to do, which is to not get into fights with your loved one. This may be the hardest prescription of all. What can work is a combination of listening and leverage. There is much to say about this, which I do in my book for families. I believe that all behavior, even illness behavior, serves a purpose. We just may not know yet what it is. By listening, asking questions, you may find out, not by crossing swords.

Leverage is about a family being a two way street: you get and you give. As a family or friend, what supports are you providing? Like a cell phone, money, car, even a place to stay. These are leverage points that can be used to negotiate for what needs to be done. What does a loved one need to do – ultimately in their interest – to continue to receive money, use the car, or stay together?

Avoiding a fight is not the same thing as being disengaged. In fact, it’s staying just as involved — in a different way. It is hard to not get into a fight, you may need help.

The second thing, therefore, is don’t go it alone. Mental health problems, including addictions, are among the most common medical problems that exist. That means that there others, in your extended family and among their friends and co-workers, have been down the same road.

Who can you confide in? Is there a spouse, brother, sister, aunt, uncle, friend, or someone who has had a depression, addiction, traumatic disorder or other mental problem and is open about it (and, thankfully, more people are)? That’s someone to turn to. You can turn to a primary care doctor or clergy, someone who has known your loved one for some time. Families can turn to school counselors or employee assistance programs at work. Advocacy organizations, like a local chapter of the National Alliance on Mental Illness (NAMI) or the Mental Health America (MHA), are terrific resources that I almost always suggest: these organizations are staffed by experienced and trained people. NAMI has families who have been there. These organizations provide information and referral, by phone or in person. AND they are free!

Don’t go it alone. This lesson has been learned with every persistent illness, including diabetes, colitis, cancer, Alzheimer’s and countless other conditions. Mental disorders, including bipolar disorder, are no different.

Third, learn about the mental health system of care, its treatments, its rules and how to work with and bend the rules. I am not talking about going to psychology graduate school. I am talking about becoming an informed and vocal advocate for your loved one. Health care in general – not just the mental health – now demands informed and assertive families and consumers.

Fourth, and this is also hard but no different from illnesses of all sorts, you will need to think of managing the illness as more of a marathon than a sprint. Managing all but short term illnesses (like infections or broken bones) means taking a long view. Sticking with it.

A family’s morale and determination will be tested. “Never, ever, give up. While often difficult to predict, a person’s involvement in care or their illness improves. Mental health professionals have seen this again and again. You need to know this. Don’t lose hope, don’t give up. Take the long view in your mind and with your efforts.

Recovery

Recovery is a word that does not only apply to addictions. Recovery is about having a life of meaning, purpose, dignity, relationships and contribution. It is what we all want, and it is possible with mental illnesses, like bipolar disorder and the many other faces of mental illness.

As we watch how Ms. Zeta Jones manages her illness there may be much to learn from someone so talented, so successful and yet ill about how to not let bipolar disorder, or any mental or addictive disease, derail or destroy a life or a family.

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This article first appeared in the Huffington Post/AOL on May 2, 2013.

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Things you want to know about psychiatric medications but didn’t know who (or how) to ask

Psychiatric medications are among the most frequently prescribed medications in this country, and throughout the world. One in ten Americans takes an anti-depressant. Yet despite the incessant barrage of multi-media drug promotions you may not have the answers to the questions you most want answered.

I asked more than a dozen expert psychiatric colleagues, and myself, the questions they most frequently receive about psychiatric medications from people who take them or their families. Here are a dozen of those many questions; the responses are mine.

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1.      What are the chances that my medication will (or will not) work?

This could be the most frequently asked question—if all who wondered dared to ask it. For a medication to be approved by the Food and Drug Administration (FDA), it must be shown to be safe and effective. “Effective” means that it outperforms the placebo effect, which can result in improvement in more that 30% of individuals.

A common example is antidepressant medications for depression, which can improve symptoms for approximately 75% of people suffering from moderate to severe illness (mild to moderate depression often responds to non-drug treatments). But the effectiveness of antidepressants depends on finding the right medication for an individual, at an adequate dose (not too little and not too much), taking it reliably for enough time and without barriers to its effectiveness like alcohol or drug abuse. Similar effectiveness is found for anti-manic and anti-psychotic medications, particularly for acute symptoms.

Medications have limited effectiveness in eating and personality disorders, except when used for another co-occurring mental disorder.

But medications do not cure mental disorders; they treat symptoms. Adequate sleep, good nutrition, moderate (or no) use of alcohol and non-prescribed drugs, psychotherapy, the hard work of recovery or rehabilitation, and support are what everyone needs to manage an illness, be it a mental or a physical illness.

2.      How soon will it work?

Some medications work in hours, like tranquilizing medications. Some can take up to 6 weeks or longer, like antidepressants. Some are meant to prevent relapse or recurrence, so they work over time. This is a good question to ask when a doctor is writing the prescription.

3.      How will I know if it’s working?

This is a crucial question. I urge patients and their families to set specific goals for treatment, early on. Medications work on specific symptoms like sleep problems or anxiety or feeling very blue or agitated; speak with the doctor about what symptoms the medication is meant to improve. Improved functioning at school and work can take more time to achieve than symptoms but if you are clear about your goals and monitor them (with others you trust) you will know if the medication is working.

4.      Will this medication change my personality?

No. Your personality is you; it is who you have been since you were young. The effects of a medication can change how you feel (more focused, more energetic, more clear-thinking—or more restless, sleepier, or without sexual desire) but that is not a change in your personality.

5.      Will this medication change my brain?

The goal of a medication for a mental illness is to change how part of the brain is working in order to improve how a person feels and thinks, and enable them to behave more like they want to. There are also unwanted side effects that can result from how a medication can affect other parts of the brain, like regions involved in appetite or alertness or muscle tone. There is no such thing as a perfect medication with only benefits and no side effects, so you will need to weigh benefits and side effects and decide if a medication is right for you.

6.      If I take this medication, does it mean I’m crazy?

Talk of craziness remains an unfortunate residue of the stigma that continues to pervade how people think of mental illness (see my recent HuffPost “The Painted Bird”: stigma and mental illness, http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-illness-stigma_b_2891227.html).

Mental illnesses are diseases of the brain and mind, not inexplicable happenings or failures of will and character. We need to think of taking medication for a mental illness as part of a comprehensive plan by which a person manages an illness – any illness – and rebuilds functioning at school, home, and work as well as with family and friends.

7.      Will I have to be on this medication for the rest of my life?

Not necessarily, but you should not stop a medication suddenly or without discussing it with your doctor. Over time, dosage can be reduced, and with planning a trial off a medication can be tried. People whose illness has gone on for years or who have had repeated episodes of acute problems usually require taking medications for a long period of time in the same way that individuals with diabetes, high blood pressure and asthma do.

8.      Will I become addicted to this medication?

None of the antidepressant, mood stabilizing, or antipsychotic medications are addicting. However, with benzodiazepam tranquilizers and some sleep medications our bodies can develop tolerance (where a higher dose is needed to achieve the same effect) or dependence (where a person experiences withdrawal symptoms if the drug is quickly stopped); this can also happen with many pain medications.

9.      Will the medication make me fat?

Many psychiatric medications bring the unwanted side effect of weight gain. But some medications used for similar conditions (for example, in the class of antidepressant or antipsychotic agents) are associated with greater weight gain than others. Carefully considering which medication to use, coupled with attention to diet and exercise, can prevent or minimize weight gain.

10.  Can I drink while I’m on this medication?

Excessive drinking (or use of non-prescribed medications or street drugs) is not a good idea for a person whose brain is affected by a mental illness. For those who have a co-occurring alcohol or drug-use disorder, abstinence will be a necessary aim. In some instances, alcohol may interfere or alter blood levels of the medication, so it is important to check with your doctor. For people with no substance-use problem and mild to moderate or stable illness, I usually say that they may be able to enjoy a drink. Try one and see how it feels. For people on psychiatric medications, keep in mind that one drink can feel like two or three.

11.  Will this medication affect my sex life?

Serotonin reuptake inhibitors (SSRIs and SNRIs), used especially for depression and anxiety disorders, can produce problems with sexual arousal as well as in achieving orgasm – in men and women. In some cases, a person’s libido, or sex drive, is reduced. For people, however, who lost their drive from depression, it can improve with treatment. There is one antidepressant, bupropion, which has not shown these problems. For other antidepressants, there are ways to help by adjusting the dose or timing of the drug or using a medication to enhance sexual functioning.

Other types of medication (for high blood pressure, heart disease and other general medical conditions) may affect sexual desire and performance, so if that is happening to you, speak with your doctor. Losing the pleasure of sex – for you or your partner – may not need to be a consequence of taking medication.

12.  My child refuses to take a medication. Can I hide it in his or her food?

Trust is the bedrock of every relationship. A family can feel very desperate and want to do something like this when a loved one refuses treatment and is suffering and failing. But the cost in loss of trust usually outweighs any (temporary) benefits.

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More answers about medications, other treatments, and more broadly about mental health care are in my book, The Family Guide to Mental Health Care.

Originally published in the Huffington Post/AOL on April 18, 2013.

 

 

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“The Painted Bird”: stigma and mental illness

As the boy in Jerzy Kosinski’s 1965 book, “The Painted Bird” wanders about Eastern Europe fleeing the Nazis who have entrapped his Polish parents he witnesses an event that is apocryphal in its depiction of stigma. He comes upon a professional bird catcher who paints a captured bird with many colors, and then releases it to the sky. The boy watches as the soaring, painted bird comes upon its flock and is mercilessly attacked by its own. The bird plummets, dead, to the earth below.

At a moment when mental health is so much at the forefront of the minds of Americans and our media it seems time, again, to try to understand the damaging views so commonly held about people with mental illness. Trustworthy information tells us that people with serious mental illnesses are no more dangerous than the general public – if their condition is treated and they are not abusing alcohol or drugs; in fact, people with mental illness are far more likely to be victims of violence than they are to be perpetrators. In addition, ample evidence also exists that effectively managed mental illnesses need not be barriers to fulfilling and lasting relationships and to achieving career aspirations.

Yet, equally compelling evidence tells us that people fear, avoid, and otherwise stigmatize people with mental illnesses despite the fact that a bird remains a bird even if its feathers are painted. A new study sheds more light on this complex phenomenon, and may better direct efforts at its elimination.

The American Journal of Public Health recently published, online, a study (one of a group of papers) on stigma and discrimination against those who suffer from mental disorders. Individuals from the USA, Europe, Asia and Africa (16 countries in all) were asked to read a short vignette describing either a person with schizophrenia or depression. While symptoms were clearly portrayed (such as paranoia, agitation, hearing voices in one case and sadness, difficulty concentrating, feeling worthless and discouraged in the other) no diagnostic label was offered, nor was gender or race, thus reducing other potential biases.

Study participants were then queried about their knowledge about mental conditions, including if it was a brain disease and if treatment can work. They were also assessed for stigma with questions about reluctance to interact with the person described, if mental illness renders people ‘inferior’ or dangerous, and if someone would experience unwanted consequences if he or she revealed they had a mental disorder.

This study revealed that while there is generally widespread understanding about mental illness, “…rejecting …notions of individual weakness… [and] moral failure…” there was a “backbone” of stigma: people with mental illness were seen as having potential for violence (especially towards themselves), as well as problems meeting role responsibilities for children (e.g., caring and teaching), and were undesirable for marrying into families. (The “Backbone” of Stigma: Identifying the Global Core of Public Prejudice Associated with Mental Illness, AJPH, Pescosolido, BA, Medina, TR, Martin, JK, Long, JS, March 14, 2013, p.e5). While schizophrenia was more likely to be seen as a brain disease than was depression there was greater stigma towards people with schizophrenia, including their social inclusion and meeting role responsibilities.

The Centers for Disease Control and Prevention (CDC) released complementary findings in a 2010 study of over 200,000 adults in 35 states, DC and Puerto Rico who were asked about their attitudes toward mental illness (What’s Your Attitude Towards Mental Illness? http://www.huffingtonpost.com/lloyd-i-sederer-md/whats-your-attitude-towar_b_615691.html). They showed that despite generally positive public attitudes that mental health treatment works, those with mental illness continue to feel that others are not ‘caring and sympathetic’. In other words, they still feel excluded among their own flock despite a public knowledgeable about mental illness and its treatments.

The authors of the American Journal of Public Health study raised doubt about whether educational campaigns that focus (exclusively) on mental illness as a medical condition, a brain disease, could reduce stigma about mental disorders.

What might engender trust in having people with mental illness serve in responsible roles and be more included in our families and communities? There are ways.

Tony Blair (UK Prime Minister, 1997-2007) established early in his administration a “Social Exclusion Unit” to implement policies to create opportunities for all to fully participate in the social and economic life of his country. These included people in poverty as well as those who by no choice of their own left them with little chance to live lives of community and contribution. Mike Rann, former Premier of the Australian state of South Australia, modeled a “Social Inclusion Unit” after Blair’s work; his focus included indigenous people, those who are homeless as well as those with mental and addictive disorders.

Closer to home, two anti-stigma efforts in the USA are actively engaged in changing public opinion.

The first is Bring Change 2 Mind (BC2M – http://www.bringchange2mind.org/), an organization founded by Ms. Glenn Close, the remarkable film, television and stage actress. BC2M seeks “To end the stigma and prejudice surrounding mental illness.” Their work is based on scientific research of what can work, and can be measured for effectiveness (their scientific advisory board is led by the first author of the AJPH article noted above). Ms. Close is working to encourage mental health ‘literacy’ and encourage people to talk openly about mental health.  BC2M also serves as a portal to other mental health organizations that can provide further education and direct help. Too many people do not understand mental conditions, their causes and consequences, or where to turn for treatment – which (when delivered in a quality fashion) is as effective as are existing treatments for many other prevalent conditions such as diabetes, cardiovascular and lung diseases.

A second effort also underway is by a coalition of the National Council for Community Behavioral Healthcare (http://www.thenationalcouncil.org/) and the Departments of Mental Health in the states of Missouri and Maryland. They are disseminating “Mental Health First Aid” (MHFA – http://www.mentalhealthfirstaid.org/).  MHFA is what every citizen can do when facing a mental health problem – until a crisis abates or someone receives professional help. MHFA can be especially useful to high school teachers and college educators, to clergy and first responders, and many others since it teaches how to understand what is happening, be non-judgmental, provide support and reassurance, and encourage help when needed. It is the mental health version of CPR.

BC2M and MHFA are two ways by which we can reduce stigma. They provide the information and skills to enable us all to live and work side by side, where familiarity can breed confidence and comfort and counter prejudice, bullying and fear. When that happens we meet one of the best measures of a moral and effective society, namely how it treats its vulnerable members.

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Originally published in the Huffington Post/AOL on March 19, 2013

 

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 Biomarkers for depression: Promise or prime time?

I scanned the table of contents of the British on-line journal, BMC Medicine, soon after it appeared in my email. A title caught my eye: “Depression Pathogenesis and Treatment: what can we learn from blood mRNA expression?”(http://www.biomedcentral.com/1741-7015/11/28). I thought about the many families that have asked me about biomarkers, especially for depression.

At a recent conference a young woman came up to me, accompanied by her parents. She described how though she was in treatment for a major depression she had not, as yet, seen enough improvement to be able to regain good functioning at work. Her parents said they had read about blood tests that could better detect and inform the treatment of depression. They asked: Did they exist? Should they get them for their daughter?

So when I saw the journal article I wondered if  there was something new that could better explain how depression comes on in a person (called pathogenesis – or how a disease process is born. Might there be new information about how to improve depression treatment?

Biomarkers are tests that uncover valuable information about a disease. Doctors, patients, and families all seek biomarkers that might help in the treatment of very common conditions that produce great suffering and burden, like depression.

Depression affects 7% of adults in the USA annually, and about one third of those people have severe symptoms that markedly decrease functioning. That’s about 17 million people over 18 who suffer this condition, about 6 million severely, every year. We all know someone who has depression and one in ten Americans are on anti-depressants. Controversy continues to brew, as well, about whether this disorder is over-diagnosed and whether anti-depressants are effective. Might there be biomarkers to better resolve who needs and can benefit from which treatment(s) for this condition?

The article described people they studied with major (clinical) depression who demonstrated “…an altered pattern of expression in several genes…compared with healthy controls.” What was especially intriguing about this study was that it focused on how our genes express themselves, not simply the actual genes.

Humans have 22 chromosomes plus a sex chromosome (X or Y). On these chromosomes are about 3 million DNA ‘base pairs’ – the small molecules wound into the iconic double helix structure that pass genetic information from one generation to the next. But the information on the DNA must be sent out in message form to operate the way the cells in our body operate. That is the work of RNA (ribonucleic acid), especially messenger RNA (mRNA), miraculous compounds that decode and guide the expression of the genetic lineage that our DNA supplies. While DNA has the blueprint for human life, RNA is required to orchestrate the protein synthesis that will tell individual cells throughout the brain and body how to function, including moving muscles, digesting food, seeing, smelling and hearing, and the astounding ability we have to feel and think.

The report in BMC Medicine focused on mRNA in blood cells, which might serve as an easily obtainable proxy for the mRNA in the brain where it influences neurotransmitters, stress hormones, inflammatory proteins and cell growth factors, all of importance in the development of major depression. What’s more, mRNA (in the brain and body tissues) has incorporated how our environment has affected our genes (called epigenetics or nurture) and the dynamic gene interactions that have altered the final expression of what nature (DNA) has provided. Might these scientists have found a way of identifying, through mRNA found in blood, a biological marker for the disease of depression?

The young woman I met and her family, like so many others, could benefit from biomarkers if:

1) There were definitive biological markers of psychiatric disease, in this case depression. Mental disorders are real yet there is no measure like high blood sugar, bad lipid levels or elevated blood pressure to demonstrate the presence of a physical illness; and

2) if there existed more of what is termed  ‘personalized’ treatment. Some medications work better for some people than others. This is true in cancer as well as with mental illness. But how can we know – aside from trial and error – which one is better so it can be used sooner and more effectively?

Depression biomarkers potentially could physically demonstrate the presence of the illness and might inform doctors how to better select which medication for which patient. But there is often a long road, full of right and wrong turns, between promise and practical application. People with mental illness, and their families, are often on the watch for useful innovation. But their precious resources, financial as well as hope, must be carefully protected. Biomarkers are being marketed today, including those for depression. Should you spend your money on these tests? Are they ready for prime time?

The authors of this study conclude that while there was a “…pattern of altered expression in several genes of interest…the temporal [timing] relationship with other factors, such as exposure to stress, is still unclear.” They add that “…we also do not know whether some of these changes in gene expression represent the marker of a genetic predisposition… [or might represent an] association between depression and inflammation.” In other words, there is promise but not more, not yet. My answer to the family I met would not change: I had said that while there is reason to believe we will see reliable biomarkers in the future, I would not advise they go for this type of testing right now.

Genetics and neuroscience rival the complexity of the physics of the universe. With genetic inheritance alone there is hardly a single or simple pathway. Often many genes are involved in complex diseases like diabetes and depression. The genes themselves actually vary in their form and expression (called genetic alleles). Those many genes, and their alleles, also are subject to highly variable expression as a result of the physical and emotional environment they encounter in individual human beings – with genes being turned on and off continuously by countless factors to which the person is exposed.  And even within the specific cells that the genes send their messages to (via mRNA), ever changing intracellular activity exerts further influence on what proteins are then synthesized that drive cellular functioning. As if that cascade were not complex enough, genes mutate: they change. Some changes are quite common and some rare but our genes are constantly undergoing changes that may be adaptive or maladaptive to our everyday lives.

Yet science is remarkable and by dint of effort, good luck and (often accidental) discovery our species enjoys vastly greater health and life prospects than our ancestors. But brain biomarkers are not what distressed patients and families should invest in right now as they seek better diagnosis and treatment of depression. Careful clinical assessment, systematically developed and followed treatment plans created between patient and doctor, ongoing monitoring, and course corrections when needed remain the state of the art and science. That is how the predominance of people with depression today can improve and experience greater pleasure, purpose and productivity.

Originally published in The Huffington Post/AOL on February 21, 2013.

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A Stroke of Insight

Dr. Jill Bolte Taylor is a neuroscientist whose life was transformed — first by illness, and then by illumination — as she beautifully conveys with wisdom and pathos in this TEDTalk, which has been viewed over ten million times. Dr. Taylor’s neuroanatomy laboratory is at McLean Hospital, a psychiatric hospital that is part of Harvard Medical School, where for over a decade I was the hospital’s medical director. I am proud to say I knew her then but left about the time her life was so profoundly changed.

Dr. Bolte knew brain disease in the form of schizophrenia because her brother had the illness. She attributes her career direction, in part, to having a brother with this condition where a young person, typically in his or her teens or early twenties, begins to show a variety of thinking and behavioral problems culminating in a psychosis, or loss of reality, that heralds the frank onset of the disease (which likely was developing in the brain from childhood but did not fully express itself until later). But, as she tells us, her brain was pirated away by a different disorder, namely a sudden stroke, the bleeding of a blood vessel in her brain, one morning some eight years before she gave this TEDTalk.

Her functional loss after the stroke was severe, as she could not speak, move the right side of her body, nor comprehend others. She required neurosurgery to drain the blood from the bleed. She required many years of rehabilitation, though she does not tell that story, before her full functioning was restored — and indeed it is, as you can tell from her riveting lecture.

What is so remarkable about her stroke, her life and her talk was the extraordinary experience she then felt and continues to — what some have called ‘oceanic’ or a spiritual awakening. This is the product, as she explains, of her right brain, the half of the brain that sees “pictures,” senses the movement of our body, receives and processes smells and tastes, and delivers the awesome capacity to appreciate oneself in relation to others. Our brain’s left hemisphere is the side that takes facts, data, and organizes them; it is the half that reasons, not the half that helps generate feelings. In a normal brain, the two sides, connected by millions of fibers, work harmoniously and give us the benefit of sensing and analyzing, of feeling and reasoning; we have in our brain the world’s greatest interactive computer (even if it loses a chess game to a machine from time to time)!

For Dr. Taylor, the unleashed, unbalanced dominance of her right hemisphere induced in her a wondrous experience. She felt, still does, the beauty of our connectivity with others, the energy that bonds us to each other, and the compassion that fosters love and unity among people. She experienced, still does, the prospect of a deep humanity and the peace that can come of a world dominated by the right hemisphere, rather than the left. What this represents is not an idea to Dr. Taylor, for ideas are for the left hemisphere. This is a feeling, a faith, which is available to all of us when our right hemisphere, by accident or intent, grows in its activities and power.

Dr. Taylor has mined from a devastating cerebral hemorrhage a transformative awakening that she wants to tell us about. Her recovery and her discovery are now our gifts to share.

Originally Published in the Huffington Post/AOL on January 4, 2013

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Children’s Mental Health after the Shooting in Newtown, CT

Eva Alisic, PhD and Lloyd I. Sederer, MD

The world has been shocked by the terrible tragedy in Newtown, Connecticut, USA, where a shooting in a primary school has resulted in the loss of 20 young children and six adults, in addition to the shooter and his mother. Our thoughts and hearts go out to their families, friends, and community, as well as to the professionals involved.

In the wake of a disaster of horrific impact and proportions, be it human made or the result of catastrophic forces of nature (as climate change has brought all too frequently in recent times), many wonder about children’s responses to traumatic events and how best to support them. In addition, many children who themselves were not directly affected will be exposed to relentless media footage, potentially propagating distress and calling for helpful responses by parents, relatives and teachers.

How do children respond to trauma?

Children’s immediate reactions vary widely. Some children are visibly frightened, agitated or upset while other children are more withdrawn, or on the contrary, can come across as very composed. In the latter instance, it is difficult for adults to judge to what extent a child has been affected.

Most children directly exposed, or living in the impacted community, will show stress reactions in the weeks following the traumatic event. Common reactions include nightmares, repetitive intrusive thoughts about what happened, avoidance of places or people related to the event, concentration difficulties, separation anxiety, heightened vigilance, irritability, and guilt feelings. In addition, the children involved in the shooting, in this case, will be mourning the loss of friends and teachers.  For some young children, this will be the first time that they are confronted with death and its irrevocability.

Children will respond differently according to their age and capacity to put their experience into words. The National Child Traumatic Stress Network has depicted age related responses, which vary from preschool children to adolescents (http://www.nctsn.org/sites/default/files/assets/pdfs/age_related_reactions_to_a_traumatic_event.pdf). Younger children may behave in ways even more childlike than their years (called regression), with less control over their feelings or behavior or even control over their toilet functions. Older children may show their fearfulness with worries, withdrawal or physical problems like stomach pain and headaches.

An excellent summary for parents on the impact of a violent event such as the Newtown shootings is also available from the National Child Traumatic Stress Network (http://www.nctsn.org/sites/default/files/assets/pdfs/psychological_information_sheet_two_pager.pdf). Also helpful is “After the Injury”  (http://www.nctsn.org/sites/default/files/assets/pdfs/psychological_information_sheet_two_pager.pdf ), which can be useful for families of injured and traumatized children; it provides clear descriptions and short videos explaining posttraumatic stress reactions and their development over time, as well as a simple checklist that can assist parents in monitoring their child’s stress reaction.

What can we do to support children in the direct aftermath of a traumatic event?

An international consortium of trauma experts has identified the five essential actions to direct us in what we all do to help survivors after a mass trauma (http://focus.psychiatryonline.org/data/Journals/FOCUS/1838/foc00209000221.pdf). These actions apply to both children and adults:

  1. Promote a sense of safety. Make sure survivors feel as comfortable as possible, and reassure them that they are safe now (provided that they are really safe).
  2. Promote calming. For survivors who are overwhelmed by emotions, help them learn to breathe slowly – with an emphasis on breathing out – and to be aware of their body and surroundings.
  3. Promote a sense of self- and community effectiveness. Survivors need to be helped to return to taking control over their own lives and decision making. Taking up normal routines as soon as possible is a fundamental rule of post-disaster responses.
  4. Promote connectedness. Social support is one of the most robust predictors of recovery. Help children and families turn to those they care for and trust to receive both emotional and practical support.
  5. Instill hope. Most people, children and adults, are resilient and will eventually recover from a traumatic event. Survivors who feel confident about their capacity to recover are more likely to experience a good outcome.

Based on these five essential actions, the National Center for PTSD and the NCTSN have developed and supported the use of  Psychological First Aid (PFA) (http://www.huffingtonpost.com/craig-l-katz-md/sandy-mental-health_b_2240907.html) by mental health professionals and first responders.

How you can you talk about the shooting with children who were not there

With the extraordinary high levels of media coverage of this shooting, we expect that many children throughout the US and internationally will become aware of this tragedy. Parents, teachers and other responsible adults will surely encounter questions about safety, even the meaning of death. Responding starts with letting children know that they are safe.

For example, young children may have difficulty understanding that repeated television coverage is not a new shooting.  For this reason alone, you will want to limit children’s media exposure and answer their questions in an open and honest manner, without using frightening language. For young children it may be helpful to explain death with analogies, for example as if they recently broke a toy that could not be fixed. The National Association for School Psychologists has a well done brochure about talking with children about violence (http://www.nasponline.org/resources/crisis_safety/talkingviolence.pdf).

Effective treatments for long-term posttraumatic stress

The gravity of the tragedy in Newtown, CT, indicates that a significant number of directly exposed children will experience significant posttraumatic stress reactions in the months after the shootings. Some may develop Posttraumatic Stress Disorder (PTSD). Cognitive behavioral therapy (CBT) is a well know therapy for children (and adults) and there is good evidence of its beneficial effects.

The tragedy in Newtown, and its predecessor violent events, should be a further wake up call for efforts to reduce the risk of future devastation produced by these events. While there is balm for the grief, fear and psychological wounds of the survivors, there is no remedy for their losses. We must attend to the survivors and gather the resolve to take the steps needed to identify those who are at risk to perpetrate these awful acts and to reduce their access to the weapons of destruction by which they wreck their havoc.

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Originally published in The Huffington Post on December 16, 2012.

Eva Alisic, PhD, is with Monash Injury Research Institute, Australia, and the National Psychotrauma Center for Children and Youth, The Netherlands, and a member of the International Society for Traumatic Stress Studies. She blogs at www.trauma-recovery.net

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Where Have All the Flowers Gone? – Thoughts after the Newtown Massacre

Where have all the flowers gone?

Long time passing

Where have all the flowers gone?

Long time ago

Where have all the flowers gone?

Girls have picked them every one

When will they ever learn?

When will they ever learn?

The lyrics in this Pete Seeger anti-war song from the 60’s (Where Have All the Flowers Gone) then guide us through the marriages of these girls to young men (all someone’s child) who would be called to war and to the graveyards that would be their fate. “When will they ever learn?” These gone soldiers in graveyards everywhere would give rise to the flowers that began the first refrain. “When will we ever learn?” the song plaintively concludes.

Mesmerized by the coverage of the Newtown massacre I could not get this tune (from my younger days) out of my head. More carnage. Only this time of even younger children, not even young men but innocents who would never come of age.

President Obama at the Newtown High School gym, on Sunday evening December 16, 2012, said enough is enough – with deep compassion and conviction. We can’t tolerate more graves, and more consoling of families whose loved ones need not have died. What can we do to spare us all more grief, to let flowers grow in front yards and not graveyards?

The Huffington Post ran a deeply chilling story on the same day called “I Am Adam Lanza’s Mother: A Mom’s Perspective On The Mental Illness Conversation In America” (http://www.huffingtonpost.com/2012/12/16/i-am-adam-lanzas-mother-mental-illness-conversation_n_2311009.html). It was written by Liza Long, the mother of a boy who wrote “I am sharing this story because I am Adam Lanza’s mother. I am Dylan Klebold’s and Eric Harris’s mother. I am James Holmes’s mother. I am Jared Loughner’s mother. I am Seung-Hui Cho’s mother. And these boys—and their mothers—need help. In the wake of another horrific national tragedy…it’s time to talk about mental illness.”

This mother describes a bright but deeply troubled young man whose fuse is getting shorter and shorter. He threatens his mother with a knife, says he will kill himself if expectations are placed upon him, and assaults his mother when she tries to get him hospitalized for treatment of a mental illness. Like too many parents her ordeal with mental health care is characterized by prohibitions detailing what cannot be done and by services that seem to require a tragic event to allow for action to be taken.

Much has been said about the delicate balance between patient rights and community (and family) safety or the difficulty talking with someone in distress (some of my posts are Dying with your rights on: mental illness, civil rights and saving lives, http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_871274.html; The Enemy is Apathy, http://www.psychiatrictimes.com/display/article/10168/2092557: and ‘Random’ Acts of Violence are Not So Random, (http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_1693714.html).

But as our President now insists, enough is enough. The time for talk – talk alone – has passed. We don’t need more deaths, be they mass murders or the deadly toll taken one person at a time: we need a way by which families can get assistance with their (and our) most vexing mental health problems.

Why not start with developing a way by which families, mother and fathers, and siblings and children too, can have a place to turn – as was so desperately needed as we discover by reading this chilling story of a mother with a son who is at risk to launch another television vigil. These families with a seriously ill member need a place to turn, a means of assistance – professional assistance and support – rather than real and imagined legal, regulatory and professional prohibitions asserting what cannot be said or done to help them help their loved one.

There are exceptionally capable family organizations, The National Alliance on Mental Illness (NAMI) perhaps being the most accomplished advocacy group of parents, siblings and children, who could help in figuring out how to engineer and deliver the assistance they need. There are other organizations, including people with mental illness who themselves were almost a CNN story.

We need to help families help their loved ones before more sorrowful flowers are watered by the blood of future victims.

Originally published in the Huffington Post/AOL on December 17, 2012.

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Mental Health and Hurricane Sandy: What can we expect, what can we do?

In the aftermath of Hurricane Sandy, opinions—some reliable, some misleading— about the storm’s potential mental health impact have proliferated. When media channels act responsibly they engage experienced experts as spokespeople; when that does not happen, wrong information adds to the public’s anxiety and can foster inappropriate clinical interventions and waste resources.

In the latter category, perhaps the greatest myths I have heard are:

  • Post-traumatic stress disorder (PTSD) can appear in the immediate wake of a disaster.
  • Watching television can cause PTSD.
  • The highly common psychic distress in the wake of a disaster is a mental illness.

Here are some facts:

Psychic distress after a disaster, which can be highly prevalent and last up to a month, generally is a normal reaction to an abnormal situation. This is known as an acute stress disorder (ASD).

Many people experience ASD after exposure to a traumatic event in which they felt intense fear, helplessness or horror. A person who experiences it is deeply shaken and cannot stop thinking about the event, he or she may have difficulty sleeping and may be jumpy or irritable or cry easily. Taking care of everyday business is hard and socializing is no longer fun. The person may smoke or drink more and withdraw from others.

These symptoms can impair functioning at school or work and within the family.

For a diagnosis of ASD to be made, the condition must come on within four weeks of a trauma and last more than a couple of days. If significant symptoms persist for longer than a month, it is likely that the ASD has progressed to PTSD (see below).

Watching television ceaselessly can aggravate a person’s distress, so people should limit their television viewing so that they remain informed but not compound their worries. Parents should monitor what their children watch. They should also provide them reassurance and hope since children do well when they feel protected and comforted by those they depend upon and trust.

PTSD is a more persistent and severe response to trauma than ASD, which always precedes it. Symptoms of PTSD include re-experiencing of the traumatic event, avoiding cues of the trauma, emotional numbing that can become consuming, and persistent symptoms of heightened arousal. PTSD can only be diagnosed if it has been at least a month since the catastrophe.

There are other conditions besides PTSD that commonly emerge in the days, weeks and months after a disaster. These include depression; anxiety disorders, other than PTSD, such as generalized anxiety and agoraphobia; alcohol, tobacco and drug overuse and abuse; and worsening of pre-existing mental and addictive disorders.

A singular focus on identifying PTSD is apt to miss these other serious and potentially disabling conditions, which can exist independent or occur alongside the disorder.

The more life threatening and ghastly the disaster, as well as the degree of what is called “exposure,”—when a person experiences direct and continuous visual, olfactory, and auditory sensations after the disaster—the more likely a traumatic state will ensue.

Direct victims of a disaster are at greatest risk of developing post-traumatic emotional problems  followed by rescue workers, followed by some of the general public. Once PTSD sets in there is evidence that it can and does persist, especially for those with early onset of the symptoms.

No definitive psychological profile characterizes those who are apt to do poorly after a disaster, except for those who already had poor coping skills. People with active or past mental disorders or who have been previously traumatized are also at greater risk. Yet not everyone exposed to a severe traumatic event will develop ASD or PTSD. In fact, most will not.

Perhaps the safest and most effective disaster mental health approach that has evolved from experience emphasizes careful listening to assess a person’s response, assessment of an individual’s capacity to cope and their risk of self-destructive behavior, non-judgmental education to help a person appreciate that their response may indeed be a “normal response to an abnormal situation,” and urging people to seek support from those they can trust. Practical coping strategies, such as getting sleep, not being alone and not abusing alcohol and drugs, coupled with the realistic provision of hope are also essential.

Psychological first aid, which employs many of these approaches, is becoming a standard of care for trauma victims. Individuals can benefit from being in a calm setting and a supportive environment and, when possible, psychological first aid is delivered in the affected community, making use of its local constituents to establish trust and ensure cultural and linguistic competence. Healthcare workers are tasked with first making sure that those they see are physically and psychologically safe. Individuals showing extreme reactions are identified and referred to professional treatment when possible.

Seeking assistance need not be shameful and should be encouraged to do so by public authorities and others.

Because post-disaster disorders like depression, anxiety, PTSD and abuse of alcohol and drugs can emerge many months after an event, public messages can be very useful when maintained over time.

After 9/11 the effort to get first responders—uniformed personnel, including fire fighters, police, emergency medical technicians and other healthcare workers—mental health services included a  powerful  ad campaign with the message “Even Heroes Need to Talk.” It is only over time that first responders may begin to suffer problems and need communication about how to seek help for themselves.

Perhaps the greatest lesson we have learned from natural and human-made disasters is how resilient most people can be. But one should not go it alone in the face of disaster, whether an individual, community, city or nation.

A disaster experience can be indelible in a person’s memory and can put lives on a very different trajectory, but that does not mean one’s response is an illness. We know that the more we support one another and understand and respond to family needs and the needs of our neighbors and community, the more likely we will be able to manage trauma, with unfortunate distress but without disorder.

For immediate assistance, people with psychic distress that exceeds what family and friends can provide have many places to turn. The American Red Cross is on-site and familiar with the emotional aftermath of a disaster. Family physicians, clergy and local mental health clinics are also important resources for people who need further assistance. Information and referral services are also promptly and capably available in New York City, 24 hours a day, from LIFENET [1-800-LIFENET]. Other impacted communities can turn to the National Suicide Prevention Lifeline [1-800-273-TALK (8255) www.suicidepreventionlifeline.org], whose services extend far beyond suicide prevention.

REFERENCES:

Galea S, Nandi A, Vlahov D (2005). The epidemiology of post-traumatic stress disorder after disasters. Epidemiological Reviews 27, 78–91.

Sederer LI, Lanzara CB, Essock SM, Donahue SA, Stone JL, Galea S (2011) Lessons learned from the New York State mental health response to the September 11, 2001 terrorist attacks. Psychiatric Services 62, 1085–1089.

Photo: A soldier assists a family displaced by Hurricane Sandy in Hoboken, N.J., Oct. 31, 2012. The soldier is assigned to the New Jersey National Guard. U.S. Army photo by Spc. Joseph Davis.

Edited by Elaine Meyer

Initially published by the Columbia University Mailman School of Public Health on November 5, 2012

Reprinted in the Huffington Post/AOL on November 7, 2012

=====================================

A Safe Place To Be Smart: The Bronx High School of Science

Mentioning the Bronx (the New York City borough that sits atop of Manhattan for those who may not know this City) can conjure up “Fort Apache”, the film from 1981 (with Paul Newman and Danny Aiello) that portrayed the danger and desperation that then boiled in sections of the Bronx. I grew up in this borough, named after a Dutchman (Jonas Bronck) when the City was settled centuries ago, and indeed, there were some pretty sketchy places. But there was another form of danger – one among youth that made it fearsome to be smart or wear glasses or tote a lot of books. My junior high school, PS 113, was like that and I learned to sneak in and out to avoid the boys who were looking to bully and shame.

I took a citywide exam in the 9th grade (the last year of “junior high” – then the interval between elementary and high school) and, to my surprise, received notice that I was accepted into the Bronx High School of Science. Me and about 900 other New Yorkers. “Science” was one of several “exam schools” (like Stuyvesant and Music and Art) where smart City kids could go for free to a high school that surely rivaled the private schools that served the rich and privileged. My first reaction to getting in was that I didn’t want to go because my best friends were not accepted (though I knew others who were); that’s what I said to my parents who remarkably did not fight me, letting me come around to accepting. That was 1959. That was when Jews, Italians, Irish and a few other “minorities” chiefly inhabited the Bronx and northern Manhattan.  The vast Diaspora of American immigrants, then as it is so today, sought to create a place in society that birth and connection did not provide. Education was the means then, as it can be today’s for aspiring generations.

Just recently, I attended my 50th (!) Science reunion. Badges showed our photos from the graduation yearbook since these were the images that formed the emotional basis for knowing each other. Some 200 alum, spouses and friends crowded into a Chelsea restaurant for an evening of dining on memories and realities.  Drink in hand I braved walking into the crowd. Start a conversation with someone, anyone, my wife said, and I did. There were only a handful of people I knew, but they all were my people, my classmates, my vintage, New Yorkers everyone no matter where they live today.

Reunions select out two groups: those who do not want to put their lives on display and those who have died. A third group, those who did not want to or could not attend, are more of a mystery – take me, for example since I had only attended one other reunion (the 25th).  Seventy one ‘Class of ’62’ graduates were listed “In Memoriam” in the evening’s program. There were only a few I knew personally but the sheer number of those who had passed  and the homage paid to them by friends who commented during the program, was a reminder of how thin is the thread of life as we know it.  One fellow I knew well had died over a decade ago. We were in the same junior high school class before we both went to Science: he was my first startling experience with true genius with his capacity to rapidly solve complex problems that try as I might took me forever; he left Science after one year to go to an Ivy League college, which he soon quit to develop his own (over time, successful) business. But he was gone, but by some grace I was not.

There was a show of hands when the MC asked how many had artificial joints or stents? How many had taken LSD? Not that many, in answer to all three questions, though more positive responses to the first two questions. An on-line survey (after all this is Science High) of the class taken before the reunion had 232 respondents and revealed that 83% were currently married (many more than once) and 81% had children; over 80% had graduate degrees (masters and doctorates); over 40% had career changes; over 40% were now retired, many said they never planned to retire, and one said he would retire ten years after he died. An overwhelming number of alums felt very positive about the school, endorsing that it made a “consequential difference” in their lives.  I could observe and consider that evening, when I listened to this information and looked around, what are the ingredients of successful aging: being smart, from families that valued assimilation, well educated, and fortunate to have lived in a culture of meritocracy. We were the winners of the precious commodities of dignity, prosperity and community.

Bronx Science’s graduating class of 2013 will be substantially Asian. This reflects the changing demographics of New York and its ever revitalizing immigrant communities.  Whoever goes to Bronx Science today, or tomorrow, will discover that it is safe to be smart. They will see that learning, mastering knowledge and valuing thinking is a gift that keeps on giving. Imagine if that experience were one that could happen in any school in New York City, or other community in this vast country? Imagine if there were many more places like Science where it’s safe to be smart, and not just for the best students with the most intact and engaged of families. Now, that would be something to be proud of.

Originally published in the Huffington Post/AOL on October 22, 2012

xxxxx

Mental Health and Hurricane Sandy: What Can We Expect, What Can We Do?

In the aftermath of Hurricane Sandy, opinions — some reliable, some misleading — about the storm’s potential mental health impact have proliferated. When media channels act responsibly, they engage experienced experts as spokespeople; when that does not happen, wrong information adds to the public’s anxiety and can foster inappropriate clinical interventions and waste resources.

In the latter category, perhaps the greatest myths I have heard are:

  • Post-traumatic stress disorder (PTSD) can appear in the immediate wake of a disaster.
  • Watching television can cause PTSD.
  • The highly common psychic distress in the wake of a disaster is a mental illness.

Here are some facts:

Psychic distress after a disaster, which can be highly prevalent and last up to a month, generally is a normal reaction to an abnormal situation. This is known as an “acute stress disorder” (ASD).

Many people experience ASD after exposure to a traumatic event in which they felt intense fear, helplessness or horror. A person who experiences it is deeply shaken and cannot stop thinking about the event; he or she may have difficulty sleeping, and may be jumpy or irritable or cry easily. Taking care of everyday business is hard, and socializing is no longer fun. The person may smoke or drink more and withdraw from others.

These symptoms can impair functioning at school or work and within the family.

For a diagnosis of ASD to be made, the condition must come on within four weeks of a trauma and last more than a couple of days. If significant symptoms persist for longer than a month, it is likely that the ASD has progressed to PTSD (see below).

Watching television ceaselessly can aggravate a person’s distress, so people should limit their television viewing so that they remain informed but not compound their worries. Parents should monitor what their children watch. They should also provide them reassurance and hope, since children do well when they feel protected and comforted by those they depend upon and trust.

PTSD is a more persistent and severe response to trauma than ASD, which always precedes it. Symptoms of PTSD include re-experiencing of the traumatic event, avoiding cues of the trauma, emotional numbing that can become consuming, and persistent symptoms of heightened arousal. PTSD can only be diagnosed if it has been at least a month since the catastrophe.

There are other conditions besides PTSD that commonly emerge in the days, weeks and months after a disaster. These include depression; anxiety disorders other than PTSD such as generalized anxiety and agoraphobia; alcohol, tobacco and drug overuse and abuse; and worsening of pre-existing mental and addictive disorders.

A singular focus on identifying PTSD is apt to miss these other serious and potentially disabling conditions, which can exist independently or occur alongside the disorder.

The more life-threatening and ghastly the disaster, and the greater the degree of what is called “exposure” — when a person experiences direct and continuous visual, olfactory, and auditory sensations after the disaster — the more likely a traumatic state will ensue.

Direct victims of a disaster are at greatest risk of developing post-traumatic emotional problems, followed by rescue workers, followed by some of the general public. Once PTSD sets in there is evidence that it can and does persist, especially for those with early onset of the symptoms.

No definitive psychological profile characterizes those who are apt to do poorly after a disaster, except for those who already had poor coping skills. People with active or past mental disorders or who have been previously traumatized are also at greater risk. Yet not everyone exposed to a severe traumatic event will develop ASD or PTSD. In fact, most will not.

Perhaps the safest and most effective disaster mental health approach that has evolved from experience emphasizes careful listening to assess a person’s response, assessment of an individual’s capacity to cope and their risk of self-destructive behavior, non-judgmental education to help a person appreciate that their response may indeed be a “normal response to an abnormal situation,” and urging people to seek support from those they can trust. Practical coping strategies, such as getting sleep, not being alone and not abusing alcohol and drugs — coupled with the realistic provision of hope — are also essential.

Psychological first aid, which employs many of these approaches, is becoming a standard of care for trauma victims. Individuals can benefit from being in a calm setting and a supportive environment, and when possible, psychological first aid is delivered in the affected community, making use of its local constituents to establish trust and ensure cultural and linguistic competence. Health-care workers are tasked with first making sure that those they see are physically and psychologically safe. Individuals showing extreme reactions are identified and referred to professional treatment when possible.

Seeking assistance need not be shameful, and should be encouraged by public authorities and others.

Because post-disaster disorders like depression, anxiety, PTSD and abuse of alcohol and drugs can emerge many months after an event, public messages can be very useful when maintained over time.

After 9/11, the effort to get first responders — uniformed personnel including firefighters, police, emergency medical technicians and other health-care workers — mental health services included a powerful ad campaign with the message “Even Heroes Need to Talk.” It is only over time that first responders may begin to suffer problems and need communication about how to seek help for themselves.

Perhaps the greatest lesson we have learned from natural and human-made disasters is how resilient most people can be. But one should not go it alone in the face of disaster, whether an individual, community, city or nation.

A disaster experience can be indelible in a person’s memory and can put lives on a very different trajectory, but that does not mean one’s response is an illness. We know that the more we support one another and understand and respond to family needs and the needs of our neighbors and community, the more likely we will be able to manage trauma — with unfortunate distress, but without disorder.

For immediate assistance, people with psychic distress that exceeds what family and friends can provide have many places to turn. The American Red Cross is on-site and familiar with the emotional aftermath of a disaster. Family physicians, clergy and local mental health clinics are also important resources for people who need further assistance. Information and referral services are also promptly and capably available in New York City 24 hours a day from Lifenet (1-800-LIFENET). Other impacted communities can turn to the National Suicide Prevention Lifeline (1-800-273-TALK (8255)), whose services extend far beyond suicide prevention.

This post was originally published on Nov. 5, 2012 at the 2×2 project, sponsored by the Department of Epidemiology at Columbia University’s Mailman School of Public Health.

xxxxx

“Doctors Make Mistakes” – A Commentary on Medical Errors

Lloyd I. Sederer, MD 10.27.2012

Dr. Brian Goldman’s TED talk, “Doctor’s Make Mistakes… Can we talk about that?” (http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html) has been viewed by over half a million people. With candor and humor this Canadian emergency room doctor and journalist describes how the kindly saying ‘to err is human’ has not really applied to doctors. Yet all doctors make mistakes, which are inescapable. The problem is less the mistakes but that medical practice has become a culture of blame that is not just bad for doctors, it is bad for patients.

Dr. Goldman is not alone, nor is awareness of medical errors new. An Institute of Medicine report in 1999, estimated that approximately 100,000 people die each year in US hospitals due to preventable medical mistakes (http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf). This led The Institute for Healthcare Improvement (IHI), in 2004, to launch its 100, 000 Lives Campaign across US hospitals, which exceeded its life saving goal in 18 months. It succeeded not by tarring and feathering doctors and nurses, or by promoting malpractice litigation. It did so by measuring performance and making quality improvement a virtue to be rewarded.

Typical errors we patients and families are apt to suffer include: how a treatment is delivered (like wrong side surgery or the wrong dose of a medication), delays in responding to abnormal tests, failure to provide antibiotics during surgical procedures to prevent infection, and inadequate monitoring or follow-up of a patient’s condition. Simple matters like hand washing in hospitals are woefully not followed, just as this simple procedure is ignored amongst everyone during flu season despite the pictures of hands under a faucet posted on walls everywhere.

The wonderful book, The Checklist Manifesto: How To Get Things Right, by Dr. Atul Gawande, a Harvard surgeon and MacArthur Fellow, tells a remarkable story a about a presurgical checklist he created with a multinational team for the World Health Organization that dramatically reduced postoperative infections (36%) and deaths (47%) in rich and poor nations, in teaching and tent hospitals. What was so ironic was that Gawande thought he himself did not need this checklist until using it prevented a patient death when he was operating (http://www.huffingtonpost.com/lloyd-i-sederer-md/is-your-doctor-using-a-ch_b_473068.html). Simple checklists have what engineers call a “forcing function,” an inescapable path that reduces errors. Yet, still only a fraction of hospitals employ checklists, of any sort, even though they have become standard fare in aviation and other precision and safety oriented settings.

Checklists are only one way to prevent medical errors. Others include “redundant operations”: When multiple people ask the same question (e.g., what’s your birthdate?, which side of your body will have the operation?) the likelihood of a treatment error drops precipitously; when doctors have their orders checked by nurses and pharmacists their (human) errors are reduced. Technology is our friend when it comes to reducing errors: physician order entry (POE), where doctors write prescriptions not on pads but into computer systems, reduces very common transcription errors by over 80%; other electronic medical record innovations include “decision support”, a nice way of saying that the computer will ask the doctor if that dose or the use of a particular medication combined with another is safe, so that doctors have live time support in managing the now vast amount of knowledge needed to practice medicine safely.

Yet another way to reduce errors is to better manage what is called “decision fatigue”, where low mental energy from lack of sleep, low blood sugar, and ceaseless demands for decisions diminishes the mind’s capacity to make good choices (Willpower: Rediscovering the Greatest Human Strength, Roy F. Baumeister and John Tierney, 2011). If you feel a bit overwhelmed when confronted by 40 different cereal brands in the grocery store, imagine what it must be like to manage the decisions needed for 40 people in a busy emergency room or doctor’s office.

In the wake of an error, doctors and hospitals must also learn to apologize and lend support to families. The days of hiding behind lawyers are thankfully becoming a part of the past. In 2006, an unusual report emerged from the Harvard University Hospitals called When Things Go Wrong: Responding to Adverse Events. The report stated that “Fears of malpractice liability, difficulties in communicating bad news, and confusion about causation and responsibility have long impeded comprehensive and bold initiatives designed to change the patient, family and clinician experience with medical error. Error can be reduced and safety improved when “…an institutional response … focuses on rapid and open disclosure and emotional support to patients and families who experience serious incidents.”  In short, it is time to stop hiding errors and to say “I am sorry” when bad things happen. It is also time to support (not blame) and train doctors and nurses by establishing a medical culture of transparency and safety.

As patients and families, we cannot sit back and imagine all is well, that the doctor knows best. Like it or not, we must be vigilant and unstinting advocates for ourselves. We are responsible for giving clear and honest information about our habits and medical care, lest we not provide doctors the information they need to treat us safely. We must screw up our courage and ask questions when we don’t understand or think that something is going awry. Writing down your questions and concerns before you meet with a doctor, who is surely pressed for time, helps optimize decision making and keeps you focused at a time when stress is high.

I am heartened by the dawn of what is called “patient centered care”. This is far more than a slogan; it is a deep and abiding commitment by caregivers to put the patient first, foremost, in a medical care system too often organized for the convenience of caregivers and administrators. There is something old fashioned yet ageless about designing a medical service system that recognizes whose life is at stake and upon whom the true burden of illness falls. We as consumers, as patients and families, should accept no less. Patient centered care could deliver greater safety and success for patients and honest pride for clinicians – not bad outcomes, I would say.

Originally published in the Huffington Post/AOL on November 2, 2012.

xxxxxx

The “War” on Drugs

Can we wage war with something that is not an actual enemy, not a sovereign power or an uprising within a nation? If indeed the metaphor of war is liberally applied, as it has been to campaigns against a variety of ills, can those wars be won?

As the United States convenes its political conventions, and September marks the National Alcohol & Drug Addiction Recovery Month, we have an opportunity to consider what has been called the “War on Drugs.” We have also witnessed the “war on poverty” and the “war on cancer”, among other ails. The history of these efforts bears attention so let’s take a short look at each, starting with poverty, then cancer and finally drugs.

In 1964, President Lyndon Johnson, in his first state of the Union address, called for an “…all-out war on human poverty.” It was part of his vision for a “great society.” President Ronald Reagan, also using the grand moment of a state of the Union address, pronounced that the war had failed, saying “My friends, some years ago, the Federal Government declared war on poverty, and poverty won.” But it took President William Clinton to reframe the problem in 1996 when he claimed the legislation passed by his administration would “…end…welfare as we know it” – principally through personal responsibility and work opportunities (more or less the name of the legislation he passed). In other words, if there was something that figuratively could be considered a war on poverty, we had lost, according to both political parties, and it was time to find not only another metaphor but a better approach.

The “War on Cancer” dates back to President Richard Nixon, who in 1971 signed the National Cancer Act that sought to find a cure for cancer. We have not won this “war” either, if indeed we can consider this effort a war. Certainly huge sums of money have funded research to end cancer. While some cancers now can be cured and others have more effective treatments that allow people to survive longer the fact remains that after forty years cancer remains a huge public health problem in this country and throughout the world. Sadly, we have not seen a significant decrease in the overall population death rate from cancer since the “war” began – though there has been notable progress with greater survival rates in recent decades, especially for children’s leukemia, cancers of the lung, prostate and colon (in men) and breast and colon (in women), in part due to earlier detection and more targeted treatments.

It was President Nixon who first used the metaphor of “The War on Drugs.” A combination of prohibiting drug use in the United States and military intervention in other countries, he asserted, would destroy the illegal drug trade. But notable global leaders, including Kofi Annan, the former presidents of Brazil and Columbia and Prime Minister of Greece, Paul Volker, and prominent writers and policy experts, issued a report in 2011 that pronounced that “The War On Drugs Has Failed.”

The casualties of this “war” are great. Since President Nixon declared war, the incarceration rate in the United States has increased over 400%, resulting in this country having the highest incarceration rate in the world. By 1994, the “war” led to one million Americans arrested each year for drugs; about one in four arrests then were for marijuana possession; more recently marijuana was the charge in half of the arrests in this country. Many states implemented “Three Strike” laws in the 1990s that mandated very long sentences. By 2008, 1.5 million Americans were arrested annually for drugs, and one in three incarcerated. There is ample evidence that our prisons are filled with people of color; African-Americans are sentenced to state prisons thirteen times more frequently than other races. Former prisoners are denied access to public housing (and other benefits) and stigmatized in hiring, thereby making the road back all the more steep.

President Barack Obama, however, in 2009, claimed that the term “War on Drugs” was not useful and would not be used by his administration. The White House Office of National Drug Control Policy (ONDCP) declared, in 2011, that “drug addiction is a disease that can be successfully prevented and treated… {and that} making drugs more available will make it harder to keep our communities healthy and safe.”

The proposition underlying war is that there is an external enemy (or collection of enemies) outside our borders or a civil uprising (such as the US Civil War and countless examples abroad) threatening the future of a nation. This is where the war metaphor applied to drugs, poverty and cancer seems to fail us from the very start. War was declared on these human problems without the conditions to win; these “wars” seem to have met the fate that has been said of many wars, namely that they last until politicians and generals run out of money, or interest.

Drugs are what people with addictions use – they are not armies at the gate. Addiction is “…self-induced changes in neurotransmission that result in problem behavior.” (http://www.huffingtonpost.com/lloyd-i-sederer-md/addiction-treatment-_b_1665302.html). There is no external enemy but instead the powerful convergence of biology and social circumstance, the interplay of nature and nurture, which produce addictions (which span alcohol, drugs, and a variety of compulsive behaviors like gambling, video games and some sexual disorders).

Can we put an end to addictions, or at least greatly reduce their prevalence and burden? This seems the core question after we move beyond the metaphor of war. I believe we can incrementally achieve a society not consumed by addictions. Not by war, but by public health and community strengthening efforts.

There are public health approaches to controlling addictions. These are very different from criminal justice efforts that lock up drug users, or engage in interdiction at our borders, or crop destruction abroad. Instead, public health focuses on prevention, early intervention and effective treatment.

Drug courts are a growing alternative to incarceration for drug possession. They allow offenders to obtain treatment instead of doing prison time. Many states have drug courts, but not enough of them (the same can be said of mental health courts).

Prevention can be delivered through public education campaigns, and by fostering strong families and school programs that give youth alternatives to drugs. Prevention is also achieved by limiting access to drugs (and alcohol) but not by their prohibition (we tried that once in the United States and by the time it was ended the consumption of alcohol was greater than before it began). Limiting access is accomplished by regulation (not necessarily legalization) and what is called “price sensitivity” (the more a substance costs the less it is used; which is particularly effective with adolescents – see http://www.washingtonpost.com/wp-dyn/content/article/2009/09/28/AR2009092802796.html).

Science may add to our ability to limit drug (and alcohol) abuse by better understanding the pleasure (reward) circuits in human brains (especially the neurotransmitter dopamine) and developing compounds that enable those people with brains that seek substances to better achieve satisfaction in relationships, work and play; or by discovering and advancing other interventions (including natural substances or altering the brain with yoga or meditation and other ways of producing calming brain patterns).

Early intervention means detecting addictive behaviors early and initiating help as soon as possible. Screening for alcohol and drugs is apt to become standard practice in primary care settings because that is where it is most apt to be discovered, insurance payment now possible for doing so, and where motivational techniques can help those who screen positive reduce their intake or seek treatment.

For those who already have developed the disease of addiction, we know that treatment can work – and that there are many roads to recovery. These include 12 Step programs (like AA and Narcotics Anonymous), medications that can reduce craving and assist with maintaining sobriety, recovery treatment programs, and a host of nutritional and non-western approaches. The evidence is very strong that the longer a person stays in treatment the more likely he or she is to succeed. Greater emphasis (and funding) for treatment, rather than interdiction and prisons, is more likely to reduce the impact of addiction on our society.

Perhaps the greatest challenge, and one that does not comport with “war”, may lie in the strengthening and revitalization of families and communities. Neighborhoods that have been scourged by poverty, crime and improbable exit from the ‘hood” are breeding grounds for addiction. The prospect of a life with work, purpose and dignity, with the hope that has inspired centuries of classes of people to move beyond the limits of their current realities, may be the most difficult yet the most powerful anodyne to addiction that exists. When war can be put aside, real and metaphorical war, we stand to find better ways (and more money) to change communities, to give youth and adults opportunities to succeed, and to fashion a life where addiction will be seen as the enemy of success, rather than as a comforting friend.

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Addiction: help you can get beyond 12-step and conventional Western medications

A Huffington /AOL Series

This Introduction is followed by 7 articles written by experts I invited to contribute. You can read these article on the Huffington Post.

Lloyd I. Sederer, MD, Medical Editor for Mental Health

“Every form of addiction is bad, no matter whether the narcotic be alcohol, morphine or idealism.”
C.G. Jung

 “When you can stop you don’t want to, and when you want to stop, you can’t…”
Luke Davies

The concept of addiction has evolved from its ancient roots in alcohol and drug dependencies to what now has been aptly called “…self-induced changes in neurotransmission that result in problem behavior.” (Milkman, H.) What continues to astound so many is that these ruinous, compulsive behaviors persist despite their obvious – at least to others – painful consequences. Quite amazingly, the addict in the throes of addition may be most blind of all to the losses he or she incurs in love, health, work and everyday life – that is, until recovery begins.

Because there is magic in naming, old habits can die hard about what we call an addiction. “And Rumpelstiltsken was his name…” said the imprisoned Queen and by uttering his name she freed herself and her child and destroyed that greedy creature. Even great wizards and witches of Harry Potter fame trembled at the name of Voldemort!  Addiction too is a name (and thus a concept) with great power and one that needs changing: it is time for its updating. Addiction is more than alcohol and drugs. Addiction is a complex phenomenon with expression in a multitude of compulsive behaviors. Addiction is also the end point of the convergence of a ménage of brain, behavior and social forces. Addiction today needs to be considered anew and so should be its remedies.

The Director of the National Institute on Drug Abuse, Dr. Nora Volkow, writes that there is good evidence for non-substance induced addictions (http://addiction-dirkh.blogspot.com/2009/12/q-with-nora-volkow.html).   Dr. Volkow wrote the brain is “…composed of a finite number of circuits for…rewarding desirable experiences…So it is almost by necessity that we’ll find significant overlaps in the circuits that mediate various forms of compulsive behaviors. We have yet to work out the details and the all important differences, but it stands to reason that there will be many manifestations of what we can call diseases of addiction. Thus, addiction to sex, gambling, alcohol, illicit drugs, shopping, video games, etc. all result from some degree of dysfunction in the ability of the brain to properly process what is salient, accurately predict and value reward, and inhibit emotional reactivity or deleterious behavior.”

Dr. Volkow was speaking to the ubiquitous presence of compulsive behaviors that we see all around us. She was talking about the pleasures that compel so many of us to act in ways we know are destructive to our lives (and to those we love) yet which we cannot seem to resist. We witness these unbridled behaviors in gambling, sexual promiscuity and porn, overeating, drug and alcohol abuse, ‘shop til you drop’ and video games, to name a few.

Recovery from addiction traditionally has been the domain of 12 step programs, dating back to Dr. Bob and AA. More recently, recovery has been aided by a variety of western medications that diminish craving and reduce painful withdrawal symptoms and thereby help control drug and alcohol abuse (http://www.huffingtonpost.com/lloyd-i-sederer-md/abstinence-may-not-be-eno_1_b_759904.html).  The first one used a large scale was methadone; more recently doctors are  using buprenorphine (http://www.huffingtonpost.com/lloyd-i-sederer-md/addiction-recovery-a-new_b_595448.html) and naltraxone. But as we learn more about the brain and its reward centers new methods of controlling addictive behaviors are emerging.

In this Huffington Post/AOL series we will consider a variety of interventions beyond 12 Step and medications. We will examine alternative and non-conventional recovery paths for people with compulsive and addictive behaviors. These have been called “complementary and alternative medicine” (CAM) – but the term “medicine” seems too narrow and we will go beyond medicine but not beyond what evidence and experience suggests can be helpful.

Addiction is a dark life, full of misery for the addict and all who love and support him or her. For those scores of millions of Americans and hundreds of millions of individuals, world-wide, who suffer the consequences of unchecked compulsive behaviors, there is hope, there are alternatives.

Life need not continue to be dark: “One must wait until the evening to see how splendid the day has been” (Sophocles). By reviewing a variety of approaches to addiction beyond 12-Step and Western, conventional medications we hope to offer readers prospects for changing how their day shall end.

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Originally published in the Huffington Post on July 16, 2012.

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The Enemy is Apathy

“I don’t know, I don’t care, and it doesn’t make any difference.”
Jack Kerouac

Congresswoman Gabrielle Giffords was gravely wounded in a shooting rampage that killed six, young and old, and wounded 13 in a Tucson shopping mall on January 8, 2011. Many imagined that event would move this country to action in ways that would truly reduce the risk of another mass murder.

After the Tucson event, there was a heartening resilience demonstrated by the victims, their families and their communities. The deep compassion shown them by countless fellow Americans was needed and wonderful to witness. But that is where the responses ended. Did we see changes in gun and ammunition laws that might prevent the ready access that exists today to weapons that can fire dozens (or more) of rounds in a minute, even those capable of penetrating Kevlar? Did we see schools or other settings where there are youth in crisis or deterioration take action and identify and implement ways to intervene rather than extrude problem individuals? Did we see the introduction of comprehensive prevention, detection and treatment programs for people with mental health and addiction disorders in community health settings?

I suppose those questions would be academic had not another twelve people died and fifty nine physically wounded (and far more emotionally traumatized) in Aurora, Colorado, a mere eighteen months later. It is frightening to listen to those who say we need not see this as a call to action. It is frightening because it speaks to and supports the apathy that is our greatest enemy.

Mental health professionals learn early and repetitively that change is really hard. We humans are deeply wedded to our ideas, to how we see the world and behave, and to what are conditioned emotional responses to the world around us. As a rule, change does not happen until the pain of continuing to be the same outweighs the comfort of maintaining the status quo. A highly popular, and effective method, of promoting change called motivational enhancement  -ME – (How to Break Free From Your Unhealthy Habits, http://www.huffingtonpost.com/lloyd-i-sederer-md/addiction-help-want-to-quit-smoking_b_802828.html) has spread throughout not just behavioral health programs but into primary medical care because of how much motivational techniques are needed to enable anyone to change.

Apathy was recognized as one of the symptoms of “shell shock” during and after the Great War (World War I). Those who are apathetic have lost the capacity to feel and act; they are disconnected and numb. Today we often regard apathy, disconnectedness, as a symptom of post-traumatic stress disorder (PTSD); that is when it afflicts an individual. What do we call it when it afflicts a whole population? A nation? I think that is called apathy. More important than what we call it is what we do about it: it is only a matter of time before another person tries to equip himself with weapons of mass destruction, not for political purposes but out of the angst, loathing, despair and mental disturbance that characterize the perpetrators of violence who have dominated our nation’s media and grief (“Random” Acts of Violence Are Not So Random,http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_1693714.html).

We know a great deal about how to reduce the risk of violence in our society and our communities. Knowledge, however, is not the limiting factor to a safer future. Our capacity to overcome apathy and to mobilize human passion, determination and action is what is in short supply. Individual and collective will eludes us. No meaningful change is just delivered to our doorsteps: we have to work really hard for it to come. Not only is the will to change resisted from within us, it has powerful external resisters as well, perhaps best described by Gandhi who said: “…first they ignore you, then they laugh at you. then they fight you, then you win.”

Apathy drains the suffering we could feel from doing nothing, from staying the same. It dulls the pain needed to motivate change. Apathy is our enemy. Pain, paradoxically, is our ally because it is one of the most powerful fuels we have to impel us to a different and better tomorrow.

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“Random” Acts of Violence Are Not So Random

Columbine, Colorado; Fort Hood, Texas; Virginia Tech; Tucson, Arizona; and now Aurora, Colorado – and too many other sites of horror – are often seen as random acts of violence. Perhaps we arrive at this view because these acts and actors are not tied to conspiracies, or to systematic terrorist plans. Instead, they generally are the actions of a severely disturbed person, typically acting alone, but not spontaneously or without careful planning.  In other words, they are not random. In fact, the perpetrators of these acts of murder and mayhem generally build their catastrophic scenario slowly, over months or longer; their progressive behavioral deterioration is often evident to others or sometimes the plan is even broadcast by the perpetrator himself. Analyses, after the fact, from families, friends, neighbors and personal journals painfully demonstrate their angst, rage, loathing of self and others, and intensifying and monocular attention to their day of reckoning.

Many of us will react with horror and think we need to lock these people up, maybe throw away the key. If we let them out, some advocate for the involuntary use of psychotropic medications. But, in fact, the trajectory to these disastrous events calls for more complex actions. These individuals herald their problems by dropping out (of school, work, treatment) or by overuse of hospital services (especially emergency rooms) or by police confrontations. Functioning deteriorates and their behaviors communicate distress. Most people are responsive to help when it is offered and provided with dignity and quality. Rare yet unthinkably awful cases go on to violence – and that is when inattention has allowed their conditions to reach an extreme. The mental health system, including substance abuse services, has been too ineffective for too long in detecting and delivering what is needed, despite the dedicated people who work in these settings.

One ‘solution’ (for those already determined to have a serious and persistent mental illness) is called Involuntary Outpatient Commitment – IOC – (or Assisted Outpatient Treatment, Mandatory Outpatient Treatment); it has been legally adopted in many (but not all) states though the requirements of this law vary substantially from state to state. As a rule, the law permits courts to mandate outpatient psychiatric treatment for people with severe mental illness who are at risk of clinical relapse or deterioration that may place themselves or others in danger and who have demonstrated by past behavior that on their own they are not apt to voluntarily comply (laws for inpatient commitment exist in all states and emergency intervention requires imminent dangerousness). What IOC can provide, when effectively organized and delivered, is clear accountability for and coordination and monitoring of a person’s condition by community service providers; it also places IOC patients at the front of a long queue for limited mental health resources (including case management, clinic and psychiatric visits, medication, even housing). The fact that a court weighs in adds an unparalleled dimension to the accountability of community service agencies.

But the number of people with serious mental (and addictive) disorders who could benefit from accountable, coordinated and accessible care far outnumbers the capacities of any IOC program, which is always time limited by a court anyway. My colleagues in many states recognize the considerable limits of IOC, and its dependence on undaunted leadership in clinical and legal services as well as adequate and sustained funding to ensure that the involuntary services demanded of the patient are in place and accessible. What this amounts to is that despite the evidence of success of IOC (and its necessity for some people who may not for years come to appreciate that they are ill) is that it sounds better than it is.

A special commission by a group of experts and government officials was created in 2008 in New York State by Mayor Bloomberg and then Governor Paterson (http://www.omh.ny.gov/omhweb/justice_panel_report/ and References 1 & 2) in the wake of a series of violent incidents in New York City that involved people with mental illnesses, including their use of drugs and alcohol. The report emphasizes two key findings: namely, that violence by people with mental illness is generally the result of their not being engaged in treatments (that can be highly effective) and their use of drugs and alcohol. The implication is that for citizens and police to have their risk of harm reduced that people with mental and addictive disorders need better early engagement and retention in proven (so called evidence-based) treatments.

Acute conditions (whether a broken arm, a heart attack, a delirium, a raging psychosis) benefit from doctors stepping in and taking control. But most conditions are chronic (like diabetes, heart disease, asthma, PTSD, schizophrenia, depression and bipolar disorder) where early detection, accessible and patient centered care (not in slogan but in reality), the involvement of families and significant others, and the provision of proven treatments are basic to their management. The same approach applies for both physical and mental disorders. With chronic disorders, unless those who are ill learn to take responsibility for and manage their illnesses the disease (not recovery) triumphs – and everyone loses.

True clinical accountability means that service providers have designated populations of patients (specified caseloads, registries of patients) for whom they are held continuously responsible (not by involuntary outpatient commitment but by contractual and medical standards); this was one idea advanced but not achieved by the Community Mental Health Act of 1963 (!) that was the foundation for the community based mental health services we have today. We also need better ways to encourage people with mental disorders to come to and participate in treatment. To achieve this latter goal will mean far more responsiveness to what patients want (again, patient centered care), peers (other patients advanced in their recovery) as community workers, and creating the experience that it is safe to seek treatment (that the result will not be activating police and locked hospital settings). I wish our provision of these effective elements of care was greater and faster than it has been to date. The need is surely there with one in five Americans annually suffering from a mental disorder that adversely affects their life and functioning.

We have no perfect treatments for a host of chronic conditions, including cardiovascular disorders, cancer, Parkinson’s disease, dementias, schizophrenia and bipolar disorder. But we have learned a lot about chronic disease management. Our challenge is to turn what we know into better delivery of the right treatments that patients receive from doctors and enabling patients to learn to manage their diseases; some call this closing the science to practice gap. The challenge is as great in physical medicine as it is in psychiatric medicine. In mental health, we need to be wary of short term, reactive ‘fixes’ stimulated by agonizing events that may have emotional appeal but are no substitute for an ongoing resolve to apply proven means of systematically improving care and accountability, which are our best chance to reduce risks to the safety of individuals and communities.

‘Random’ is not so random. We have not adequately implemented prevention, screening, early intervention and ongoing engagement in good treatment that would better recognize patterns, detect disorders and assure accountable ways to respond. We can close this gap, we know how. When we do, and I believe we can, our communities will be able to meet the complex goals of public safety, personal liberty and high quality clinical care.

REFERENCES:

  1. Smith,TE, Sederer,LI. Changing the Landscape of an Urban Public Mental Health System:  The 2008 New York State/New York City Mental Health-Criminal Justice Review Panel. Journal of Urban Health, Bulletin of the NY Academy of Medicine. No. 87, Vol. 1, January 2010, pp 129-135;

http://www.springerlink.com/openurl.asp?genre=article&id=doi:10.1007/s11524-009-9407-y

  1. Smith TE, Appel A, Donahue SA, Essock SM, Jackson CT, Karpati A, Marsik T, Myers RW, Tom L, Sederer LI:  Using Medicaid claims data to identify service gaps for high-need clients:  The NYC Mental Health Care Monitoring Initiative.  Psychiatric Services. Vol. 62, No. 1, January 2011; pp 9-11

Originally published in the Huffington Post on July 22, 2012.

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ADDICTION: AMERICA’S MOST NEGLECTED DISEASE

The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) released on June 26, 2012, a report on addictions that is remarkably comprehensive and even more remarkably honest in portraying the virtually utter failure to identify and effectively treat addiction in the USA.

The report, titled Addiction Medicine: Closing the Gap between Science and Practice, starts with the premise that addiction is a disease. Addiction is not recreational drug use, or risky behaviors (like adolescent binge drinking or buying drugs on the street). They focus on abuse and dependence on alcohol, legal and illicit drugs, and tobacco. While the authors recognize a group of addictive/compulsive behaviors they are not covered in this report.

CASA Columbia is a renowned research center on addiction. For the past five years it brought together a team of addiction, public health and judicial experts, universities, medical centers, and other mainstream officials under the direction of Drew E. Altman, PhD, President and Chief Executive Officer of the Kaiser Family Foundation, to study and survey the field of addiction in order to give us a landscape report of such precision and breadth. Scientific literature was reviewed, extensive surveys were conducted (throughout the USA and an in-depth survey in New York State), leading researchers and experts were interviewed, focus groups were held, and state and federal licensing, certification and accreditation rules and regulations were examined. Care was taken to hold to high standards of analysis and evidence. In short, this is one tome we ignore at our own peril.

Their definition of addiction is alcohol and drug (including tobacco) abuse (compulsive use despite clear harm to relationships, work and physical health) and dependence (where the body experiences withdrawal when blood levels of a substance drop).

Their definition of treatment is that of psychological and social therapies (like motivational interviewing/motivational enhancement therapy, see http://www.huffingtonpost.com/lloyd-i-sederer-md/addiction-help-want-to-quit-smoking_b_802828.html, cognitive behavioral therapy (CBT) provided individually and in groups, the often highly effective but controversial contingency management approaches that reward abstinence, and family therapies) and medications used to treat additions (like naltrexone, nicotine replacement and buprenorphine – see http://www.huffingtonpost.com/lloyd-i-sederer-md/abstinence-may-not-be-eno_1_b_759904.html and http://www.huffingtonpost.com/lloyd-i-sederer-md/addiction-recovery-a-new_b_595448.html); they do not include detoxification (typically repetitive, expensive, and often medically unnecessary interventions that are generally ineffective in promoting recovery), peer and religious-based counseling, emergency room and prison/jail services. Don’t bother to pick up this 573 page report (more than half of which is appendices and references) if you believe addiction is a failure of will, a form of moral turpitude, or habits where people should ‘just get over it’ (though some future campaign should try to change your mind).

The consequences of untreated addiction, and its predecessor risky alcohol and drug use, are chilling. The report concludes that “Risky substance use and addiction constitute the largest preventable public health problems and the leading causes of preventable death(emphasis mine) in the U.S. Of the nearly 2.5 million deaths in 2009, an estimated minimum of 578,819 were attributable to tobacco, alcohol or other drugs.” The report also estimates the costs of addiction and risky substance use behaviors to government coffers alone to exceed $468 billion, annually. Yet, and here is the most important finding of all, only one in ten people with addiction to alcohol and/or drugs report receiving any treatment – at all. Can you imagine that measure of neglect were the conditions heart or lung disease, cancer(s), asthma, diabetes, tuberculosis, or stroke and other diseases of the brain?

Tobacco use is the leading preventable cause of death and disability in this country. But the catastrophic effects of addiction do not stop there: the report considers car crashes where 40% of fatalities involve someone under the influence; the fivefold increase in prescription drug overdose deaths (see http://www.huffingtonpost.com/lloyd-i-sederer-md/prescription-drug-abuse_b_1076166.html) since 1990 where OD fatalities exceed traffic accidents!; increased risk of heart and lung diseases, cancer and sexually transmitted diseases; parental substance abuse which increases the risk of their children performing poorly in school and developing conduct and trauma disorders, asthma, ADHD, depression and, of course, addiction itself. Family dysfunction warrants particular notation since addiction produces financial and legal problems (property and violent crimes) and increases domestic violence, child abuse, unplanned pregnancies, and motor vehicle accidents.

The report is exhaustive in the ways it considers legal and illicit drugs, alcohol and tobacco. Each section is clear, compelling and exceptionally well supported with tables and references. A thorough analysis of why we are at this deeply troubling state of neglect examines how addiction has been systematically omitted from medical care; how treatment providers are terribly undertrained to deliver a range of proven treatments; how treatment programs are not sufficiently held accountable for delivering evidence based practices; and how private insurance payers have eluded the provision of adequate benefits and defaulted payment to the public sector. But what we need to know far beyond the inescapable evidence of how big and bad the problems are is what can be done?

The opening recommendation is a page out of every good textbook of public health. Start by detecting a problem that is – by inattention or aversion – kept out of sight. We do not deal with what we do not confront. Over 80 million people (!) in this country, ages 12 and older, abusively engage in substance use without meeting criteria for addiction (defined above) and represent an exceptional opportunity to intervene early and effectively, yet this is not happening. Simple screening tests for alcohol, drugs and tobacco exist and can be made standard practice throughout medical care (and in educational and counseling settings). SBIRT – Screening, Brief Intervention and Referral for Treatment – is a recognized, proven and even reimbursed medical procedure that awaits general use despite the consequences of not using it.

The report offers a set of treatment recommendations, and asserts importantly that comprehensive treatment (combining psychosocial and pharmacological interventions) is generally better than reliance on one approach alone. There is an abundance of information on treatment beginning with stabilization of the disease and continuing on to acute care with therapy and medications. The authors provide critically important and urgently needed information about how chronic disease management techniques extant throughout medicine today need to be applied to addiction. Nutrition and exercise are woven into the treatment approaches. AA, NA, SMART and other longstanding and effective recovery programs find their way into the report as “Support Services”, revealing its particularly medical and judicial framework.

One finding that may pertain to readers of this post, or people they know, is that public attitudes about the causes of addiction “…are out of sync with the science.” Their survey work reveals that one third of Americans still regard addiction as a “…lack of will power or self-control.” We can be our own worst enemy and local and national efforts to change minds and hearts are needed.

Further recommendations are framed as major sections on how to close the science to practice gap (to make happen in everyday practice what we know from science that works); commencing a national public education campaign; mandating program adherence to proven practices; establishing quality improvement tools and procedures to steadily and progressively improve program performance; insurance reform; and organizing Federal oversight into one agency on addiction.

There is so much more in the report that this summary cannot cover. Among the findings readers may also want to take guidance from are on special populations (from youth to the elderly, and including veterans, pregnant women and those with co-occurring medical and mental health disorders); on Parity legislation and the do or die role of funding prevention and services; and education and practice standards. The report serves both as a call to action and an encyclopedic warehouse of information.

The CASA Columbia report’s strengths are its veracity, clarity and credibility, the last based on the excellent science they summarize and the caliber of the report’s authors. A shortcoming is that it was developed by experts in medicine, addictions, public health and jurisprudence: as a result, it does not report on the emerging and abundantly used field of complementary and alternative approaches to addiction ‘treatment’ (such as yoga and acupuncture) nor dedicate much report real estate to 12 Step and related recovery models. Nor does the report consider how making legal substances more expensive and more difficult to get could be used as means of controlling youth drinking and other compulsive habits (though CASA Columbia did consider these interventions last year in a report on Adolescent Substance Abuse (see http://www.casacolumbia.org/templates/publications_reports.aspx and http://www.huffingtonpost.com/lloyd-i-sederer-md/problem-drinking_b_315922.html).

Practitioners, policy makers, educators and responsible citizens should more than consider Addiction Medicine: Closing the Gap between Science and Practice. It needs to become an agenda for action. Not doing so will mean that this country would have decided to continue to neglect its most prevalent, destructive and costly of diseases.

Originally published in the Huffington Post on June 26, 2012

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Comparing psychiatric and general medical medications: what does the evidence say?

The debate continues to rage about whether psychiatric medications work. This controversy especially has brewed about antidepressants and antipsychotic medications, some of the most widely used medications in the world.  An important study just published in the British Journal of Psychiatry sheds light (not just makes for heat and wind) on this vital subject.

In a carefully constructed research study called a meta-analysis (where the results of many studies are examined to answer specific questions) the authors provide (in their words) “…the first… panoramic overview of major drugs.” They looked at 48 different drugs used to treat 20 general medical diseases and 16 different drugs used to treat 8 psychiatric diseases. The researchers concluded that the psychiatric drugs, overall, were as effective as those used in general medicine.

Their research approach was to select a specific disease and then look at rigorous studies on the response of that disease to medications commonly used to treat it. Examples for general medical diseases included:

-          In chronic heart failure, how well were angiotensin converting enzyme inhibitors and receptor blockers, beta-blockers and diuretics in reducing death and how did digitalis do in reducing hospital admissions?

-          How effective were proton pump inhibitors (PPIs) in controlling symptoms for acute reflux esophagitis and in maintaining control of those symptoms?

-          How effective was aspirin therapy in preventing cardiovascular events and death?

-          In the treatment of Parkinson’s disease, how effective were drugs that increase brain dopamine?

-          How well did steroids and beta-2 agonists control chronic asthma?

-          What about the efficacy of chemotherapy for breast and lung cancer?

Some other common diseases (and their treatments) they reviewed included hypertension, hypercholesterolemia, and rheumatoid arthritis.

The researchers also asked, and answered:

-          In people with schizophrenia, how well did antipsychotic medications reduce overall symptoms and prevent relapse?

-          In bipolar disorder, how effective were mood stabilizers in acute mania and for relapse prevention?

-          In major depression, how well did antidepressants (ADs) work for acute depression and for relapse prevention? (By the way, they found better for the latter, though the data is confusing for the former because ADs were used in mild and moderate cases where their performance is not as robust as it is with severe depression).

-          For people with Obsessive Compulsive Disorder (OCD) how did the Serotonin Reuptake Inhibitors (SRIs) do in controlling symptoms?

-          How effective were psychostimulants on the symptoms of Attention Deficit Hyperactivity Disorder (ADHD)?

They also reported on treatments for Panic Disorder and Alzheimer’s disease.

While some individual drugs for (a few) medical conditions outperformed the psychiatric drugs they studied (and a few did not perform as well!), as a whole the two groups were about the same in terms of their efficacy.

The authors also noted that the benefits of medications can accrue over time – a reminder that continuous (ongoing) treatment makes more of a difference. This is a message for patients, families and policy makers alike.

All medications have side-effects and risks, not only benefits. Informed patients and their families need to carefully weigh, and discuss with their doctor, risks and benefits when making decisions about their health, including the use of medications.

It is important for those affected by psychiatric illnesses to see this research. When it comes to benefits, psychiatric medications hold their own when compared with general medical medications in the treatment of a great number of diseases that affect so many people.

REFERENCE

The British Journal of Psychiatry 2012, 200:97-106; Stefan Leucht, Sandra Hierl, Werner Kissling, Markus Dold and John M. Davis – Putting the efficacy of psychiatric and general medicine medications into perspective: review of meta-analyses

Originally published in The Huffingon Post/AOL Healthy Living March 28, 2012

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Trauma and adversity in childhood: history need not be destiny

LlOnce again, the American Academy of Pediatrics is demonstrating its clinical leadership. Two recent, groundbreaking reports (The lifelong effects of early childhood adversity and toxic stress and Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health www.pediatrics.org/cgi.doi/10.1542/peds.2011-2662) by the Academy boldly declare what has been known but too hidden from sight: namely, that brain and emotional development is profoundly disrupted by childhood adversity and trauma.

The pediatric academy quotes Frederick Douglass who said “It is easier to build strong children than to repair broken men.”

Toxic stress, or early environmental trauma, has been proven to disrupt normal brain development and trigger genetically predisposed diseases. The tragic results include impairments in the ability to regulate emotions and learn; to adapt socially with others; and produce, in adolescence and adulthood, lifelong physical and mental disorders, including heart disease, asthma, arthritis, obesity, diabetes, cancer, depression, substance abuse and PTSD. Trouble staying and succeeding in school are also common, as are brushes with the law.

Adverse Childhood Events, or ACEs, were initially studied by Kaiser Health of Southern California and then by the World Health Organization (WHO) World Mental Health Survey Initiative. ACEs include:

  1. Direct psychological abuse
  2. Direct sexual abuse
  3. Direct physical abuse
  4. Substance abuse in household
  5. Mental illness in household
  6. Mother treated violently
  7. Criminal behavior in household

The greater the number of ACEs, the greater the risk of developing a chronic disease, or multiple chronic diseases. From Post-traumatic disorder research we know the greater the severity and frequency of the trauma the more like it will burn itself into the brains neural circuitry.

The mechanisms by which early childhood adversity lays its toxic roots are numerous and complex. The manifestations are as specific as youth engaging in impulsive and dangerous behaviors (well beyond normal adolescent risk taking), including reckless (and drunk) driving and unprotected sexual behaviors, which can result in sexually transmitted diseases and teenage pregnancies. The mechanisms are as fundamental as the unregulated and ongoing release of stress hormones, including cortisol and adrenaline, which weaken body defenses (compromising the immune system’s ability to protect from infection and cancer or to turn our immune systems against us in the form of autoimmune diseases), raise blood pressure, promote plaque formation in arteries, and are linked, neurologically, to depressive and post-traumatic stress illnesses.

The specialty of pediatrics was first to develop “medical homes” (popularized today with Federal enabling legislation) designed initially for the young with serious and chronic illnesses whose proper care needs to be monitored and clinically managed by one responsible (accountable) doctor and clinic. Pediatricians have long used screening tools to track childhood development and more recently many have introduced depression screening (and treatment paths) as basic tenets of good care. Their declaration, through these recent reports, of the impact of childhood trauma is a rallying call for what heretofore was another example of ‘don’t ask, don’t tell’.

There are many proven approaches to these problems. Among them are:

-          Home visits by nurses to mothers identified as being at high risk for emotional problems (e.g., Dr. David Olds’ Nurse Home Visiting Program)

-          Primary care screening and early intervention for depression in moms

-          Pediatric screening and early intervention for depression and addictive disorders in youth

-          Parental skills training programs (e.g., Positive Parenting, The Incredible Years, Bright Futures, About Our Kids)

-          Youth support programs (e.g., Big Sister, Big Brother, after school programs)

-          Pediatric medical homes that holistically support child development and deliver health, mental health and wellness services

-          Trauma-focused mental health programs (for youth already affected)

The health of our youth, today and into their futures, can be protected. We can prevent the diseases and disabilities that result from childhood adversity and trauma. State and national budgets can be protected from decades of preventable health, correctional and social welfare expenditures. By following the wise counsel of the American Academy of Pediatrics, and other professional and policy groups, early experience need not be destiny for countless children, their families and their communities.

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REFERENCES

Committee on Psychosocial Aspects of Child and Family Health, Committee on

Early Childhood, Adoption, and Dependent Care, and Section on Developmental and

Behavioral Pediatrics, Garner AS, Shonkoff JP, Siegel BS, Dobbins MI, Earls MF,

Garner AS, McGuinn L, Pascoe J, Wood DL: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health.

Pediatrics. 2012 Jan;129(1):e224-31. Epub 2011 Dec 26. PubMed PMID: 22201148.

Shonkoff JP, Garner AS, Siegel BS, Dobbins MI, Earls MF, Garner AS, McGuinn L, Pascoe J, Wood DL. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. 2012 Jan;129(1):e232-e246. Epub 2011 Dec 26. PubMed PMID: 22201156.

Association of Childhood Adversities and Early-Onset Mental Disorders With Adult-Onset

Chronic Physical Conditions:Scott,KM, Korff, M, ScD; Angermeyer,MC Benjet,C, Bruffaerts,R, de Girolamo,G, Haro, JM, Le´pine,J-P, Ormel, J,  Posada-Villa, J, Tachimori, H, Kessler, RC, Archives of General Psychiatry Volume 68, August 2011

Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report, Volume 59, December 17, 2010.

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The DSM-5: Will it work in clinical practice?

Lloyd I Sederer, MD*

The debate rages on about DSM-5, the latest diagnostic manual of psychiatric disorders due for release next year by the American Psychiatric Association (APA).

Arguments abound about what disorders should be included (and what should listed within each respective disorder, like autism or psychosis) and what should not be included; what is science and what is opinion (when kindly considered ‘opinion’); what stigmatizing dangers may exist from diagnosis; and the sheer volume of conditions that will find their way into the printed pages of this manual. Conspiracy theories, favorite headline grabbers, claim that the APA is in bed with Pharma companies. Others see a psychiatrist cabal that seeks wheelbarrows of money from the sales of this next edition.

A diagnostic manual of mental disorders cannot be eluded. Clinicians need specific ways of declaring what they observe to be one condition or another so they can speak to each other and to patients and families. Researchers need reliable diagnoses to study whether treatments work, and the course and prognosis of diseases. Every insurance entity, including Medicare, Medicaid, United, Aetna, BC/BS, Kaiser and countless others, requires a diagnosis for payment – just as they do for heart and neurological conditions, asthma, diabetes, cancers and all the other maladies that impact the human race. International classifications of diseases, as well, must harmonize with the DSM to inform global public health practices and research. The DSM is not going away.

As the winds of controversy swirl something is going on that you might want to know about, and that might – might – settle some of the contention. The APA is field testing the DSM draft to see how it works. Now that’s a good idea.

The DSM-5 Field Trials

The draft DSM-5 is being tested in real-world clinical settings. Two studies will examine how the diagnostic criteria work with those who will actually use and be impacted by DSM-5, namely patients and clinicians.

The first, and larger, of the two field trials involves 11 Academic Medical Centers (AMCs) in the United States and Canada. These sites were selected from 65 applicants based on their capabilities to recruit and study a diverse group of participants (e.g., children, adults, and seniors as well as ethnicities). This trial will allow the APA to compare the prevalence (rates of a condition in a population) of the disorders among AMC patients who would be given a DSM-IV diagnosis with those who would be given a similar diagnosis using the new criteria in the DSM-5.

The second type of field test involves Routine Clinical Practice Settings (RCPs). This DSM field trail will specifically examine small group or solo practices. The field work will involve a random selection of general adult psychiatrists and specialists in geriatric, child/adolescent and addiction psychiatry, and those that consult to medical colleagues as well as psychologists, advanced practice psychiatric nurses, licensed counselors, licensed marriage and family therapists, and licensed clinical social workers. This study will especially focus on how feasible and useful are the new criteria as well as the manual’s measures of severity of illness.

The field trials will concentrate on conditions that are new (e.g., autism spectrum disorder), or that are significantly different than the preceding manuals (e.g., personality disorders), as well as conditions at the forefront of public concern such as post-traumatic stress disorder. The field trial participants, however, will have all the new, proposed criteria for their use and input.

In addition to the proposed diagnostic criteria, the field trials will assess “severity measures” and cross cutting symptom lists (new to the manual). Participants will use a severity rating scale and measures for a clinician to record symptoms such as anxiety, depressed mood, substance use, or difficulties with sleep or attention that occur across a wide variety of diagnostic conditions. In everyday practice clinicians see people, for example, with depression who also suffer with anxiety; or individuals with bipolar disorder or PTSD who have insomnia. The field trials will assess whether the severity measures and symptom lists provide useful information and capture clinical change over time, which is essential to how clinicians determine response to treatments.

Previous DSM III and IV field trials did not ensure that participating clinicians were not affiliated with the manual’s development; in fact, previous field trials were done by the experts who drafted the manual. The current DSM-5 field trials also use a larger and more diverse sample of participating clinicians and patients. These actions were taken to help to reduce bias and improve the generalizability of the findings. Patients and clinicians also have an unprecedented voice in shaping the proposed manual and its measures.

What then happens?

 The results of the field trials will be reported at the APA annual meeting this May and shared with professional and consumer groups for their feedback. Reports will also be published in peer-reviewed scientific publications. The field trials and feedback received from patients, consumer advocacy groups, and the public will inform further revisions to diagnostic criteria or severity and symptom measures.

There has been a lot of smoke from the DSM fires. The field trials should help all concerned see through the smoke and into the embers of advancing the complex and continuous process of improving what we know about diagnosis in psychiatry.

For more information see the DSM-5 website: www.dsm5.org

Please see my two previous Huffington Posts on the DSM:

-          The American Psychiatric Association’s New Bible (Part I of a Two Part Series), July 26, 2011 — http://www.huffingtonpost.com/lloyd-i-sederer-md/the-american-psychiatric-_b_906333.html

-          The DSM-5: The Changes Ahead (Part 2), September 9, 2011 —   http://www.huffingtonpost.com/lloyd-i-sederer-md/dsm-5_b_961966.html

*Disclosure: I am an APA member. I have held numerous elected state and national positions at the APA and worked there from 2000-2002.

Originally published in the Huffington Post/AOL on February 6, 2012.

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Mysterious Illness at the Le Roy School: Understanding Conversion Disorders

When we get embarrassed, our faces turn red.

When we get nervous, our hearts pound and our palms sweat.

When we feel really sad, we cry.

Our minds can — and do — speak through our bodies. All the time. Yet sometimes it can seem hard to believe.

Recently, the media has burst with stories about 15 teenagers (all but one of them girls) in Le Roy, N.Y., a small town east of Buffalo, where their tic-like symptoms and uncontrolled utterances have baffled local residents, school officials and families. The NYS Department of Health, in collaboration with the Centers for Disease Control and Prevention (CDC) and local physicians, has been on the scene. These agencies have assisted in the examination of the teenagers as well as in searching for possible environmental causes such as viral or bacterial diseases and toxins in water and soil.

Erin Brockovich, renowned for championing the investigation of a California power company that allegedly polluted a city’s water supply (and played by Julia Roberts in the 2000 movie sporting Brockovich’s name), has sent her investigative team to Le Roy.

To date, there is no evidence that any toxin or infectious agent is causing the outbreak of symptoms in these 15 adolescents. Monitoring of symptoms and their possible causes continues.

Distress abounds in this community and among the teenagers and families affected. In the absence of evident physical causes for these symptoms, clinicians and public health officials understand that the mind has the power to produce these problems.

There is abundant medical literature reporting clusters of young people with symptoms like those in Le Roy, and many other physical problems, without any physical cause. A classic paper appeared in the New England Journal of Medicine, almost 20 years ago, from the Massachusetts General Hospital, describing 41 school-age youth in a town near Boston who developed a variety of symptoms including abdominal pain, shortness of breath and fainting; some required hospitalization. No physical causes were discovered and all improved over time. Since then, many other articles have appeared — reporting outbreaks in this country and other nations.

Medical symptoms that prove to have no infectious or toxic basis can be explained by how the body can express emotional distress. This is often called conversion disorder (literally, where emotional distress is converted to bodily symptoms) or somatoform disorder, where physical symptoms are not the result of a physical illness. The symptoms truly look like a physical disease but are rooted in stress and distress and typically begin in adolescence.

These young people are not “faking” their symptoms. They are having a physical response to emotional distress. They are in considerable distress, as are their families, and they cannot simply stop, or control, the symptoms they are having.

Hippocrates, the Greek father of medicine, hundreds of years before Christ, called this problem hysteria. Without the sophistication we have today where we appreciate how the mind and body are inseparable, the Greeks attributed hysteria (a condition then regarded specific to women) to “the wandering womb.” A woman’s womb was thought to move from its proper place and settle elsewhere in the body where it produced symptoms. A recent movie, A Dangerous Method , dramatized hysteria in a young woman almost 100 years ago.

Independent of what is causing the problems in the Le Roy youth, stress aggravates any medical disorder, be it physical or mental in nature. Perhaps more importantly, stress interferes with a person’s ability to recover from their condition, whatever the cause.

The Le Roy adolescents need to continue under the care of specialists, like neurologists and infectious disease experts, as well as their family doctors. They, as well as their families, should consider counseling if they believe it would be helpful to assist in managing the stress of these symptoms and the concerns they raise.

References:

Small, GW, Borus, JF: New England Journal of Medicine March 17, 1983

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Originally published in the Huffington Post/AOL on February 3, 2012.

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Casinos for Kids

You can hear the sounds of excitement from afar – before you see the vast well of games and the legions of children (and adults) swarming around the scores of hyperbolic machines with brilliant flashing lights and swelling sounds that rival modern atonal music. You have arrived at a casino for kids.

Of course they are not called casinos. I am not sure what they are called – and it doesn’t matter. It’s what they deliver – not what they are named – that counts. Look around. Is there a window? A clock? A rectangular wall? Nope. You are in a rounded cocoon without boundaries of any sort that might ground the visitor in reality. A number of business franchises have made these settings ubiquitous and highly successful, in this and other countries.

Addiction traditionally was defined as “a chronic, relapsing disease characterized by compulsive drug seeking and abuse and by long-lasting changes in the brain” (National Institute of Drug Abuse http://www.drugabuse.gov/). Scientists have come to understand addiction as not confined to alcohol and drugs. Broader definitions of what produces addiction are necessary to account for the variety of compulsive behaviors in youth and adults that, like drug and alcohol abuse, persist despite harmful consequences. While gambling certainly occurs without compulsiveness or harm, just as drinking does, both carry the risk of addiction. Some predictable percentage of people who use or gamble will escalate to the uncontrolled behaviors that cause profound distress and disruption in their lives as well as that of their families and communities. The need to manage these addictive behaviors has produced not only AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) but also GA (Gamblers Anonymous – http://www.gamblersanonymous.org/qna.html).

The Director of the National Institute on Drug Abuse, Dr. Nora Volkow, has written that there is good evidence for non-substance induced addictions (http://addiction-dirkh.blogspot.com/2009/12/q-with-nora-volkow.html).   Dr. Volkow wrote the brain is “…composed of a finite number of circuits for…rewarding desirable experiences…So it is almost by necessity that we’ll find significant overlaps in the circuits that mediate various forms of compulsive behaviors. We have yet to work out the details and the all important differences, but it stands to reason that there will be many manifestations of what we can call diseases of addiction. Thus, addiction to sex, gambling, alcohol, illicit drugs, shopping, video games, etc. all result from some degree of dysfunction in the ability of the brain to properly process what is salient, accurately predict and value reward, and inhibit emotional reactivity or deleterious behavior.”

In casinos for kids, in addition to the games there are drinks and food everywhere you turn: high sugar, high fat foods including huge glasses of sugary beverages; nachos and potato skins in which swim cheese and bacon; sour crème like it was running water; and chicken and buffalo wings as plentiful as kudzu. These foods fuel the brain and body for the high intensity, electronic world of video games (and the few retro toss the ball games embedded among the digital delights). These are foods that antecede (and later accompany) the nicotine and alcohol that youth will graduate to further stimulate the reward centers of the brain.

There is also the paper gaming tickets of varying values in casinos for kids. Youth and adult players buy these at a gazebo located at the very center of the well of machines so there is never far to walk to convert paper money for valueless paper that lets you play. The tickets are paper versions of gambling chips, of course. There is a store at the rear where wads of tickets can be exchanged for stuffed toys of every color in the rainbow. The machines are programmed to let some win, some of the time, just like in any casino. But make no mistake: the house always wins.

Brilliant, I thought. The gaming (gambling) industry has developed and propagated youth gaming centers, gambling prep schools if you will, which can serve as gateways to adult casinos and breeding grounds for compulsive gambling. I’ll bet that the rates of compulsive gambling and video game addiction will increase in the years to come. In fact, I’ll give you odds.

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Originally published in The Huffington Post/AOL on January 24, 2012.

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Sleepwalking is for real

I have had trouble sleeping for about 25 years. I am amongst legions of people who share the same trouble.

Some have difficulty falling asleep. They toss and turn as thoughts race through the brain while infusing the body with neurotransmitters and stress hormones that further rev up our engines. Some awake after several hours to have the same experience as their going to bed insomniacs, only later in the night. Still others make it until early in the morning when their mind overpowers the tired body and robs it of more needed rest. Some poor souls have all three but that is uncommon.

There are many causes for these forms of nocturnal misery.  If trouble sleeping plagues you or someone you care about then talk to a doctor because a sleep disturbance may be the tip of a medical iceberg. Loss of physiologically restorative sleep also impairs concentration, performance and judgment. Many simple and good remedies exist.

I want to report on one remedy I tried that transported me to quite a remarkable experience, namely sleepwalking.

I fall asleep immediately (thank goodness) but soon awake, again and again, with my mind suffused with dreams and experiences from the most mundane to the otherworldly. When my sleep problems worsened in recent years, I sought medical and alternative medicine consultations and cures. My three sleep studies (done by an EEG, an electroencephalogram, and an innovative home device under development) all had remarkably consistent findings: I drop into slumber but then awake as often as dozens of times a night – though not significantly attributable to apnea (breathing problems), neurological illness (restless legs syndrome or early Parkinson’s disease) or other known causes. The conclusion was that my sleep is disrupted (I knew that) for reasons not understood (at least not signaling worrisome diseases).

What could I do? There are the general measures of avoiding caffeine late in day, getting exercise, limiting alcohol to modest consumption, not getting all riled up before bedtime and the like: this is called sleep hygiene. I had been trying these but with limited effect. As a doctor, I am not against medications but tend to be conservative and hoped to avoid sleeping pills.

But my fatigue was wearing me down. After a year or more of waking in the morning needing a nap I decided to try various sleeping agents. I tried melatonin, homeopathic remedies and other non-prescription aids without benefit.

I had taken Ambien® (zolpidem) on overnight plane flights and it had worked. I began on a trial of this medication, in its short and longer acting forms. It was helping, a little, in that I awoke less often and my overactive dreaming was muted. I was concerned about getting dependent on a sleeping pill but zolpidem’s pharmacology suggests it does not produce withdrawal or a need for higher doses. I began taking it a few nights a week to see if I might change my sleep pattern.

Then one night the strangest thing happened. After a few hours of sleep, I got up, went to the bathroom and ran water for a bath. My wife was sound asleep, as is her great fortune. It had been awhile since I took a bath in this country and never in the middle of the night. The water was pleasantly warm when I immersed myself. I realized that the t-shirt I had left on was getting drenched so I took it off and draped it over the tub’s edge. I wondered what I was doing in the bath but it was pleasant and I continued to soak luxuriously, not bothering to lather with any soap. I carefully replaced the towel on the rack but left the bath mat on the floor and wet garments scattered about. When I awoke in the morning the proof of my twilight behavior was indisputable: a wet shirt and towels in the bathroom, a closet cabinet open where I had fetched fresh and dry underwear that I was now wearing, and a dim recollection of having taken a relaxing bath. My wife did not awake so could not confirm my meanderings but could see the detritus I had left.

When I told my doctor about my sleepwalking experience he said we better find another medication. I know he was not trying to deprive me of tub pleasures but rather prevent some unwelcome accident during the night, whatever that might be.

Sleepwalking, I thus attest, is for real. I don’t know the full measure of what is possible during this altered state. I don’t want to find out. I would rather toss and turn, or maybe just get up and take a bath.

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Originally published in Healthy Living, Huffington Post/AOl, on December 15, 2011.

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Screening our youth for what ails them

In another needed response to the obesity epidemic affecting American youth (and the adults they will become) the National Heart, Lung and Blood Institute, part of the Federal National Institute of Health, has declared that pediatricians should be checking cholesterol when kids reach the age of 9 and before they are 11, and again when they reach 17 and before 21. The American Academy of Pediatrics, the national professional association for pediatricians, proceeded to endorse the Institute’s recommendation.

A popular business maxim is ‘what gets measured gets managed’. When a child’s blood sugar is 400 everyone jumps and insulin is on the way to prevent a diabetic coma. When a person’s blood pressure is 180/120, child or adult, that number drives doctors, patients, and families to get the pressure to a normal number, hoping to do so before that poor soul strokes out.  From a public health standpoint, for a population of people of whatever age, when a specific measure becomes standard operating procedure in medical practice the sooner everyone, including doctors, nurses and patients, learns to medically – or by life style interventions – manage the condition that threatens to undermine their wellbeing and abbreviate their time on earth.

Levels of cholesterol, blood pressure, and sugar drive a doctor’s practice because they are numbers in black and white in a medical record. They are inescapable reminders that work needs to be done. No one can rest, provider or patient, until that number is in ‘the normal range’. That’s why requiring cholesterol screening early and repeatedly is a good thing: measuring cholesterol means we all are far more apt to manage it – and reduce the risk of developing the heart and blood vessel diseases that will compromise the quality and duration of the lives of those affected.

In April of 2009, the US Preventative Task Force issued a report about screening for depression in children and adolescents, a disorder whose presence and impact on functioning is no less worrisome than high cholesterol. The Task Force studied “…primary care screening for Major Depressive Disorder among children and adolescents ages 7 to 18 years, including evaluating the accuracy of screening tests and the risks and benefits of treatment with psychotherapy and/or SSRIs.” It concluded that “…available data suggest that primary care feasible screening tools may be accurate in identifying depressed adolescents, and treatment can improve depression outcomes”. But they stopped short by stating “…treating depressed youth with SSRIs {antidepressants} may be associated with a small increased risk of suicidality {note: not completed suicide but rather feeling suicidal} and therefore should only be considered if judicious clinical monitoring is possible”.  Who would dare say that treatment proceed only if “clinical monitoring is possible” for youth with high sugar or blood pressure? Why is depression different?

It is possible to screen, monitor and manage depression when it is made a standard of medical care. It is already successfully going on in some exemplary pediatric (and adult) practices. It will be possible when depression is recognized as no less a problem than diabetes or high cholesterol. It will be possible when we stop treating mental problems as secondary citizens in the world of public health. Which should happen since the World Health Organization has alerted health ministries globally that by 2030 neuropsychiatric disorders* will be the leading contributor to the ‘global burden of disease’, a measure of years of life lost as a result of living in less than full health and to early death.

Right now our car is checked with a battery of tests during a regular inspection. We can’t drive our car (legally) without passing inspection by fixing what is wrong. Why would we drive our body without treating what ails it? Why not ensure that medical ‘inspection’ (and treatment) includes depression than see lives break down because we neglected to detect and treat, early and effectively, so common and potentially disabling a disorder?

*Includes bipolar disorder, depression, schizophrenia, epilepsy, alcohol and drug use disorders, Alzheimer’s and other dementias, Parkinson’s, PTSD, OCD, and panic disorder.

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   Originally published in the AOL/Huffington Post on November 15, 2011       

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Prescription Drug Abuse -The New Killer on the Block

Every 14 minutes a person dies of a drug overdose in the United States. This means over 35,000 deaths every year exceeding motor vehicle crashes, homicides and suicides!

The Director of the White House Office of National Drug Control Policy (ONDCP), R. Gil Kerlikowske, a former police and justice official, has called the illegal use of prescription drugs, especially narcotic medications in pill form, the nation’s “fastest-growing drug problem.” What once dominated the world of overdoses in the USA, namely heroin, has been eclipsed by the prescription painkillers (see below).  These drugs are termed opioid analgesics referring to substances produced from the opium poppy or manufactured synthetically with the same pain killing effects on the human brain (analgesic means lack of pain).

Where are the drugs coming from? Over 70 percent of those who have abused prescription narcotics got them from a friend’s or relative’s prescription.  In other words, the supplier is no stranger. And the problem starts early:  a 2009 national survey done by The Substance Abuse and Mental Health Services Administration (a Federal agency) demonstrated that one in three youth, 12 and over, began their path to drug abuse by using prescription drugs for non-medical purposes, namely to get high.  Teens now report, according to a report by the National Center on Addiction and Substance Abuse at Columbia University, that it is easier to get prescription drugs than beer.

In 2009, hydrocodone (Vicodin™ and generic equivalents) was the most prescribed prescription drug in the USA – twice that of the second most prescribed drug, Lipitor™.  Sales of opioids have increased more than six-fold since 1997, as reported by the Drug Enforcement Administration of the US Department of Justice.

We’ve learned through experience in drug control that police-like interventions of finding bad guys and locking them up doesn’t work. Public health approaches stand a far better chance of reducing abuse, saving lives, and even saving money. While no single approach works for the diversity of problems that drive this epidemic, there are a number that have proven effective in states that have implemented them, and that have gathered the support of the Centers for Disease Control and Prevention (CDC) and the ONDCP. Some of these involve you.

 FOR YOU AND YOUR FAMILY:

Getting rid of unused medications: this involves drop boxes, conveniently located so that families can dispose of medications they no longer need, including opioids. Most people do not know what to do with medications they are no longer using, and are concerned about flushing them down the toilet. Drop boxes are a simple solution.

A medicine cabinet inventory: this simple form (http://www.oasas.ny.gov/pio/documents/MedicineCabBrochure.pdf) helps individuals and families keep track of medications they have in the home. If you watch you liquor cabinet you surely should watch your medication cabinet.  If you keep an inventory you can tell if pills are missing and, if so, this is an opportunity to talk to your children or other family members about prescription drug abuse. It is an alert that you need to protect your family members from gaining access to dangerous medications.

FOR PROFESSIONALS and GOVERNMENT AGENCIES:

Prescription Monitoring Programs:  these are programs run by states in which pharmacies supply the state with information on who is prescribing what medications to which patients in what doses. This may sound like surveillance – and it is. Thirty three states, including New York, have a prescription monitoring program (PMP) where pharmacies are required to send data to state health departments about controlled substance prescriptions (which include opioids – and tranquilizers and sedatives as well). This allows state health departments and drug control agencies to pinpoint their education and intervention efforts at doctors and clinics.

Official Prescription Form: many states now use special prescription pads that are numbered and very difficult to forge.  These are so effective that a blank prescription itself has a significant street value, not just the pills themselves.

Educational Resources for professionals: doctors and other medical professionals benefit from bulletins, guidelines and training programs (see the work of the NYS agency for alcohol and substance abuse – www.oasas.state.ny – including its Opiates and Addiction Medication Workbook and Guide for Acute Pain Management For Patients Receiving Maintenance Methadone or Buprenorphine Therapy). More work is needed to better educate doctors about how people with chronic pain are best prescribed analgesics in ways that appreciate their suffering while also offering other means of reducing pain than just high doses of narcotics.

Narcan™: this medication is an antidote, given by injection, which immediately reverses the respiratory depression that is typically the cause of death in narcotic overdose deaths. It can be given easily by any bystander.  Narcan™ is used as a part of an overall drug abuse strategy called “harm reduction” where instead of ‘just saying no’ there is a recognition that it is important to keep people alive until they themselves can avail themselves of treatment and successfully say no to drugs.

These are a few of the strategies in use and in need of more widespread implementation. The work ahead is not about keeping pain medications from patients in need. It is about good medicine and public health: identifying who needs opioid medications for pain and other disorders; establishing the best practices to meet the needs of these individuals; discovering the service gaps between what people need and what they are getting and promulgating best practices to close this gap (called the ‘science to practice gap’); and monitoring who is doing what needs to be done and intervening in a variety of ways, from education to enforcement, with those who can do better.

Doing all this is hard work. It takes a partnership among patients, families, doctors, clinics, professional associations and government agencies. It takes good communication and sophisticated tracking of what works for whom. It takes ongoing dedication to a needed cause. When those elements of a campaign to reduce opioid abuse and overdose death are in place we will save a lot of lives.

Initially published in the AOL/Huffington Post on November 11, 2011 (graphic of trends available there)

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The American Psychiatric Association’s New Bible – The DSM-5: The Changes Ahead

Part II of a Two Part Series*

Part I of this series (http://www.huffingtonpost.com/lloyd-i-sederer-md/the-american-psychiatric-_b_906333.html) described the process underway to reconstruct the American Psychiatric Association’s Bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), creating a 5th edition after more than 20 years of DSM IV.  Time for a new model.

The DSM is a hefty tome that specifies 283 mental illnesses, categorized by disorders, including mood, anxiety, eating, sleep, personality, impulse control, adjustment, substance-related, schizophrenia and other psychoses, delirium and dementia, developmental impairments and other diverse conditions.

In Part I of this series, I described how the APA is trying to ensure public transparency, continuous input and ongoing improvements into the drafting of the DSM-5. In this second part, I will cover some of the actual changes in how diagnoses will be made for the DSM-5. In theory, DSM-5’s new and revised diagnostic conditions will reflect the additional scientific information gathered since the last edition as well as efforts to better cluster and recognize the varied levels of severity of conditions; it will also provide measures for patients, families and doctors to determine if treatment is working. Let’s look at some examples.

I will start with substance abuse and addictive disorders since they are ubiquitous throughout the world – and as controversial as they are universal.The current draft of DSM-5 proposes that “substance use disorder” replace what we now think of as abuse (seen by behaviors) and dependence (evidenced by withdrawal when the body is denied its drug). Each intoxicant would have its own section, such as alcohol use or inhalant use disorder. The website identifies the primary reason for this revision as the view that the term “dependence” is misleading: we are urged to not confuse the fact that tolerance and withdrawal are normal responses to some prescribed (read medically necessary) medications that affect the central nervous system and thus should these physical states should not be seen as an illness.  A Substance Disorder, instead, is a distinct syndrome that includes compulsive drug-seeking behavior, loss of control, craving, and marked decrements in social and occupational functioning. Maybe we can reduce stigma with this revision? A good question that time will answer.

But the addiction soup gets thicker when it comes to wondering what indeed is an addiction? Is gambling (yes, probably)? Is sex? How about internet (without porn)? The votes are not in.

Another critical – and very controversial – diagnostic grouping is Autism Spectrum Disorders. Is there an epidemic going on? You would think so to listen to the news. The workgroup’s recommendation for a new category of Autism Spectrum Disorders reflects its view that Autism and Asperger’s Syndrome (think Dustin Hoffman and “The Rain Man”) are a continuum from mild to severe. Many families and advocacy groups are a bit agitated about ending the distinction, which would have effects (likely good and bad) on policy, clinical programs and funding.

In the world of developmental disabilities, the DSM revisionists want to do some wordsmithing on Intellectual Developmental Disorders. “Mental Retardation”, the experts urge, should be changed to “intellectual developmental disorders” (which would bring the DSM in line with the International Classification of Diseases proposal for its 11th edition – see Part I for insight into the international scene). But importantly, and realistically, severity of an intellectual disability would not be based only on IQ but by impairment in adaptive functioning as well. That is really overdue.

Another critical cluster of disorders is called “Schizophrenia Spectrum and Other Psychotic Disorders.” These are serious and often persistent mental illnesses where a person has profound impairments in being able to appreciate the reality about him or her, and diminished functioning in education, work and social relations. The revisions for these conditions, which affect about 1% of the population but are among the most costly in terms of loss of quality of life and social cost, are less controversial but allow for an extensive assessment of severity that includes hallucinations, delusions, disorganized thinking and behavior, loss of mental capacity (cognitive impairment) and diminution of feelings, expression and even the ability to act (called avolition, or loss of the ability to start an action). This detailed assessment is a very good idea but is raising questions about the paperwork burden of completing severity measurement scales.

Premenstrual Dysphoric Disorder (PDD) is a serious mood problem in women that occurs during the premenstrual period. It will appear in the appendix to the main body of the DSM-5 text. The evidence is that this is distinct from premenstrual mood swings (PMS). The addition of this condition could help promote its recognition and promote more research (and better treatment) on this common and disturbing condition. Is this pathologizing monthly lunar-menstrual mood swings, some wonder?

Another debated condition is what is called Mild Neurocognitive Disorder. The aim of this brand new disorder is to identify people at risk for developing dementia, including both Alzheimer’s disease and vascular dementia (caused by loss of blood supply to a region of the brain). Symptoms include memory and language loss as well as attentional and reasoning impairments. Do you want to know if you have dementia?

There is a lot more – including eating disorders, personality disorders (a huge and evocative topic since we all have personalities), and traumatic stress disorders (all the more critical in light of our soldiers, domestic violence, sexual abuse, and disaster victims). You can see all of this, and more, on the DSM-5 website (www.dsm5.org). The design of each section on a disorder is very well done since there are tabs for the proposed revision, the rationale for the revision, severity scales, and the current DSM IV to compare to.

Perhaps one of the most important changes in the DSM is called Dimensional Assessments (noted above in the discussion of schizophrenic disorders). DSM IV has had the problem of fitting neatly into the complexity of human symptoms: people with schizophrenia have problems with depression, anxiety, even insomnia. There has been, to date, no means to account for these problems, their severity – and perhaps most importantly – to determine if a person is improving in treatment. Dimensional assessments will enable clinicians to record the presence of a variety of problems as well as their severity (very severe, severe, moderate and mild) and thereby be able to track how a person is doing over time, and in response to different treatments. This is as needed as it is complicated and demanding.

No wonder the APA constructed 13 work groups, over 160 people, to revise the DSM – even before it has to go through the gauntlet of its internal committees, councils and the APA Board of Trustees. Some will say, have said, a fool’s errand. After all, how many angels can dance on the head of a pin? I say, however, medicine is a science. Psychiatry is a branch of medicine, a huge limb, in fact, in need of continuous pruning, watering and shaping. Science is not perfect. But the quest for the perfect, in progressive approximations, is what separates science from fiction, opinion from evidence, and guesswork from clinical medicine.

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Originally published in the Huffington Post/AOL on September 9, 2011.

For more information see the DSM-5 website: www.dsm5.org

*Disclosure: I am an APA member. I have held numerous elected state and national positions at the APA, worked there from 2000-2002.

 

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Rapid Cycling Bipolar Disorder: in the Office and on ‘The Street’

Rapid cycling bipolar disorder is a turbulent and psychologically painful condition characterized by four or more major mood shifts in the course of a year (sometimes even in a week). Moods go up or down in this condition and are demarcated by a rapid switch to a state of the opposite polarity. Rapid cycling states can come at any time, and are known to appear and disappear.

Rapid cycling bipolar disorder is perilously vulnerable to outside influences, notably both those that are troubling and deleterious or, alternatively, uplifting and beneficial. Stressful events are famous for precipitating shifts into low or high states of mind. The condition begs for a stable environment and a predictable and reliable future.

This disorder is notoriously difficult to treat. Among the remedies used are mood stabilizers, anticonvulsants and anti-psychotics (!) When one intervention fails, as often happens, another is piled on; then another. In some tragic cases, all this effort is to no avail. In other cases, where the cycling abates, the myriad of interventions leaves little clue as to which one may have made a difference.

Lives are put in shambles, families rendered asunder, workplaces disrupted and resources dangerously stretched when rapid cycle bipolar disorder sets in and affects individuals and their communities.

Rapid cycling is typically associated with a poorer longer-term prognosis. One cycle, up or down, seems to trigger another, and another. The more cycles there are, the more likely another cycle will explode upon the scene leaving those affected thunderstruck and anxious as to whether they will ever escape the condition’s grip. Over time, hope can fade. Over time, resources dwindle. With little to live on and scarce opportunity for a better future individuals may have little choice but to rely upon government entitlement programs.

You might think I am talking about my business, psychiatry, where we recognize a condition with these features and call it “rapid cycling bipolar disorder.” But, instead, as I tuned into relentless media reports coming from Wall Street to Tokyo all this past week, I started wondering about the equity markets – and our societies. What we are witnessing seems to meet all the diagnostic criteria for rapid cycling bipolar disorder. Without effective interventions, reductions in stress and a good dose of hope (see Raising the Hope Ceiling http://www.huffingtonpost.com/lloyd-i-sederer-md/raising-the-hope-ceiling_b_922343.html) the prognosis is not good. We need a game changer for this condition wherever it may appear.

This commentary first appeared  in the AOL/Huffington Post Health Living Section on August 26, 2011.

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Raising the Hope Ceiling

After a disgraceful show of Washington blaming and shaming the US debt ceiling was raised at the 11th hour, deferring a default that no one could brook. This spectacle, coupled with a legion of global financial woes, has triggered a massive descent in stock values and a rush to find solid sources of capital – witness the unending purchase of gold. What lies ahead? Prediction, as has been said, is particularly difficult, especially about the future – though the clamor of commentators has grown deafeningly greater (in inverse relationship to the Dow).

I am no economist, just a psychiatrist. So I think about raising the hope ceiling, not just the debt ceiling. Hope is no ephemera, no wispy notion that lacks substance. Hope is a solid source of emotional capital we humans need to bear misfortune and pain in order to find a way to recover from whatever hole we are in. As a doctor, I see my job to help my patients find sources of hope as they pursue whatever treatments and actions are most likely to bring relief and wellness.

In a stunningly clear and frank manner Dr. Drew Westen asked in the NY Times (Sunday Review 8.7.2011) “What Happened to Obama?” Put another way, what happened to the apparent man of conviction who stirred our hopes and rode into the White House upon them? I wonder who we have to raise our personal and nation’s hope ceiling?

Why do I think days of prayer organized by politicians will not raise the hope ceiling?

Why do I think tycoons and talk show hosts proffering whatever (unregulated or regulated) fixes they admire will not raise the hope ceiling? It was Woody Allen who remarked that if you want to make god laugh, tell him you have plans.

Why do I think that sequestering gold or Swiss Francs will not raise the hope ceiling?

The course of history has been more defined by its leaders, good and evil, than by the circumstances that may have vaulted them into power. It was Adolph Hitler, despite his generals, who opened another front against his ally Russia and suffered defeat while Winston Churchill rallied his fellow citizens to stay the course in the darkest of days, keep hope alive, and triumph.

When will we see our leaders attend to the hope ceiling? Leadership, and with it hope, is about the unwavering pursuit of what is yet popular. This moment of national and global crisis calls for leaders who will speak to us as much about the nature (and value) of hope as about the dangers of debt. We are all waiting, some more hopeful than others.

This opinion piece first appeared in the Healthy Living Section of the AOL/Huffington Post on August 9, 2011. It was also covered in the WSJ.com (http://onespot.wsj.com/politics/2011/08/09/63b94/lloyd-i-sederer-md-raising-the-hope).

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The American Psychiatric Association’s New Bible: The DSM-5: Making it Happen

(Part I of a Two Part Series)

For the fourth time since 1952, when the first edition appeared, the American Psychiatric Association (APA)* is again revising its diagnostic manual. Who cares, some may ask? Seems like a lot of people do care – and should. Is there dispute about what is being drafted, and how it is being done, by this organization of 38,000 member psychiatrists? Indeed.

The DSM-5 is shorthand for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The APA began revising the 4th Edition (which had undergone some minor revisions and thus was called DSM-IV-TR) in 2000 with the goal of releasing the 5th Edition in 2011 (when the international coding system for billing was due to change – see below). Estimates now are that it will appear in 2013. It has been 20 years since the last full revision and one is overdue. The DSM is a hefty tome that specifies 283 mental illnesses, categorized by disorders, including mood, anxiety, eating, sleep, personality, impulse control, adjustment, substance-related, schizophrenia and other psychoses, delirium and dementia, developmental impairments and others. It also provides a system for adding the presence of general medical illnesses as well as ratings of functioning and stress.

Were you to open the book to a particular illness, say depression, you would see a list of symptoms (for depression these include sleep and appetite problems, difficulty concentrating, sadness and guilt) whose presence must be met for a specific duration of time for a person to warrant that diagnosis. You would be instructed to ensure that the condition you are observing is not due to something like thyroid disease or a drug that depresses the central nervous system – both of which can cause depression and would require different treatments. You would learn something about the course and prognosis of the illness but would read nothing about what causes the illness, nor would you find information about specific treatments. The DSM has eschewed, to date, delivering information about the causes and therapeutics of mental disorders. Instead, its goal for decades has been to characterize the signs and symptoms of an illness with enough clarity and specificity that mental health professionals around the world observing the same condition would arrive at the same conclusion about what they are seeing; this is called reliability and has been the DSM’s grail.

There are four reasons (at least) why diagnosis, and thus the DSM, matters:

1. Most public and private payers in the U.S. healthcare system only reimburse for treatment of psychiatric diagnoses formally recognized in DSM (though having a diagnosis does not ensure insurance coverage or payment). Our medical care system, be it for psychiatric conditions or any illness, is based on diagnosis. You can only be admitted for care in a clinic, doctor’s office or hospital if you have an illness, which means you have a diagnosis. In short, no diagnosis, then no treatment and no payment. In fact, FDA approval for the treatment of a medication for a psychiatric disorder requires that it be listed in the DSM: no diagnosis, no drug approval.

2. There would be no way to judge the quality of medical care were there no diagnoses. Neither patients nor medical teams could know whether a treatment is effective for a particular condition without a diagnosis, nor would they be able to customize treatments by dose, duration, safety and side effects, age, race and ethnicity, acute or chronic care, and the like. Quality is the appropriate provision of the right treatment for a specific diagnosis – sometimes described as doing the right thing right.

3. Diagnoses can provide socially acceptable reasons for not functioning as normally expected. To wit: he has had a myocardial infarction and will be out of work for a month; she has influenza and cannot attend classes; she has a serious depression complicating her diabetes and cannot attend to her family and work because she must enter the hospital for care for both conditions. Moreover, disability and entitlement programs (like Medicaid and Medicare) require a diagnosis for a person to be eligible for support a person might not otherwise receive.

4. There are those who say diagnosis makes a difference in reducing the stigma that people with mental illness experience. Maybe, for some, having an understandable medical condition does help reduce harsh judgments by others; depression may have achieved that standing, as perhaps has PTSD. For other disorders, like schizophrenia and bipolar disorder, as some of my colleagues have said, it will be their effective treatment, especially reductions in frightening or socially disruptive behaviors, which will actually reduce stigma.

In sum, diagnosis makes a big difference. So, we better get it right. Enter the APA and their effort to get the DSM more right after 20 years of stasis. The APA constructed 13 work groups, over 160 people, to revise the DSM, along with review and critique by the APA’s internal committees, councils and board of trustees.

In an effort to publicly share progress in DSM-5 development and solicit feedback from the manual’s users, the APA posted online their draft material and twice invited comments; their website has received over 7 million visitors, 40 million hits, and 10,000 comments. Potential members of the drafting teams were required to fully reveal and divest themselves of any potential conflicts of interest (e.g., industry consultations, stock ownership, or helping to market a medication) before being appointed. This set the process back by some time, but created an unprecedented level of transparency. Now, field trials have begun at 11 academic medical centers throughout the country with a variety of mental health professionals. In addition, real-world office practice sites will soon begin trials by psychiatrists, psychologists, social workers, nurses and counselors. The APA is working with the World Health Organization (WHO) to set up field trials in primary care settings.

In short, a great many experts are creating the latest DSM while being subject to professional and public scrutiny of their motives and their product, and it is about to be test-driven in hospitals and offices to see how it works. The iterative and open DSM-5 development process has and will permit continuous improvements along the way. Yet none of this guarantees excellence, though it fosters it and allows for a more trustworthy process.

Criticism has especially collected about delays and public perception. The already two-year deadline extension has taken a lot of attack — despite explanations about the workgroup membership vetting and need for sophisticated field trials. Yet the really critical deadline lies ahead (October 1, 2013) in time for the DSM-5 to be linked to the ICD-10-CM (the International Classification of Diseases, 10th edition – U.S. Clinical Modification). The ICD is a disease coding (billing) system produced by the WHO, modified by the U.S. Federal Government, and required for all Medicare, Medicaid, and private insurance claims. In other words, the DSM provides diagnostic criteria and the ICD provides billing codes: both are actually needed for medical business to be done. Ironically, if the DSM-5 had been published in 2011 (using current ICD-9-CM codes) it would have to be republished with the new ICD-10-CM codes in 2013! Unintended delays, in fact, have resulted in a synchrony that will enable clinicians and administrators to have the new diagnostic system and the updated billing codes arrive at the same time. And they would not have had to buy a DSM in 2011 and an updated one in 2013.

The APA was also trumped for a while in communications about the DSM by experienced experts, Dr. Allen Frances, the editor of DSM-IV in particular, who has been critical of virtually all aspects of the DSM-5 development process. His initial critique left the APA looking flat-footed about what it was doing to make things right.

These are serious issues. But they are not being ignored. Time will tell if they will be properly corrected. The DSM-5 development process has been less than perfect. The final DSM-5 product could be at risk for not being as clinically meaningful and usable as it needs to be. As for the former, I am reminded about what Churchill said about democracy: “… the worst form of government except {for} all the others that have been tried”

As for the latter, more about the product in Part II of this series where I will discuss the actual diagnostic and content changes proposed for the DSM-5. These include a new category of behavioral addictions; revisions in disorders of development previously described as mental retardation; far more about mental disorders affecting children, including considering introducing what is now called ‘risk syndromes’ to foster early identification and intervention; a focus on the co-occurrence of disorders, which is often more the rule than the exception; and ‘dimensional assessments’ which are basically means by which clinicians can evaluate the severity of a person’s condition and monitor if treatment is working — to name a few. Will the 5th Edition exonerate itself from its critics? The world of mental health needs that to happen.

For more information see the DSM-5 website: http://www.dsm5.org

*Disclosure: I am an APA member. I have held numerous elected state and national positions at the APA, worked there from 2000-2002, and currently sit on the Council on Research and Quality Care.

Originally published in The Healthy Living Section of the AOL/Huffington Post on July 26, 2011

http://www.huffingtonpost.com/lloyd-i-sederer-md/the-american-psychiatric-_b_906333.html

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What does suicide prevention have to do with improving health care?

At a recent suicide prevention symposium hosted by the NYS Office of Mental Health (Disclosure: I am the agency’s Medical Director), Dr. Lee Goldman, Dean of Columbia Medical School, began the day by remarking that there has been an 80% (!) reduction in deaths from heart disease in the past 50 years. Dr. Goldman was highlighting how what seemed like inevitable mortality rates two generations ago could be systematically and dramatically altered by reducing risk and intervening early and effectively; lives can be saved and pain and suffering for potential family survivors can be blessedly mitigated.

That was a heartening opening in light of why this meeting was called: Ten years ago a national strategy to reduce suicides in this country was launched built on a platform created by Former Surgeon General David Satcher. Yet despite many well considered efforts there has been no reduction in deaths, which now are greater than ever, about 36,000/year according to the latest statistics. NYS Mental Health Commissioner Mike Hogan called this New York meeting to consider what this state of near to 20 million people might do to reduce deaths by suicide, and the grim consequences they cast. Our work would build on and resonate with a national effort underway.*

We began by hearing several success stories. First, we heard how Henry Ford Health System in Michigan, a large health insurance plan with some 500,000 members that delivers medical services to its subscribers and others (~10,000 visits/business day), set a goal for what they called “Perfect Depression Care.” The vast predominance of people who complete suicide has an active mental illness, particularly depression. Not willing to tinker around the edges, they pursued a radical approach that set zero deaths as their goal. They implemented screening, proven principles and practices for the care of all chronic illnesses (including diabetes, heart disease and depression), immediate access to appointments, and continuous and robust quality improvement – and after several years of progressive reductions in deaths they achieved and maintained 2 ½ years of zero deaths by suicide.

We next heard how Kaiser Permanente of Northern California, an HMO with over 3 million members and 20 medical centers, instituted a remarkable plan for primary care suicide prevention (i.e., in general medical services not mental health clinics). They introduced screening for depression, anxiety, substance abuse, and intimate partner violence, coupled that with treatment practices known to work, and scrutinized every suicide for what improvements could be made.

Finally, we heard how Magellan  Health Services, a large national mental health managed care company, implemented suicide prevention in Arizona by focusing on those people whose risk for suicide was 6-12 times the general population, namely those people with a serious mental illness. They trained clinicians, standardized the provision of best practices, stressed community based care, and engaged families and those who survived an attempt; they have reduced deaths by 48% and inpatient admissions among their subscribers by 51%, indicating risk reduction as well as cost savings.

What was so notable from the presentations was that “suicide… was just the tip of the iceberg”, as the last speaker remarked. The vast problem below the surface, one that can be avoided, is not doing the right thing. We actually know what is right: setting very high standards (don’t be afraid of perfection); systematically identifying people at risk; relentlessly providing proven methods of intervention; crossing boundaries between general medical and mental health care and staying with people when they move from one care setting to another (like from hospital to home); regularly assessing performance with measures that are as clear and understandable to patients and families as they are to clinicians; and zealously pursuing opportunities for improvement when problems appear, as they always do.

Deadly consequences happen, in effect, from suicide just like from heart disease, when we do not do the right thing as unfailingly as we can. Good medical care does not know the difference between illnesses. The same principles govern health care for every disease, physical and mental. Reducing rates of suicide is about improving health care. We will need to abide by these very same access and quality standards in order to manage the diseases that afflict our generation, especially those that derive from habit disorders and age, including diabetes, hypertension, asthma, obstructive lung diseases, Parkinson’s and Alzheimer’s disease, and the multiplicity of ails that derive from smoking, overeating, sedentary life styles and stress.

A colleague from the NYS Health Department, Dr. Foster Gesten, in the summing up at the end of the day suggested that strategies for saving lives could be “deep and wide.” Deep are those that health care systems with accountability for identified individuals or populations could implement in NYS – as we learned are going on in Michigan and Northern California (as well as the very notable work throughout Washington State). Wide are the practices known to work universally that are ready for prime time and wide application, like screening to identify high risk people, treatment care paths, open access to appointments, careful attention to transitions from one service site to another, informed and ‘activated’ patients and families, and health information technology that provides decision support and communicates essential information to those who need to know. Reducing death by suicide would be one of many fortunate outcomes from improving our health care system.

Achieving change in health care is very hard to do. It entails an unwavering ambition for excellence and zealous attention to details. I am reminded about something Michelangelo was reported to have said: “Trifles make for perfection, but perfection is no trifle.”

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*Last year, Federal Secretaries Sebelius (Health and Human Services) and Gates (Defense) launched the National Action Alliance for Suicide Prevention bringing together government and military officials, experts, people with mental illnesses, family members, foundations, and others to fashion a plan that would be more focused and successful than the efforts of the past decade. Commissioner Hogan and a number of those who attended the NYS symposium are members of the Action Alliance.

 Originally published in the Health Living Section of the AOL/Huffington Post on July 18, 2011

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‘Dying with your rights on’: mental illness, civil rights and saving lives

I am a psychiatrist who has treated patients for over 35 years, run all varieties of psychiatric services, and worked in City and State Government. But I still cannot bear to read or hear a story of a fatal outcome for a person with a serious mental illness who dies from neglect or some form of self-harm. I was especially distressed to read an article in The New Yorker (Rachel Aviv, May 30, 2011, Annals of Mental Health) called “God Knows Where I Am: What should happen when patients reject their diagnosis?” The article deeply troubled me because of the outcome for the person it profiled: Linda Bishop was found dead, presumably from starvation and hypothermia, in a home she had broken into in New Hampshire several months after she had a two year psychiatric hospitalization. Her last journal notation was in January, 2008, and her body was accidently discovered in May.

Neither Bishop’s sister, a long time advocate for her (who works in the justice system), whom a court years earlier declined to make her legal guardian, nor Bishop’s daughter were informed of her condition during her extended stay in New Hampshire’s state hospital – nor were they told when she was discharged. Instead, a fantasy relationship that Bishop had for years in her head, with no contact with the man, was her plan for support, even marriage, upon leaving the hospital.

Linda Bishop’s story of multiple psychiatric hospitalizations, misdemeanor (non-violent) offenses and time in jail, abandonment of her teenage daughter, assertion that she was not mentally ill and thus of course refusal to follow any treatment plan, lack of evidence that she could care for herself, and self-imposed distance from her family was all too familiar to me, and colleagues working in public mental health, even if the details of her situation may vary in some ways from others. Recognized experts (and long time colleagues) Drs. Tom Gutheil and Paul Appelbaum in 1979 (!) aptly called this type of tragedy “rotting with their rights on.”

Our laws stipulate that Bishop had to consent to provide information to her family, which she did not. Privacy violations would have been the consequence of the hospital contacting her family during the hospital stay or at the time of discharge. Bishop’s ‘right’ to live where (and how) she wanted derives from legal rulings that stipulate a person’s right to live in what is called “the least restrictive setting.” The letter of the law had been met. And the patient died.

Arguments have been made on the polar extremes of this dilemma. On one side are patient rights advocates who are stalwart about privacy and self-determination. In fact, legal organizations are present to defend these rights in state hospitals throughout this country. Considerable legal rulings now protect individuals from involuntary hospitalization and involuntary treatment by requiring court action to achieve both, with the exception of emergency situations. On the other side are advocates calling for increasing commitments of people with serious mental illness, including outpatient commitment (and requiring that those committed take psychiatric medications for their disorders), and longer hospital stays.

Never having been one for extremes, except maybe when it came to my playing sports, I believe there are viable middle grounds – even if difficult to reach.

For example, nine years ago the first Mental Health Court was established in New York City, under the remarkable (and continued) leadership of Judge Matthew D’Emic. There are now 7 such courts in NYC, about 25 in NYS and approximately 200 around the country (not counting drug and domestic violence courts). A mental health court accepts referrals from other courts where there appears to be a mental illness complicating the crime. Court mental health specialists evaluate the person for a mental illness and if present the defendant can plead guilty (in NYS) and be ‘sentenced’ to court ordered treatment under the supervision of the judge; other states may divert the person from jail, have charges held in abeyance pending completion of the treatment program, or other procedures according to  local statute . This form of supervised treatment is typically for a year (the maximum sentence for a misdemeanor). More recently, there are mental health courts working with felons where the court ordered treatment can go on for years.

For example, outpatient commitment exists in most every state already (it has been the case in NYS when instituted over 10 years ago after Kendra Webdale was pushed before an oncoming subway train). The law, Kendra’s Law, has been renewed twice, each time for five years. We don’t need more outpatient commitment (though some state statutes warrant updating) – we need more outpatient treatment that works.

Which brings me to my main point: outpatient mental health services in this country don’t work very well, despite the dedicated people who work for them. The result is that early intervention and the provision of comprehensive, continuous, proven (evidence-based) treatments is being delivered to less than 20% (!) of people who need it. That means more than 4 out of 5 people are not getting what they need for their illness and recovery. Lack of good care coupled with lack of housing are the principal drivers for the clinical deterioration, chronic homelessness, use of jails and prisons as institutions to contain people with mental disorders, and suicidal and violent behaviors among those who are mentally ill. This country is in need of a mental health overhaul, as candidly portrayed in the President’s New Freedom Commission on Mental Health (December 2002, http://govinfo.library.unt.edu/mentalhealthcommission/index.htm – Disclosure: The Commission’s chair was Michael Hogan, PhD, now Mental Health Commissioner for NYS, and my boss).

Mental health has treatments that work. It has mission-oriented professionals and provider organizations. But it lacks organization, accountability, and financing that pays for what is accomplished rather than what is simply done. Sounds familiar? That’s because mental health care is part of health care, where the same issues apply in capital letters.

As this country grinds its way to a more responsive, and hopefully affordable, health care system what can be done now? For one, mental health clinics can be held to specific standards of care and their licenses made dependent on delivering those standards. Measurement based care can be introduced (required) where improvement from mental illness is tracked just like we track blood pressure, blood sugar and lipids. Incremental financing reforms can better support evidence-based practices as well as outreach and engagement of those hardest to reach and retain in care. People in recovery from mental illness (called peers or consumers) can be made a part of the public mental health system so they serve as navigators and trusted persons for those wary of mental health care. And no one stands a decent chance of getting better from a serious mental illness without safe and reliable housing with access to quality health and mental health services.

Indifference is cruel and costly. We can make a difference. People can have their rights and their lives – and their families too. That’s what health care, including mental health care, is really all about.

Appelbaum PS, Gutheil TG: Rotting with their rights on: constitutional theory and clinical reality in drug refusal by psychiatric patients.  Bulletin of the American Academy of Psychiatry and the Law 1979; 7:308 317

This article first appeared in the HEALTHY LIVING SECTION of the AOLHuffington Post

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