All Opinion pieces are written by Dr. Sederer

Contents:

- 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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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 5^th 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 11^th 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 11^th 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, 5^th Edition. The APA began revising the 4^th Edition (which had undergone some minor revisions and thus was called DSM-IV-TR) in 2000 with the goal of releasing the 5^th 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: 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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