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Effective Personalized Strategies for Treating Bipolar Disorder

on Saturday, 17 August 2013. Posted in General

Bipolar disorder causes havoc in patients’ lives. Even in the best of circumstances, successful treatment is challenging

Effective Personalized Strategies for Treating Bipolar Disorder

By Stephen V. Sobel, MD

Bipolar disorder causes havoc in patients’ lives. Even in the best of circumstances, successful treatment is challenging. Treatment targets constantly shift; patients are frequently nonadherent; and comorbidity is the rule, not the exception. Diagnosis of bipolar disorder is often difficult. Comorbidities need to be identified and addressed if treatment is to be effective.

The importance of an accurate diagnosis

With apologies to Charles Dickens, bipolar disorder is often experienced as the “best of times and the worst of times.” This polarity often causes bipolar disorder to be undiagnosed, overdiagnosed, or misdiagnosed. Bipolar disorder is associated with a significantly elevated risk of suicide. Moreover, bipolar patients often use highly lethal means for suicide.1 Contributing factors include early age at disease onset, the high number of depressive episodes, comorbid alcohol abuse, a history of antidepressant-induced mania, and traits of hostility and impulsivity.

Bipolar I disorder, with episodes of full-blown mania, is usually easier to diagnose than bipolar II disorder, with episodes of subtler hypomania. Recognizing that the primary mood state may be irritability rather than euphoria increases the likelihood of diagnosis as does the recognition that symptoms often last fewer than the 4 days required for diagnosis by DSM-IV.2 Focusing more on overactivity than mood change further improves diagnostic accuracy, and the use of structured questionnaires is helpful.

Given the greater frequency of depression than manic episodes in bipolar disorder, what clues indicate bipolar disorder rather than unipolar depression? The Table lists factors that may help identify unipolar depression.

A moving target needs moving treatment

Effective personalized treatment recognizes bipolar disorder as a biopsychosocial disorder, but mood-stabilizing medications are the backbone of treatment. These medications fall into 3 categories: lithium, antikindling/antiepileptic agents, and second-generation antipsychotics. The mechanisms of actions by which these medications work are numer-ous and include increasing levels of serotonin, γ-aminobutyric acid, and brain-derived neurotrophic factor (BDNF) and decreasing glutamate levels; modifying dopamine pathways; stabilizing neuronal membranes; decreasing sodium channels; decreasing depolarization; decreasing apoptosis; and increasing neural cell growth/arborization.

Double-blind placebo-controlled studies of the medications—lithium, divalproex, carbamazepine, and atypical antipsychotics—used to treat symptoms of acute mania have demonstrated a response rate of approximately 50% to these drugs. Response was defined as a 50% decrease in symptoms using the Young Mania Rating Scale (YMRS) with onset of response within a few days.

An increasingly intriguing aspect of treatment with lithium and atypical antipsychotics involves their effect on BDNF. In a study of 10 manic patients treated with lithium for 28 days, most (87%) showed an increase in BDNF level (ie, from 406 pg/mL to 511 pg/mL). 

Factors that suggest bipolar depression rather than unipolar depression

In a typical 3-week study of acute mania, approximately half of the benefit was seen by day 4. A 3-week, double-blind, inpatient study of olanzapine and risperidone in 274 patients with acute mania found that of 117 patients who had a less than 50% decrease in the YMRS score at 1 week, only 39% responded and 19% had symptom remission at end point. Of 40 patients with a less than 25% decrease in the YMRS score at 1 week, only 25% responded and only 5% had symptom remission at 3 weeks. Of 157 patients who had at least a 50% decrease in the YMRS score at week 1, 84% responded and 64% had symptom remission at 3 weeks.4 Clinically, a medication change should be considered for patients who do not demonstrate substantial benefit by week 1.

A meta-analysis comprising 16,000 patients who had acute mania found that the most effective agents were haloperidol, risperidone, and olanzapine. The least effective were gabapentin, lamotrigine, and topiramate.5

A combination of medications—typically lithium or an antiepileptic with an atypical antipsychotic—is often necessary to successfully treat acute mania. A meta-analysis found the response rate increased from 42% to 62% when an antipsychotic was added.6

Bipolar depression has proved to be more resistant to medication treatment than mania. The same medications are used, with lamotrigine for maintenance treatment. The FDA has approved Seroquel, Seroquel XR, and Symbyax (the combination of olanzapine and fluoxetine), for the acute treatment of bipolar depression. Studies of acute bipolar depression have typically lasted 8 weeks. Approximately half of the benefit oc-curs by week 2, with statistical separation from placebo between weeks 1 and 3.7-9

The best treatment is prevention

Patients who have bipolar disorder almost always require lifelong maintenance treatment, frequently with 2 medications: one to prevent the upside (ie, hypomania/mania), and another to prevent the downside (ie, depression).

Findings from a registration trial showed that lamotrigine more effectively prevented depressions than lithium but lithium prevented mania/hypomania more effectively than lamotrigine.10

Another study added placebo or lamotrigine to lithium treatment for 124 patients. The median time to relapse/recurrence was 3.5 months for those taking lithium monotherapy but 10 months for those who received combination treatment.11

The effectiveness of a combination maintenance regimen was also seen in a study of 628 patients with bipolar I disorder treated for 2 years: 65% of those taking lithium or divalproex alone experienced a recurrence compared with 21% who received quetiapine added to lithium or divalproex.12 However, combination treatment may result in more adverse effects and increased risk of drug-drug interactions.

The best mood stabilizer

The best mood stabilizer for a patient is the one he or she will take. No matter how effective a medication is, it will not relieve symptoms if it is not being taken. The key to effective personalized treatment of bipolar disorder is a good patient-physician connection in which the patient is part of the treatment decision-making process.

Psychotherapy is an integral part of the effective treatment of bipolar disorder, not just an augmentation strategy. Psychotherapies that are helpful include cognitive-behavioral therapy and social rhythm therapy.13 Psychotherapy can focus on several areas, such as education, comorbidities, medication adherence, and interpersonal relationships. In addition, therapy can challenge the automatic, distorted, and dysfunctional thoughts and help the patient maintain social rhythms (eg, consistent sleep). The involvement of family members in treatment enhances success.

Patients may stop taking their medications because the adverse effects become intolerable; they may miss what they perceive as their more satisfying and productive hypomania; and they might believe that a period without symptoms means that they are cured and no longer need medications. One study of 3640 patients with bipolar disorder who made 48,000 physician visits found that 24% of patients were nonadherent (defined as missing at least 25% of doses) 20% of the time. Factors associated with nonadherence included rapid cycling, suicide attempts, earlier onset of illness, anxiety, and alcohol abuse.14

Patients who have bipolar II disorder spend far more time depressed than hypomanic. Lithium appears to be less effective than antikindling agents for rapid cycling as well as for mixed bipolar disorder states.15

Maintenance treatment is necessary for patients with acute mania or acute depression; therefore, choose medications that are more tolerable to the patient to facilitate long-term adherence. Recognize that medications may need to be adjusted or changed—in the acute phase of illness, rapid efficacy is often the priority, while medication adherence is the priority during the maintenance phase.

Other factors to consider when choosing the best medication for a particular patient include:

• A history of treatment response

• A family history of response

• Adverse effects of a particular drug

• Drug interactions

• Pregnancy

• Breast-feeding

Antidepressants

The use of antidepressants in bipolar disorder is controversial because they may induce rapid cycling, especially in patients with episodes of rapid cycling.16 In a study by Altshuler and colleagues,17 patients who had breakthrough depression despite treatment with a mood stabilizer were treated with antidepressants for at least 60 days. Patients who had symptom remission for 6 weeks were followed up for 1 year: 36% of patients who continued antidepressants for longer than 6 months relapsed versus 70% who discontinued antidepressants before 6 months.

A randomized discontinuation study with antidepressants found no statistically significant symptomatic benefit in the long-term treatment of bipolar disorder.18 Trends toward mild benefits, however, were found in patients who continued antidepressants. This study also found, similar to studies of tricyclic antidepressants, that rapid-cycling patients had worsened outcomes with continuation of modern antidepressants, including SSRIs and SNRIs.

An NIMH study of 159 patients who had breakthrough depression despite receiving a mood stabilizer were treated with sertraline (mean dosage, 192 mg/d), bupropion (mean dosage, 286 mg/d), or venlafaxine (mean dosage, 195 mg/d) for 10 weeks with a 1-year follow-up.19 At the end of 1 year, only 16% of the patients had continued remission while more than 55% had switched to mania/hypomania. The worst results were seen with venlafaxine and the best with bupropion.

In a study by Sachs and colleagues,20 patients who had breakthrough depression despite being treated with mood stabilizers were randomized to paroxetine (mean dosage, 30 mg/d), bupropion (mean dosage, 300 mg/d), or placebo. No significant differences on any effectiveness or safety outcome, including remission rates or affective switch frequency, were found.

Overall, these studies indicate that the role of antidepressants is limited and that, in fact, a trial of a mood stabilizer cannot be considered to have failed unless the failure occurs in the absence of an antidepressant. A meta-analysis of 18 studies with 4105 patients found that combination treatment including a mood stabilizer and an antidepressant was not statistically superior to monotherapy.21

When symptoms persist

Establish the context of each appointment by focusing on changes in occupational, social, family, and health status. Evaluate medication regimens, with a focus on effectiveness for carefully chosen target symptoms and adherence to treatment, as well as medication tolerability and patient attitudes. Be alert to the emergence of early symptoms of mood change, and adjust medications if necessary. Remember that treatment modalities often need to change over time.

Mood stabilizers should be optimized with combination therapy for sustained remission. Antidepressants may worsen the disease course, and a true trial of a mood stabilizer can-not occur within the setting of antidepressants. If symptoms persist, ask: Is the patient taking anything that is making symptoms worse, eg, drugs, alcohol, or antidepressants? Is the patient taking the medications? Is treatment adequate? Is another condition (including subclinical hypothyroidism) interfering with treatment? Is psychotherapy being ignored?

Effects of Pharmacokinetic and Pharmacodynamic Changes in the Elderly

on Saturday, 20 April 2013. Posted in General

PK & PD Changes

Effects of Pharmacokinetic and Pharmacodynamic Changes in the Elderly

This interesting article explains and demonstrates the need for monitoring and altering psychotropic medications and dosages in older patients.

http://www.psychiatrictimes.com/display/article/10168/2123794?pageNumber=1

Getting an In-Depth Look at Depression

on Saturday, 15 June 2013. Posted in General

The mental health screening site Help Yourself Help Others provides this infographic showing that 17-20 million Americans develop depression each year. Common symptons and an explanation of the different forms of depression are listed below

Getting an In-Depth Look at Depression

God's Psychiatrist

on Monday, 08 July 2013.

Funny portrayal of a psychiatrist analyzing some events in the Old Testament

God's Psychiatrist

By H. Steven Moffic, MD

Chapter 1. A Psychiatrist in Biblical Times

In Genesis, it is described that man, and then presumably woman in a first example of matchmaking, is created in the image of God. Imagine a modern day psychiatrist time traveling back to observe this creation. If you don’t believe in such a God, but are a parent, think of a child created, at least half genetically speaking, in your image.

As holy as it may seem to be created in the image of a God, would a psychiatrist think that this was mentally healthy? What happens to the children of parents who want their children to fulfill their own dreams? Could it be too much of a narcissistic wish and expectation to be created in anyone’s image? Wouldn’t this make normal separation and individuation more difficult, the psychiatrist wondered?

Indeed, the psychological challenges and problems for Adam and Eve emerge quickly in the Garden of Eden. The psychiatrist observing this scenario wondered about offering a walk, as Freud did about a century ago with Mahler, to discuss the temptation and symbolic meaning of the Serpent and the Tree of Knowledge. But the psychiatrist wondered if this was an impossible paradox to resolve. Without knowledge, how does one understand the risks of obtaining knowledge?

So Eve goes ahead, and she and Adam are banished from the Garden in shame. If our psychiatrist could have met them in this wider world, perhaps they could have processed their shame and the current status of their relationship before they had children. Instead, the result is 2 sons, Cain and Abel, who portray the first sibling conflict and competition, so severe that Cain murders Abel.

After this tragedy, history seems to progress adversely until Noah. Noah is said to be the best of his time. In the Ark that he builds, his family, animals, and himself survive drastic environmental and climate changes. If a psychiatrist were also on the Ark, there would have been ample time to discuss how Noah felt about the responsibility of saving the world, and how he might prepare himself for a different future. As it turns out, he becomes drunk afterward. Noah might have needed detox and Alcoholic Anonymous; his family might have sought support from Al-Anon. However, just like the lives of so many modern day celebrities, their lives and the story goes on without completing treatment.

The next major figure is Abraham. No one claims to know, not even himself, why he is chosen to start a new religion. Later on in his life, sibling rivalry emerges again, but now between stepbrothers. After Abraham has his son Ishmael by the handmaiden, Hagar, Abraham and his wife Sarah have their own son, Isaac. Can’t you just predict the need for some challenging family therapy? Instead, Sarah, with the apparent approval and support of God, orders Ishmael to be banished. Abraham acquiesces, and God, to seemingly even things out a bit, says that Ishmael will start his own Kingdom, which many have taken to become the Arab people.

Abraham is later asked to sacrifice Isaac. Any psychiatrist might say that at times of exasperation, a parent might think of sacrificing their child. But this time it includes the actual preparation, without the apparent knowledge, of Sarah. Isaac is spared at the last minute, but to a psychiatrist, it might seem that he suffered PTSD. Sarah may have died soon afterward from the shock of grief.

Without treatment, as family problems are wont to do, the sibling conflicts continue in Isaac’s sons, Esau and Jacob, and then again in Jacob’s sons. Esau also goes off in exile, perhaps to start what will become the Roman people.

This story should be enough to call forth a psychiatrist, shouldn’t it? Finally, do we see the prototype of God’s psychiatrist in Jacob’s son, Joseph? Though Jacob’s favoritism, culminating in his giving Joseph the coat of many colors, seems to produce excessive narcissism, Joseph overcomes the trauma of being sold by his brothers and given jail time in Egypt, to use his prophetic interpretation of dreams. He attributes this skill to God, succeeding beyond anyone’s wildest dreams in a new culture, in which he prepares successfully for climate change, forgives his brothers, and is united with his father. After this family forgiveness, the cycle is broken and there is just “normal” sibling rivalry depicted in the Old Testament.

With the psychological path cleared in one way, but challenging in another, Moses arrives. A psychiatrist in the court might wonder if his stuttering was a consequence of an unusual child rearing, both in the Egyptian court, where he is adopted, and with the surreptitious involvement of his own family. Maybe he was dealing with buried anger, too. Moses, despite being so humble, has several outbursts of anger, which cost his entry into the Promised Land. Would anger management and/or a prn calming medication have helped him? If he were calmer, perhaps he would have recommended group psychotherapy for those disgruntled among his people, and maybe then sought psychoanalysis for himself. Following the death of Moses, the Old Testament ends.

Chapter 2. Psychiatry in the Common Era


Let’s go on to the Rabbis who replaced Jewish priests in the diaspora outside of Israel after the beginning of the Common Era. They seemed to grasp some therapeutic principles that would help sustain the Jewish people and keep them together over the next 2 millennia, despite pogroms, exiles, and most recently, the Holocaust. They came to interpret the Old Testament in different ways and on many levels, including the Talmud, Midrash, Kabalah, weekly Torah study around the world, and pastoral counseling. In the early Middle Ages, one particular Rabbi—Maimonides—who was a general physician and philosopher all in one, conveyed basic concepts of mental well-being, supportive psychotherapy, and even the basis of our most popular and evidence-based therapy, cognitive-behavioral psychotherapy.1

Nevertheless, there was still no formal field of psychiatry, that is, until a Jewish physician emerged about a century ago to complement the work of Kraepelin. Sigmund Freud, after a childhood as an honor student in Jewish religious schools, went on to take the new field of psychiatry to a different level with his psychoanalytic theories.

Like Joseph, Freud arrived at his conclusions after analyzing his own dreams. The difference is that Freud analyzed the conflictual issues in his dreams, and Joseph analyzed their prophetic meanings. In the ensuing therapeutic process, different levels of interpretation paralleled the Rabbis’ interpretation of the teachings in the Torah.

Was Freud God’s psychiatrist at long last? Not likely. Actually, Freud’s views may reflect why a psychiatrist was not around from the beginning of humanity in Biblical times. Freud, though publicly valuing his Jewish cultural background and involved with B’nai B’rith meetings in Vienna, was famous (or infamous) for claiming that religion was an illusion, an opium for the masses, and that belief in God was a matter of the transference of feelings toward one’s parents.

Freud also seems to underestimate anti-Semitism, which labeled psychoanalysis as that “Jewish science,” only leaving his home at the last minute when his daughter’s life was threatened. Since Jewish theology values action over thoughts and beliefs, Freud’s actions—to find new ways to heal people—couldn’t be more Jewish. What did it mean, then, that Freud died on Yom Kippur, the Day of Atonement, in 1939? And if he was thinking of his death in the physician-assisted morphine mental state, did he reassess his feelings about God?

What about that other famous psychiatrist from Vienna, who studied some with Freud? That was Viktor Frankl. In one of life’s ironies, he lived for a time in close proximity to Hitler. What if he, or another psychiatrist, had at one point been able to treat Hitler during his troubled childhood? As it turned out, however, Dr Frankl2 was about to go to America, only to have an existential crisis:

Should I foster my brainchild, logotherapy . . . or should I concentrate on my duties as a real child of my parents and stay by them?2

He returned home to find the letters of the Ten Commandments stating to honor thy father and mother. He let his Visa lapse. Sent not long after to Auschwitz, he became a sort of concentration camp psychiatrist, struggling to give meaning to the struggle to survive. That meaning was to see his wife again and to lecture about the psychological lessens learned. Only the latter came to pass. After the war, he resettled in Vienna and remarried a Christian woman. He soon published the perennial best seller, Man’s Search for Meaning, and established Logotherapy, a “therapy of meaning.”

Although I was trained in Freudian psychotherapy in the early 1970s, by the end of my clinical career, I came to follow the path of Freud to Frankl by focusing on the meaning of life for the decreasing amount of time I had with each patient.3

Did Dr Frankl end up believing in a God? He never would say.

In our time, it seems that the number of psychiatrists who believe in a God are increasing, parallel with the decreasing influence of Freud’s ideas. Jewish psychiatrists, although still prominent in the newer areas of group psychotherapy, cognitive therapy, understanding brainwashing, and even Freud’s predicted psychopharmacology, are nevertheless decreasing in their relative numbers.

Perhaps the notable example of a Jewish psychiatrist who clearly and overtly believes in God is Dr Abraham Joshua Twerski, who is also a Rabbi and scion of a Hasidic dynasty, and specializes in substance abuse. For a comparable Christian psychiatrist, we can cite the late Dr E. Mansell Pattison, who was also a minister.

Chapter 3. The Moral of the Story

What, then, is the moral of this tale, as Hannah, my grandchild of 2 Rabbis, would ask? Just in time, a valued teacher and colleague asked, “Isn’t God a Psychiatrist”? If God is a psychiatrist and we psychiatrists were also created in God’s image, and if we psychiatrists have come currently to view religion and psychiatry as more overlapping than conflictual, then together we can work to help and maybe even improve human nature. Amen.

References1. Pies RW. The Judaic Foundations of Cognitive-Behavioral Therapy. Bloomington, Ind; iUniverse; 2010.
2. Scully M. Viktor Frankl at Ninety: An Interview. First Things. April 1995. http://www.firstthings.com/article/2008/08/004-viktor-frankl-at-ninety-an-interview-18. Accessed April 1, 2013.
3. Moffic HS. The meaning of life in a 15-minute med check. Psychiatr Times. May 19, 2011. http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1864201. Accessed April 1, 2013.

- See more at: http://www.psychiatrictimes.com/god’s-psychiatrist-april-fool’s-tale-3-chapters/page/0/2#sthash.cfTiiQbN.dpuf

- See more at: http://www.psychiatrictimes.com/bipolar-disorder/god’s-psychiatrist-april-fool’s-tale-3-chapters#sthash.1Ku3jKyS.dpuf

Incorporating Health Information Technology Resources in Psychiatric Practice

on Wednesday, 16 January 2013. Posted in General

Computers in the Consulting Room

Incorporating Health Information Technology Resources in Psychiatric Practice

This was a fascinating article from the Psychiatric Times Vol. 29 No. 12. I was most interested in page 2 of the article that covered: "communication with patients" as that is the foundation of bStable. Page 3 covered "the impact of HIT on the patient experience, and especially on the relationship between doctor and patient, is an emerging area of interest in informatics research and a compelling issue for clinical study". Anyone reading this post have any thoughts or experience with HIT in the consulting room with patients or your therapist or clinician?

Iron Man 3: Reconciling Psychiatry’s Warring Camps

on Sunday, 28 July 2013.

Tony Stark could really use bStable to figure out what's going on in his head...

Iron Man 3: Reconciling Psychiatry’s Warring Camps
 

[Spoiler alert: You might choose to wait to watch the movie—or read this article. —Eds.]

In Iron Man 3, former arms manufacturer Tony Stark is a superhero who aspires to facilitate world peace. In the process, he wages a one-person war against villains who aim to overthrow the powers that be and attain world dominion. Given his mighty missions, who would expect Tony Stark (the Iron Man) to propose peace between warring schools of psychiatry and to attempt to reconcile the armies of the mind with the armies of the brain?

No one, probably—and that’s what makes this twist in Iron Man 3 so intriguing. Tony Stark embarks on a psycho-philosophical quest when he asks if he defines Iron Man, because he manufactures Iron Man’s suit, or if his personal identity is subsumed by this intense public persona. Jungians, Eriksonians, Kohutians—and others—will delight in this dilemma.

Admittedly, Iron Man 3 has a much more involved, action-oriented plot. The psychiatry subtext is just that: a subtext. Still, this subtext speaks directly to neuropsychiatrists, psychopharmacologists, psychotherapists, just plain psychiatrists—or whatever they call themselves. The epilogue that begins after the film ends fleshes out this footnote.

Neuropsychiatry figures prominently in this 2013 riff on the Marvel Comics 1963 character—but so do aerospace engineering and international politics. The MacGuffin of the movie is a substance known as “Extremis.” Extremis enters the CNS via a virus and binds with the brain, promoting DNA changes that send electronic and neurochemical signals to weaponize the body, impart superhuman strength, and make machines move by mind-power alone.

Iron Man 3 does not dwell on Extremis, but comic book fans will recall the original story line in which Extremis facilitates direct brain-based connections with inanimate armor.1 That process allows Tony Stark to become one with his armor. He can now accomplish humanly impossible feats. In other words, Tony becomes Iron Man, both in body and in mind. Hence, his existential identity question emerges.

Unlike some superheroes, Tony Stark is a mere mortal, even though he is a genius inventor and industrialist. He battled the bottle and was a philanderer, but he abandoned his wanton ways to become a philanthropist who devotes his vast fortune to saving the world, even (or especially) if it means putting his own life in peril. Iron Man’s red armor recollects the red cape of the Man of Steel, for both Iron Man and Superman fly through the air. However, Superman’s powers are inherent, while Iron Man’s abilities depend on man-made machinery.

Appropriately and convincingly, Stark is played by actor Robert Downey Jr, whose own struggles with substance abuse were well publicized. Downey’s back-story enhances the casting choice, as does his ability to combine tongue-in-cheek comedy with action-adventure swagger.2

Like Batman, Iron Man fetishizes gadgets. Both possess vast wealth. Unlike Batman, Iron Man designs and builds his own contraptions without relying on his butler. Stark understands neurotransmitters enough to explain how Extremis operates. His conversation sounds fanciful, except for the fact that strikingly similar engineering feats are already in the works.

Minds can communicate with machines in real life, and not just in reel life. For instance, recent news reports revealed that electrode-laden caps allow wearers to communicate with a plane via the mind alone.3 The cap-wearer makes the plane change course when he or she concentrates on making a fist with one hand or the other. The Defense Advanced Research Projects Agency has been experimenting with such technologies for years. Private industry will soon bring related bioengineering feats to commercial markets. Such One Step Beyond–style “mind-control” was previously the province of parapsychology, but no more.

Still, the Iron Man 3 story itself remains science fiction. In Iron Man 3, Extremis has supercharged an army of invaders. World powers and underground conspirators are in hot pursuit of this mysterious substance that can potentiate their evil goals. They are ready to battle Iron Man and anyone else who tries to obstruct their plans to overtake humanity. A once-suicidal scientist, an easily swayed botanist, and a drug-addicted actor figure into the fast-paced plot.

After the movie ends, and after Tony Stark has disarmed his enemies and rescued his love object, spectators are in for another surprise: an epilogue involving Tony Stark and Dr Bruce Banner. The epilogue screens after the last credits roll, when the film is officially over.

In this scene, Tony sits on a sofa, wearing his “civvies,” his armor out of sight. Tony recounts his triumphs and travails. Superhero fans know Dr Banner (Mark Ruffalo) as the physicist who turns into The Hulk whenever his anger is aroused. He becomes big, green, and amygdala-driven. Superficially, this scene looks like a teaser for the forthcoming Marvel film, Avengers 2, which features both Iron Man and The Hulk. However, psychiatrists who listen with their third ear hear tacit messages embedded in the dialogue, replete with reflections about rifts in mental health care.

Tony talks to Dr Banner “. . .and thank you, by the way, for listening. There’s something about getting it off my chest and putting it out there in the atmosphere, instead of holding this in. I mean, this is what gets people sick. . . . Wow, I had no idea you’re such a good listener. . . to be able to share all my intimate thoughts, my experiences with someone . . . it just cuts the weight of it in half. . . and the fact that you’re able to help me process . . . you heard me?”

At that moment, the camera shifts to Dr Banner, who sits in a chair behind the couch. How curious! A film that revolves around neuropsychiatry, DNA alterations, neurotransmitters, and bioengineering comes around full circle to highlight the importance of talking, processing, communicating, and sharing.

Tony Stark never implies that talking it out would have changed anything—or that he wanted to change anything. (Thank goodness, for that would deprive both him and his audience of both past and future action-adventures!)

Yet he endorses the value of making meaning out of life experiences, including save-the-world kind of experiences. He affirms his belief that psychotherapy can contribute to this philosophical pursuit. Unfortunately, he has chosen someone who is “not that kind of doctor.” It’s not just that Dr Banner is a physicist, and a hard scientist, but Dr Banner tells Tony that he does not have the “temper . . . or temperament” to do that kind of doctoring: Dr Banner turns into The Hulk when his emotions are aroused—not a good trait for a therapist.

DISCLOSURES

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City. She is the author of Superheroes and Superegos: Analyzing the Minds Behind the Masks (Santa Barbara, CA: Praeger/ABC-CLIO; 2010) and several other books, for which she receives royalties.

REFERENCES

1. Ellis W, Granov A. Iron Man Extremis Director’s Cut. New York: Marvel Comics; 2010.

2. Packer S. Superheroes and Superegos: Analyzing the Minds Behind the Masks. Santa Barbara, CA: Praeger/ABC-CLIO; 2010.

3. Kingson JA. An old Torah, older sunken boats and a seriously old primate. New York Times. June 10, 2013. http://www.nytimes.com/2013/06/11/science/old-sunken-boats-an-older-torah-and-a-seriously-old-primate.html?_r=0. Accessed July 12, 2013.

- See more at: http://www.psychiatrictimes.com/neuropsychiatry/iron-man-iii-reconciling-psychiatrys-warring-camps?GUID=027D74F9-294C-4019-B4F6-6C862BE2E981&rememberme=1&ts=27072013#sthash.LMZFrt8J.dpuf

Lithium, Lithium, Lithium, Lithium, Lithium, Lithium

on Saturday, 26 January 2013. Posted in General

Uh, Let's Stop and Think First People

Lithium, Lithium, Lithium, Lithium, Lithium, Lithium

I presented bStable as part of a session on computerized life management systems for the management of bipolar depression at the International Review of Bipolar Disorders May 8th, 2009 in Lisbon, Portugal with Dr. Andreas Erfurth, from the Department of General Medical Psychiatry, University of Vienna. 

At the conference I was AMAZED at how many researchers were totally fixated on lithium research! All I heard was them chirping like birds: "lithium, lithium, lithium, lithium, lithium". Then: "gold standard, gold standard, gold standard, gold standard".

Wow. I've talked with A LOT of people with bipolar disorder and FEW TO NONE are on Lithium. It can make:

your hands shake uncontrollably, make you very thirsty, want to pee a lot, diarrhea, throw up, pack on the pounds, mess with your memory, impair your concentration, make you drowsy, make your muscles feel weak, HAIR LOSS, make you look like a teenager with ACNE and FAT due to decreased thyroid function.

Sound fun?

The researchers should read this article:

http://www.sciencedaily.com/releases/2012/09/120921092502.htm

and stop the knee-jerk reaction "oh, you have bipolar disorder, let me put you on lithium" and start to THINK first and realize every patient is different. Thoughts??

Mood & Food

on Monday, 27 May 2013.

We've heard it before. More evidence...

Mood & Food

It’s time to send your patients to the “Farm-acy,” Drew Ramsey, MD, told attendees at the American Psychiatric Association Annual Meeting. Ramsey, assistant clinical professor of Psychiatry at Columbia University College of Physicians & Surgeons, was one of several speakers at the standing room only workshop “Prescription Brain Food: From Bench to Table.”

The brain, Ramsey explained, needs to be nourished; he noted it consumes about 420 calories a day. To function properly, the brain requires omega-3 fatty acids, folate, fiber, choline, iron, zinc, and vitamins B12, D, and E among other nutrients. So can a patient’s diet affect their mood and mental (in addition to physical) well-being?

Yes, Ramsey answered, pointing to some interesting studies exploring diet, nutrition, and mood disorders. In one study, researchers followed 10,094 initially healthy participants for a median of 4.4 years.1 To better understand the association between diet and mood, participants were assigned a Mediterranean dietary pattern score, which positively weighted the consumption of vegetables, fruit and nuts, cereal, legumes and fish.  A monounsaturated- to saturated-fatty-acids ratio and moderate alcohol(Drug information on alcohol) consumption also had a positive influence on the score. On the other hand, consumption of meat, meat products, and whole-fat dairy were negatively weighted. The researchers found an inverse relationship between adherence to the Mediterranean diet and risk for depression, suggesting this diet has a protective role against the development of mood disorders.

Similarly, Ramsey told attendees about a study comparing a diet high “whole” foods (eg, high in vegetables, fruits and fish) with a diet high processed foods.2 Tasnime N. Akbaraly, PhD, and colleagues found that those who most closely followed the whole foods diet had lower odds of depression as measured by the Center for Epidemiologic Studies – Depression scale (odds ratio = 0.74) while those who had ate diets high in processed foods had increased odds of developing depression (OR = 1.58). This could have great clinical implications, Ramsey explained, since patients with psychiatric disorders often don’t eat properly.

The diet-mood link seems to be evident across the lifecycle, he added. Ramsey sharedfindings from a study of 7,114 adolescents aged 10-14 years.3 Participants completed dietary questionnaires, which were then used to determine healthy and unhealthy diet quality scores. The Short Mood and Feelings Questionnaire was used to measure depression. Once again, this study found an inverse relationship between good, healthy eating and the development of depression. Indeed, adolescents with higher unhealthy diet scores had a 79% increased risk of depression, Ramsey noted.

With increasing data supporting good nutrition for improved mood, Ramsey said all clinicians should take the time to chat with their patients about their diet, nutrition, and making good choices. “It is a low-cost, risk free intervention that will help your patients,” he said.

He advised clinicians to routinely discuss diet and nutrition with patients during visits, inquiring about what they eat and creating an open dialogue. He counsels his patients as appropriate to try to include healthier choices, like beans to increase folate intake. Mushrooms add lycopenes to the diet, he added. He reminds patients to consume fatty fish, and reminds them that there are options beside salmon. He suggests that his patients swap berries for other sugar-filled desserts and to favor grass-fed beef when consuming meat.

At the very least, patients will be eating healthier. But Ramsey believes these steps and patients’ visits to the “Farm-acy” will help them to build a better brain.

National Alliance on Mental Illness (NAMI) - North Carolina 2013 Crisis Intervention Team Conference

on Sunday, 24 February 2013.

McGraw Systems Proud To Support This Important Event

National Alliance on Mental Illness (NAMI) - North Carolina 2013 Crisis Intervention Team Conference

The Crisis Intervention Team (CIT) is a partnership formed to divert individuals living with mental illness from arrest through the creation of more effective interactions among law enforcement, providers, individuals with mental illness and their families.

The 2013 North Carolina Statewide CIT Conference provided opportunities for collaboration that moved us toward our common goals of safety, understanding and services to those with mental illness in crisis. The Keynote Speaker was Justice Evelyn Lundberg Stratton, co-founder and former co-chair of the Judges' Leadership Initiative, a professional association that supports cooperative mental health programs in the criminal justice system. Justice Stratton shared her vision that the courts, in partnership with the mental health system, can affect positive change in the lives of many defendants whose mental illness has led to criminal activity.

The Lunch Keynote was presented by Antonio Lambert, who provided an honest account of an individual living with a mental illness and how his struggles with the law ultimately led to his own recovery.

National speakers Clarke and Tracy Paris provided a 2-part workshop that helped police officers, police employees, and first responders deal with the struggles associated with police work, Cumulative Stress, and Post Traumatic Stress Disorder (PTSD). 

Neanderthal Psychologists & Therapists

on Saturday, 26 January 2013. Posted in General

Get a Computer or Die!

So this article from Psychiatric Times:

http://www.psychiatrictimes.com/display/article/10168/2118508

got me very upset. It is from Dr. Geller who is a Professor of Psychiatry at the University of Massachusetts Medical School and Facility Medical Director, Worcester Recovery Center and Hospital in Worcester, Mass. 

He obviously is in the Stone Ages!! Wake up dude! Basically to summarize the article... he thinks if you put a computer in a therapist's office, everyone in the world will have a patient's mental health records. What??? Comments??? 

Omega-3 Supplements

on Friday, 25 January 2013. Posted in General

bStable + Psychotropics, Exercise, Meditation and Eating Well + Fish Oil?

Omega-3 Supplements

Many bStable customers are either newly diagnosed, trying to stay "stable" or are having major problems with their psychotropic medication regimen and want to reset and establish a baseline to measure their progress towards wellness. Most of those who I talk with going through those various stages trying to regain and keep control of their life are experimenting with fish oil.

Lots of the bStable customers I have spoken with that have raved about using omega 3 fatty acid supplements have taken: Omax3, Nordic Naturals and OmegaVia.

 

A debate that is ongoing is do they help with mood disorders (seems they do) and if so, are the higher end brands worth the extra cost and if so, which ones are best. Thoughts? 

Overdiagnosis: Examine the Assumptions, Anticipate New Bipolar Criteria

on Saturday, 20 April 2013. Posted in General

Bipolar Disorder

Overdiagnosis: Examine the Assumptions, Anticipate New Bipolar Criteria
By James Phelps, MD | March 13, 2013
 
Dr Phelps is Director of the Mood Disorders Program at Samaritan Mental Health in Corvallis, Ore. His Web site gathers no information on visitors and produces no income for him or others. He is the author of Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder (New York: McGraw-Hill; 2006), from which he receives royalties. He stopped taking honoraria from pharmaceutical companies in 2008.
 
Overdiagnosis of bipolar disorder is an increasing concern, particularly since the widely cited study by Zimmerman and colleagues.1 Findings from that study indicate that there is a problem with overdiagnosis (positive predictive value of only 43%) as well as with the much less publicized parallel finding of 30% underdiagnosis (sensitivity of 70%).

A recent review noted a much lower underdiagnosis rate of 4.8%, which is an inaccurate interpretation of the original data.Zimmerman and colleagues themselves allude to the higher figure.3

Will the new criteria in DSM-5 address these varying claims of overdiagnosis and underdiagnosis? After all, concern about overdiagnosis is one of the driving forces behind these debated changes.4 I’ll take up that question in the next essay in this series, suggesting that the new criteria will not significantly improve positive predictive value—the most debated aspect of diagnostic accuracy. But an important step should precede that review of predictive value and specificity, namely, a careful examination of the very concept of overdiagnosis.

Consider the implicit assumptions.

Bipolar disorder is like bacterial sepsis or mononucleosis: a patient either has it or he does not. One of the origins of dichotomous diagnosis in psychiatry is bacterial. The discovery that many debilitating illnesses were caused by invasive bacteria was a tremendous medical advance. An illness was present if the offending agent was present and absent if it was not—the first of Koch’s 4 postulates. But this perspective has been carried forward into the realm of mental health, where emerging understanding of phenomenology is not consistent with this black-and-white, yes or no way of thinking.5,6

The DSM’s dichotomous system—mental illnesses are either present or absent—is an accurate model for bipolar disorders. Consider the sheer number of genes and consider the role of environmental variation in modifying gene impact, as seen in the short/long variation of the serotonin transporter gene and depression vulnerability, where an otherwise substantial gene effect is completely overridden by benign up-bringing.7Imagine the number of combinations of genes and environments possible and imagine the array of phenotypes that would emerge from them?

A DSM-5 committee considered all of these factors in their 2006 discussion of whether to introduce a spectrum approach to diagnosis in the upcoming edition. Virtually everyone involved was in favor of incorporating a “dimensional” approach (as opposed to the current “categorical” approach). Michael First8 wrote a masterful summary of those proceedings. Ironically, at this meeting, the mood disorders subgroup chose to work on the spectrum of depression severity, not the unipolar-bipolar spectrum. That side step leaves the entire “overdiagnosis” debate open, in spite of a new DSM.

The Structured Clinical interview for Diagnosis (SCID) is a valid gold standard. Even if one presumes that bipolar disorder can be regarded as present or absent and that a diagnostic system should operate accordingly, another major assumption remains: the SCID is a realistic gold standard against which to judge clinicians’ diagnoses. Obviously, the only way to judge diagnostic accuracy is to have some means of recognizing whether the illness is truly present. The SCID is accepted in this role, because psychiatry lamentably has little else to replace it. Is it adequate?

Administering the SCID consists of asking questions in a semi-structured fashion. All the SCID does is ensure that all relevant diagnostic questions are asked in a systematic fashion. The trick in using it is to keep the instrument from interfering too much with the patient’s account of his symptoms. At best, interference can be kept to a minimum.

So, why would we uncritically accept the idea that an SCID user who does not know the patient and whose relationship with the patient can only be hampered, not enhanced, by the instrument he is using, generates a more definitive diagnostic impression than a clinician who actually knows the patient? The advantage of the SCID is in its completeness. It does not otherwise enhance the accuracy of data. Those who accept that the study by Zimmerman and colleagues1 demonstrates overdiagnosis are tacitly accepting that a clinician who does not know the patient, wielding an instrument that does not enhance the clinical relationship, is the authority. If the SCID says bipolar disorder is absent while the clinician says it is present, the clinician is wrong.

While I deeply respect the importance of this kind of research, the underlying logic is necessarily simplistic. Therefore, any conclusion of overdiagnosis based on this study is likewise an oversimplification.

Consider a recent study of bipolar screening tests in which the gold standard was instead a 1-year confirmation of the initial diagnosis.9 While not ideal (eg, clinicians were not blind to their initial diagnosis), it has longitudinal validity regarding what the patient “truly has.” Or, consider a study of pediatric mood and attention-deficit diagnoses by Chilakamarri and colleagues10 in which underdiagnosis of bipolar disorder was a far greater problem than overdiagnosis, but which is cited far less frequently than the Zimmerman study.1 Perhaps because there was no SCID for the gold standard—only experienced clinicians?

Risks of overdiagnosis

None of the above considerations diminish the negative impact of an inappropriate diagnosis.8 The effect of potential “grief for the lost healthy self,” akin to the impact of a diagnosis of diabetes, should give pause. Stigma risks are broad, from the impact on the patient’s sense of self, to friendships and intimate relationships, to serious unintended consequences in divorce proceedings or employment. Treatment risks are also broad—certainly beyond those of serotonin reuptake inhibitors. The risk of diluting true bipolar disorders with a fundamentally different disorder is likewise significant, as is the impact through this dilution on our ability to identify appropriate treatments when psychiatry has more targeted options in the future.

In the next essay in this series, I will examine whether the new DSM criteria will significantly address this diagnostic dilemma: can they improve accuracy? That essay will focus on specificity. Can tightening DSM criteria (as DSM-5 attempts to do in 2 important ways) improve on specificity? How much of an improvement in positive predictive value can thus be produced? Will it raise the value of a bipolar diagnosis beyond a coin toss?

Overmedicating Patients

on Tuesday, 22 January 2013. Posted in General

Clinicians are sometimes flying blind

Overmedicating Patients

I once met a girl diagnosed with Bipolar Disorder I at an Annual DBSA event who was on 21 different medications! Yes, 21 medications! Obviously, the patient had multiple comorbid conditions and a lot of the patients I run into have several medications in their constantly changing "psychotropic cocktail". But 21?? I've seen psychiatrists fall into a deadly trap of chasing symptoms with psychotropics. Have you? Without constant and transparent visibility into how the patient is doing with a particular regimen, this trap is very easy to fall into. Thoughts?

Panic Disorder

on Saturday, 14 December 2013. Posted in General

Part 1 of this 2-part podcast series, Stephen V. Sobel, MD, sheds some light on the pathogenesis.

Panic Disorder

Panic disorder is a tremendously vexing challenge: keys to its management include appropriate use of psychotropic medication and psychotherapy predicated on an understanding of the biopsychosocial underpinnings. In part 1 of this 2-part podcast series, Stephen V. Sobel, MD, sheds some light on the pathogenesis. (For Part 2, please click here).

See more at:

http://www.psychiatrictimes.com/panic-disorder/panic-disorder-keys-management?GUID=027D74F9-294C-4019-B4F6-6C862BE2E981&rememberme=1&ts=31102013#sthash.l1FBhlrv.dpuf

Parents With Bipolar Disorder - WAKE UP!

on Saturday, 27 April 2013. Posted in General

IF THERE IS ONE TOPIC AROUND BIPOLAR DISORDER THAT PISSES ME OFF MORE THAN ANYTHING, IT IS THIS!

Parents With Bipolar Disorder - WAKE UP!

PARENTS WHO SHOVE THEIR HEAD IN THE SAND AND NEVER ADMIT THEY ARE SICK AND SPEND THEIR LIFE TALKING ABOUT HOW THEIR CHILD IS SICK INSTEAD OF TAKING RESPONSIBILITY FOR THEIR OWN ILLNESS NEED TO BE PUT AWAY.

LOOK AT THE FACTS IN THIS ARTICLE. BIPOLAR DISORDER HAS A STRONG GENETIC FACTOR. ADD ABUSE ONTOP OF THAT FROM A PARENT THAT WON'T ADMIT THEY HAVE BIPOLAR DISORDER AND PHYSICALLY AND EMOTIONALLY ABUSES A CHILD ON A DAILY BASIS - THAT IS SICK.

 

Psychiatric Times. CHILD AND ADOLESCENT PSYCHIATRY

Offspring of Parents With Bipolar Disorder

By Karen Dineen Wagner, MD, PhD | February 8, 2010

Dr Wagner is the Marie B. Gale Centennial Professor and vice chair of the department of psychiatry and behavioral sciences and director of child and adolescent psychiatry at the University of Texas Medical Branch at Galveston.

It is generally held that the offspring of parents with bipolar disorder (BD) are at risk for BD. The degree of risk is an important question for both clinicians and parents. A

recent study of bipolar offspring by Birmaher and colleagues1 sheds light on this issue.

These authors compared the lifetime prevalence of bipolar and other psychiatric disorders in children whose parents had–or did not have–BD. The study involved 233 parents with BD and their 388 offspring and a control group of 143 parents without BD and their 251 offspring.

Parents with BD were recruited from outpatient clinics and advertisements for participation in the study. On the basis of diagnostic interviews, 158 parents had bipolar I disorder and 75 had bipolar II disorder. The majority (80%) of the parents interviewed were female. The mean age of parents with BD was 40 years. Sixty-four percent of parents reported that the onset of their mood disorder occurred before they

were 20 years old. Parents with BD were less likely to be married at the time of intake and had a slightly lower socioeconomic status than parents without BD.

The offspring of parents with BD did not have to be symptomatic to participate in the study. The mean age of these children was 12 years; 49% were female; and 88% were white. Fewer than half (42%) were living with both biological parents.

The rate of bipolar spectrum disorder in the offspring of parents with BD was 10.6% versus 0.8% in the offspring of control parents. The rate of bipolar I disorder was 2.1%; bipolar II disorder, 1.3%; and bipolar not otherwise specified (NOS), 7.2%. The rate of BD increased substantially–to 29%–when both parents had BD.

Overall, the offspring of parents with BD were at significantly greater risk (52%) for any Axis I disorder than those in the control group (29%).

The majority (76%) of these offspring experienced childhood-onset bipolar disorder before age 12 years. Bipolar NOS was the most common first episode of illness. Rates of comorbidity in these youths were high: 51% had anxiety disorder, 53% had disruptive behavior disorder, and 39% had attention-deficit/hyperactivity disorder (ADHD).

http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1490412

1

Psychiatric Times. Vol. No. February 8, 2010Psychiatric Times. Vol. No. February 8, 2010

The authors concluded that there is a 14-fold increase in the rate of bipolar spectrum disorder in youths who have a biological parent with BD. If both parents have BD, then the offspring are 3 times more likely to have BD.

The mean age of youths in this study was 12 years. Prevalence rates may therefore be an underestimate because some children with depression may become bipolar in adolescence. It is recommended that clinicians who treat adults with BD inquire about the functioning of their children to provide appropriate early intervention.

Posttraumatic stress disorder and substance abuse

In a family study of BD in youths, Steinbuchel and colleagues2 investigated the relationships among adolescent BD, posttraumatic stress disorder (PTSD), and substance use disorder (SUD). Because adults with BD who were severely abused as children are at high risk for SUD, these investigators sought to determine whether there is a similar association in adolescents.

A total of 105 adolescent offspring of parents with BD and a control group of 98 youths without mood disorders participated in this study. The diagnosis of BD was based on structured psychiatric interviews. SUDs included any alcohol(Drug information on alcohol) or drug abuse or dependence.

Rates of PTSD were significantly higher in adolescents with BD than in the control group. Sixteen percent of youths with BD had full or subthreshold PTSD compared with 3% in the control group. These youths had experienced trauma in the form of physical abuse, sexual abuse, witnessing of death, or family violence. Rates of SUDs were higher among youths with BD than in those in the control group (32% vs 4%, respectively). Alcohol was the most frequently used substance (86%) followed by marijuana (71%) and tobacco (29%).

What was the temporal order of these disorders? In half of the cases, BD preceded PTSD. In the other half of cases, PTSD was diagnosed before BD. For those youths in whom SUD developed, the majority had BD followed by PTSD and then SUD.

This study confirms an association between PTSD in adolescents with BD and subsequent development of SUD. Rates of SUD were higher in those youths who met full criteria for PTSD than for those with subthreshold symptoms. The findings reveal that BD increases the risk for PTSD, which in turn increases the risk for SUDs. The investigators suggest that treatment of adolescents with BD may prevent trauma related to the development of PTSD and subsequent SUD. It is recommended that clinicians who treat adolescents with BD evaluate for the presence of PTSD and SUD.

References

1. Birmaher B, Axelson D, Monk K, et al. Lifetime psychiatric disorders in school-aged offspring of parents with bipolar disorder: the Pittsburgh Bipolar Offspring study. Arch Gen Psychiatry. 2009;66:287-296.

2. Steinbuchel PH, Wilens TE, Adamson JJ, Sgambati S. Posttraumatic stress disorder and substance use disorder in adolescent bipolar disorder. Bipolar Disord. 2009;11:198-204.

 

 

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