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 eight 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 policymakers 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.
References:
[1] 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." The British Journal of Psychiatry 2012, 200:97-106.
Originally Published by Huffington Post on March 28, 2012.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
"Any sufficiently advanced technology is indistinguishable from magic." --Arthur C. Clarke
In fact, advances in neurotechnology are capitalizing on the brain's remarkable sleight of hand.
Neurotechnology refers to the applied science of understanding the brain, consciousness, thought, and higher-order activities of the mind. Neurotech's brainchildren are today's mental magic. Such fantastical items include electrode-laden "thinking caps" or Transcranial Direct Current Stimulation (TDCS) to enhance human concentration; neuroimages of our dream lives, and perhaps even our waking thoughts; remote artillery weapons that soldiers can fire at a combatant by mind control; and video games operated by the player's thoughts. These aren't a sci-fi creation; now they're real.
Advancing from science fiction to applied science is a fast-growing, $8-billion business, with investments from commercial, military, and academic interests. This might seem to be good news for countless sufferers from neurological (e.g., Alzheimer's and other dementias, Parkinson's disease, Multiple Sclerosis, stroke, etc.) and mental disorders (e.g., depression, PTSD, OCD, mania, etc.). But for every scientific step forward, there is the chill of possible diabolical applications -- where there's neural firing, there's apt to be the smoke (and mirrors?) of self-serving and questionable ethics.
This is the first of a two-part series examining emerging neurotechnologies and their potential value. In the second post to follow, we will consider their ethical and practical conundrums.
The diagnosis and treatment of behavioral health conditions has yet to fulfill the promises of the 1990s, the so-called "Decade of the Brain." Since then, technological wizardry has transformed our markets, if not our lives. The next iProduct comes with lines of consumers snaking around the block. But for the people who just want to feel well, diagnostic and treatment advances in psychiatry and neurology still lack a magic bullet.
Here's the good news: With neuroimaging advances, the brain is a veritable neural Google Map. Functional MRI (fMRI) neuroimaging, as well as PET and CT scans, now allow medical scientists to observe a highly detailed landscape of the brain that reveals locations where mental diseases emerge, where behavioral therapies might do their job, and how a drug can find entry into the brain. It can even pinpoint the brain's "funny bone" -- or which neurons light up when we laugh at a joke.
An fMRI scan uses an electromagnetic field to navigate the brain, much in the same way a compass has guided travelers for millennia. One notable neuroimaging explorer is Dr. Helen Mayberg, a neurologist who identified a tract of brain tissue deep within the frontal cortex known as "Area 25," a region that is likely a "nerve center" for depression. When a depressed person responds to treatment with antidepressants and cognitive behavioral therapy (CBT), neuroimaging reflects a corresponding response in Area 25.
Beyond imaging to pinpoint neural landmarks and monitor responses to therapeutics is repetitive Transcranial Magnetic Stimulation (rTMS), an example of using applied science to treat depressed (and anxious) people. Resembling a large wand, rTMS is an FDA-approved treatment for depression in which a low-frequency electromagnetic pulse is applied to specific areas of the brain through the scalp, never directly touching the brain; it is performed safely in your doctor's outpatient office. Research demonstrates that rTMS improves mood -- and without the side effects of medication or using electroconvulsive therapy (ECT). Moreover, rTMS may help lessen the intrusive thoughts of obsessive-compulsive disorder, improve the painful apathy associated with certain psychotic disorders, and diminish chronic pain due to migraine headaches and phantom limb syndrome.
Broaching the realm of science fiction, rTMS may even have an effect on our thoughts and morality. When the wand is waved over the brain's right temporoparietal junction, it seems to exert a neuronal "superego" force! In one study, research subjects responded to a morality play where they were asked whether Cain should slay Abel. Chillingly, rTMS was able to dampen study participants' ability to judge right from wrong. Remember the brainwashing of Laurence Harvey in The Manchurian Candidate?
rTMS is not alone. Modern electro- and magneto-encephalography can now detect tumors, find stroke sites, and localize areas prone to epilepsy. Deep Brain Stimulation (DBS) utilizes a surgically implanted probe -- a brain "pacemaker" -- that stimulates brain regions instrumental to Parkinson's disease and depression. Brain-computer interfaces (BCI) are poised to enable a person's thoughts to operate a computer that could drive a wheelchair, operate a pain pump, or communicate for people who can think but not talk.
Advanced drug delivery systems are being developed to zero in on diseased brain sites or turn on genes that could promote cell growth -- and do so with little damage. Smart drugs or "nootropics" that selectively boost the neural circuits of memory and cognition are another budding frontier. And why not have an amnesic pill to erase bad memories or disabling trauma? Perhaps most incredible is the field of optogenetics, where specially engineered, light-activated (or inactivated) neurons are implanted in the brain to control anxiety. This work is underway with mice, a few cortical steps away from man. Beam me up, Scotty.
As science makes a reality of what has been science fiction, we will face questions of how to best apply neurotechnologies. Should these advances be limited to helping those who have illnesses? Or should they bolster the performance of a wartime soldier, enable a C student to get straight As, or supercharge corporate CEOs? Should an MRI or an EEG be used for lie detection or "brain fingerprinting"? If a magnetic wand can influence human morality and tip right to wrong (or vice versa), then what mischief lies ahead in using neurotechnologies to perform Jedi mind tricks on unwitting victims?
In part two of this article, we will look at how the value of neurotechnologies may go astray in the hands of mere humans.
The opinions expressed here are solely those of Drs. Erlich and Sederer, as physicians and public health advocates. Neither receives support from any pharmaceutical or medical device company.
Originally Published by Huffington Post on March 21, 2011
Once 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" -- 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.
Originally Published by Huffington Post on February 2, 2012.
Depression is an arch enemy if you suffer from one of many chronic, physical illnesses. It appears all the time, as an unwelcome intruder, in people with diabetes, heart and lung diseases, cancer, Parkinson’s disease and asthma. It impairs our ability to recover from these, and other, medical problems. Depression escalates health care spending for other medical disorders unless it is detected and treated.
Consider this: Depressed patients are at twice the risk of developing cardiac and artery disease (CAD) and stroke. They are four times more likely to die within 6 months after a myocardial infarction (MI or heart attack). They are three times more likely to be non-compliant with treatment – a reflection of how the illness diminishes our ability to or interest in taking care of ourselves as well as its harmful effects on the body’s stress response, immunity and hormones. As a result, those people, for example, with diabetes and depression average four times greater health expenditures. Individuals with major depression make an average of twice as many visits to their primary care physicians as do nondepressed patients – though not for their depression but for a myriad of other symptoms which are explainable when the depression is uncovered.
Goodness, these are troubling statistics. This state of affairs is not because there are bad doctors (though there are some of those just like in any profession). It is because depression has not yet gained a needed foothold in the standard operations of every primary care doctor's office. We have not yet begun to screen for depression and set as a clinical standard the proven ways of effectively detecting and treating depression in general medical care settings.
Primary care practices have become the principal sites of medical care where adults with common mental health problems in this country (and throughout the world) go for care. These individuals seldom announce they are there for a mental condition. But good medical practice will readily reveal it. Moreover, most patients prefer to have their health and mental health care delivered in one place, by the same team of clinicians. This is called integrated health and mental health care.
Depression also will hurt you at work. It reduces the productivity of our businesses through absenteeism and presenteeism (showing up but not being able to do much). Data from the “National Expenditures for Mental Health and Substance Abuse (MHSA) Treatment” indicates that the U.S. spent $104 billion on mental health and substance abuse treatment in 2001. In 2005 total spending on mental health and substance abuse services was $135 billion. While depression clearly has a significant economic impact on society, the estimated total costs of depression in the US (in 2001) were $44 billion, in 1990 dollars. However, the majority (72%) of costs incurred by society are indirect costs in the form of reduced productivity, absenteeism, and mortality – not the direct costs of care. Medical care costs (inpatient emergency and outpatient medical and/or psychiatric care) comprised only 25% and medications were only approximately 3% of overall costs. In other words, it costs more to NOT treat depression than it does to treat it.
Depression is today the leading cause of disability (by Years of Life Lost, YLLs) and the 3rd leading contributor to the global burden of disease (DALYs 2008). Projections are that by 2030 neuropsychiatric disorders will be the leading contributor to the global burden of disease (these conditions include depression, bipolar disorder, schizophrenia, epilepsy, alcohol and drug use disorders, Alzheimer's and other dementias, Parkinson's, MS, PTSD, OCD, and panic disorder).
Moreover, depression is highly associated with suicide. Estimates are that as many as 90% of completed suicides occur in people with an active mental disorder, depression in particular. An estimated 60% of people over 55 years old who took their lives were in a primary care doctor’s office in the month before their death: otherwise known as a missed opportunity to detect and intervene.
What About Quality of Care For Depression in Primary Care Today?
The answer is short and troubling: The quality is poor.
• Less than half the people with depression are properly diagnosed
• Less than half of those get any treatment.
• In total, one in eight (1/8) people with depression receive “minimally adequate care” (defined by minimal therapy visits and/or appropriate medications).
Yet treatment is effective: As many as 75% of individuals with depression will improve with appropriate diagnosis, treatment, and ongoing monitoring.
What Can Be Done?
A lot. In fact, a very specific approach to treating depression in primary care can achieve remarkably beneficial effects. This approach is well represented by the “Collaborative Care” model developed by the University of Washington. The success of Collaborative Care has been studied and now replicated in 40 (!) studies, including
in rural areas as well as in ethnically diverse and impoverished populations. The core elements of Collaborative Care are:
• Screening for depression (and in some instances other mental and alcohol and drug disorders): this involves the use of a screening tool that provides a depression score that improves when the condition improves.
The PHQ-9 is an example of a depression measurement tool.
• Measurement-based, stepped care: The abnormal score, once the diagnosis is established (the doctor, not the test, makes the diagnosis), is followed over time. Evidence-based depression care paths direct the treatment. If a defined care path is not followed or does not result in improvement then changes in treatment are made.
• An ‘activated’ patient: Patient education and engagement in their own wellbeing is an essential component.
• A care manager: The discipline of this person is far less important than their unrelenting attention to helping a patient engage and remain in treatment and self-care.
• Psychiatric consultation to the primary care physician: This means an active, weekly review of cases that do not improve, not waiting for the PCP to call.
• Training of clinical and administrative staff.
• Ongoing performance measurement and quality improvement of the delivery of integrated care.
In December, 2010, a game changing article was published in the New England Journal of Medicine by Dr. Wayne Katon and colleagues. This article showed that the collaborative care approach not only improved depression, it significantly improved blood pressure, diabetes control and lipid levels. For patients and doctors, this is the Holy Grail: an approach that benefits health and mental health!
Doctors are good learners. If they need to do something they will learn to do it. If you measure their performance they learn how to do it even better. We see that with rates of immunization, mammography, reducing surgical complications, and evidence-based treatment of a host of common and serious diseases like diabetes, asthma, and heart disease. But general medical physicians have yet to tackle depression (even though it is ubiquitous in their practice) because it has not been systematically measured and monitored.
Collaborative Care can be done. It will take clear standards of care, training, and ongoing quality improvement. Not doing it carries a price we cannot afford: human suffering, morbidity and mortality, as well as great family and economic burden. At first, leadership medical groups will need to show it can be done. Then others will find the determination and the ways to follow-suit.
Work Underway in New York State
A collaboration between the NYS Department of Health and the NYS Office of Mental Health is underway to progressively implement Collaborative Care in primary care settings. ‘Early adopters’ will identify how to succeed and demonstrate that patients and providers can take pride in their achievements. These state agencies will seek the aid of the University of Washington and the Institute for Healthcare Improvement to provide training in Collaborative Care and to scale it up across NYS Stand by for more information that will emerge in the months ahead on this initiative to integrate health and mental (behavioral) health.
Conclusion
There was a time when you or a loved one would have gone to a family doctor and you would not have had your blood pressure measured. A time when we did not measure blood sugar (much less the ongoing measure of glucose control, the hemoglobin A1c), or cholesterol. A time when care paths were places to walk in shaded glens, not treatment protocols. Not so today.
Some day we will look back and wonder how we did not measure and treat depression, and other behavioral health disorders, in primary care? We are starting on the transformation road now. It will be uphill and bumpy. So is all change.
A legendary, if notorious, character said: “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them.” He was Niccolo Machiavelli; he lived in the 1500s. Times may have changed, but not what it takes to get something done.
But it was Mahatma Gandhi who said in a more recent century, “…first they ignore you, then they laugh at you. then they fight you, then you win.”
Originally Published by Mental Health News in Spring 2012 Vol. 14.
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 be
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 happens then?
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.
Originally Published by the Huffington Post on February 6, 2012
I have had a lot of jobs, maybe more than most people of even my vintage. In the workplace, as well as in other domains, my basic premise is that leadership is earned. It is not granted by role or rite of passage. Once achieved, leadership is not sustainable without continuous proof of concept: what did you do today, or at least yesterday? In other words, leaders must demonstrate their value in a ceaseless and tireless way. For physicians, in a world dominated by administrators and insurance plans, our leadership may best be rendered through what is called “expert authority”—where a physician’s unique and extensive knowledge of diseases and therapeutics, and of human nature, serves as the basis of his or her authority and the platform for leading.
Expert authority, like the leadership it seeks to exercise, must be earned. It is earned by having the capacity to know what works medically and why; translating the complex into the comprehensible; speaking clearly and concisely and in language meaningful to others; having the emotional intelligence to understand and respond to the concerns of others, particularly patients and families; and working well in teams and being able “to manage your boss.”
Be grateful to those who do good work. Find opportunities to thank them and enable them to shine. Find ways for them to do more. Don’t be afraid to push people; they usually need it. When you do, make sure that you let them know you believe in them, and then support them. Don’t be afraid to set high standards; no one I know has died of hard work.
Measure, measure, measure. Establish metrics that are understandable to your mother. Because when your efforts meet the undying forces of clotted interests, as they surely will, you will need to prove that what you are doing is working. Then despite any criticism that is raining down on your efforts, you can resolutely point to the evidence that what you are doing is working (and kindly acknowledge their concerns).
Enjoy the journey. The Spanish have an expression: se hace camino al andar—the road is made by walking it. You will be surprised by where you go and by the places you will discover, in yourself and in the community you call work.
Originally Published by Psychiatric Services in February 2, 2012
Since I am a physician in a medical world generally led by administrators and driven by insurance plans, I believe in what is called “expert authority.” A doctor is singularly equipped with knowledge of diseases and their treatments and, ideally, a compassionate comprehension of human nature. Yet his or her leadership is not apt to be by executive order but by “expert” authority. So I offer the following list (with all due deference to Mr. Letterman) for physicians, especially those working in health care organizations – from today’s clinics to tomorrow’s accountable care organizations.
My top 10 "David Letterman" physician leadership list
10. Know where you want the work to go, how and why. Be unsparingly lucid and repetitive about what you are trying to achieve since not everyone will be able to read your mind.
9. Read a lot. Not just in your specialty or only in medicine.
8. Learn to write. Start with email, which should exemplify clarity and economy of words. Graduate to memos. Learn the art of the two-page concept paper; then the one pager. Then graduate to papers, or blogs or whatever avenues you have to reach your desired audience. Write about what you are doing, since there is no time to write about anything else. Write with others when you can, since that will improve your thinking and writing.
7. Learn public speaking. Learn how to fashion a concise message and how to deliver it. Articulate every word and project your voice as a way of respecting your audience. No one should have to strain to listen to you. They have to hear you in order to comprehend.
6. Find mentors you admire and want to emulate. They will provide the ideals you need and embody your psychological and professional development.
5. Be a team player and stay with good bosses and rewarding work environments as long as possible, since they won’t happen very often. Learn to “manage your boss."
4. Remember that job satisfaction for professionals, in general, is less about money and more about mission, (expert) authority, desirable colleagues, a learning work environment, quality of life (including family and friends) and pride in achieving results.
3. Be a change agent, an innovator. Don’t wait for others. Restlessly look for what can be improved and how you can make that happen.
2. Change jobs. It has been said that "change is a tonic." Change usually will happen to you, but if it doesn’t, find ways to take on new tasks or jobs, in different settings, with different people and demands.
1.Try not to have work totally dominate your life – like I do.
Being effective as a physician and as a health care professional has changed since the days I trained. Yet a trustworthy physician’s capabilities of knowledge, experience, respect and humanity are ageless. While you may not be able to predict where the work will take you, you can enjoy the ride. You may be pleasantly amazed by the people, places and work you will discover on the path our profession provides.
Originally Published by the American College of Physician Executives on Feb. 10, 2012.
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," by the National Institute of Drug Abuse. 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).
The Director of the National Institute on Drug Abuse, Dr. Nora Volkow, has written that there is good evidence for non-substance induced addictions. 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 and high-fat foods, including huge glasses of sugary beverages, nachos and potato skins in which cheese and bacon swim, sour cream 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.
Originally published in The Huffington Post on January, 24 2012.
Visit my website www.askdrlloyd.com for questions you want answered, reviews, commentary and stories.
Cries for emotional help come in all forms. We witness these cries in ways direct and indirect: from outright requests to help me stay alive to the less direct but no less obvious self-starvation of anorexia or leaving empty pill bottles or illegal drugs in plain sight.
We recently witnessed a modern-age cry for help when Sinead O'Connor declared on Twitter: "does any1 know a psychiatrist in dublin or wicklow who could urgently see me today please? im really un-well... and in danger." Why a celebrity needs Twitter to find a psychiatrist is beyond me. Sure, we can all quip about how hard it is to get an appointment with a doctor, but I suspect that is not what this was about.
Nor can I know, since I am not personally familiar with this celebrity, her medical community, resources, or for that matter, her state of mind when she turned to such a ubiquitous form of social media for help. But as a psychiatrist, I understand how people reach out in ways that we need to listen to: The ultimate fear is that they will find no one there, which is the saddest situation of all. Suicide, as has been said, is not just the product of hopelessness; it is the result of believing that you are all alone, with no one to turn to and no means of exiting from the psychic pain that is crushing your soul.
Mental or emotional pain hurts no less than physical pain. In some ways, mental anguish can be more unbearable because it is often laced with several horrible additives. The first is a common tendency for a person to blame themselves for the condition they are in: They feel guilt, shame, a failure for not having willed themselves better. In addition, there is stigma: The way that people with mental disorders are shunned, castigated and marginalized as if that person is a low-life who needs "to get a life." External injury is thus added to personal agony and self-blame. Topping it all off, there is no broken bone, tumor or infection to point to that explains what's causing the pain. This can create upheaval in a person's sense of self as they search for a way of comprehending what does not have the same explanatory power as do the myriad of conditions that appear visibly on the body, or by blood or imaging tests, or by looking at cells under a microscope.
The Australians launched a social media campaign a few years ago called "R-U-OK?". The Aussies suggested something far more personal and meaningful than waiting for someone to arrive at an emergency room after an overdose or sending a distress signal by email, Twitter, Facebook or some other channel in our rapidly-expanding universe of social media. If you see someone in emotional distress or displaying the consequences of psychological problems (such as social isolation, compromised work performance, poor self-care), they urged to reach out to that person: Ask, R-U-OK? and then sit back and listen non-judgmentally and support the part of that person that wants to live, to love and to be connected to their family, friends and work community. It is there, I assure you, but often buried under hurt and disappointment and hopelessness.
Don't be afraid of saying the wrong thing. Saying nothing, letting somebody stew in their psychic pain, is far more likely to result in something unfortunate happening than is offering a kind word and support for taking what steps are needed to begin to change a situation or treat a problem. When no one asks, when no one notices, cries for help generally escalate -- and not only by tweeting.
Human behavior is purposeful. We do things for a reason. Sometimes that reason (or reasons) is obvious and sometimes not. Behavior is "crazy" only until we understand it, then it is not crazy anymore. Self-destructive behavior happens for a number of reasons, including a need to communicate with others how bad the pain and loneliness is.
You may not be able to answer a celebrity's Twitter cry. But you can listen for cries for help from those you love, from friends and from co-workers. You can answer their cries for help. If not, who knows where or how the cry will next appear?
Originally published in The Huffington Post on January, 18 2012.
Visit my website www.askdrlloyd.com for questions you want answered, reviews, commentary and stories.
A book review of "Henry ’s Demons: Living with Schizophrenia , A Father and Son’s Story", by Patrick Cockburn and Henry Cockburn
Remember Pete Earley’s book, "Crazy: A Father’s Search Through America’s Mental Health Madness?" Earley, a former Washington Post journalist, tells the story of his son, who suffers with a psychotic illness, and the madness of America’s mental health (and correctional) system. There is nothing quite like having a top-notch professional journalist on a mission to deliver a compelling story. We now have another fine journalist who brings us into the world of mental illness, family, community, and the mental health system—but from across the Atlantic, in the United Kingdom, via Henry’s Demons. Through alternating father and son chapters, Henry’s Demons depicts Henry Cockburn’s descent into and slow emergence from severe mental illness. His father, Patrick, is an accomplished war reporter for the Financial Times and the Independent whose life is forever changed by his son’s mental illness; he wrote the majority of the book. Henry was the first of two boys in the Cockburn family, where the mother was a college professor who cared for the boys, while the fatherwas usually at far-off and dangerous war zones. Henry was a creative child who never quite fit in with his peers, and he smoked a lot of marijuana as a teenager (”too much,” he remarked).
Through father and son, we enter the world of mental illness in personal and painful ways. However, memoirs are now common, and suffering is often their métier. What distinguishes this book are the plethora of lessons learned, none delivered in didactic or pedantic ways but instead through narrative and experience. I recommend this book to families and mental health practitioners because it teaches us 1) that what we often see as denial (“there is nothing wrong with me”)is a means by which a person defends his or her identity and grasps to maintain the integrity of his or her very being; 2) that moments of lucidity in people with mental illness where they see the gravity of their illness and its consequences on their lives may be impossible for them to endure; 3) that mental illness can induce a state of idiosyncratic narcissism in those affected, in which concern about the effect of their illness on their families and others seems to vanish; 4) how marijuana and other mind-altering drugs erode what little protection against mental illness a constitutionally vulnerable person may possess; 5) how families can be seduced into unaffordable financial investments to care for their loved one when, in fact, the care that they may buy is often no better, and many times worse, than what a good public sector service system can provide; 6) that families that communicate with others about their struggle discover that they are not alone, which can be essential in continuing to be able to provide support over a lifetime to a loved one with a mental illness; 7) that intramuscular administration of antipsychotics for some people who will not take oral medications may be the only way to build a foundation of sanity, on which critical psychosocial interventions can occur; 8) that clozapine, which is proven to be more efficacious for treatment-resistant schizophrenia, is substantially underutilized; and 9) that we have yet to establish the community equivalent of the asylums of the 1800s, where people with serious mental illness can have safe and supportive communities in which recovery can take place.
Patrick is a keen observer of the limits of mental health care and the profound turmoil that mental illness produces in those closest to the ill person. His journey began by thinking that schizophrenia was a disease to be cured, but he evolved to understand it as a disorder that can be controlled and need not drive a person to states of dangerous behavior and a life fated to be without love or work. Henry tells his story with seeming naiveté and remarkable vividness, still half-believing the varied delusions, hallucinations, and psychotic views of the world he experiences. However, he does so from a growing state of recovery in which he can understand what unhinges him (e.g., smoking marijuana, not adhering to his medication regimen) and what he needs to do to contend with his psychosis. As the book ends, both father and son have achieved a sense of growing optimism that their lives, while irrevocably altered, can be rebuilt in ways that they have yet to fully understand.
Originally Published in the American Journal of Psychiatry January 2012.
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Lloyd I. Sederer, M.D., is Medical Director of the New York State Office of Mental Health (OMH), the nation's largest state mental health system. As New York's “chief psychiatrist”, he provides ...Read More
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