Are doctors starting to ease off on prescribing psychotropic drugs to young kids?
This seems to be the conclusion of a new study published in the journal of Pediatrics this week. The study’s design was relatively simple: gather data on 2-to 5-year-olds from national health surveys, and see what trends emerge. The findings? While behavioral diagnoses in young children have increased over the past two decades, prescriptions for psychotropic medications have been cut in half.
Why was there a prescription peak that has now stabilized, and what could explain the drop? I contacted Dr. Tanya Froehlich, a contributing author of the study and associate professor at the University of Cincinnati Department of Pediatrics, to shed some light on this phenomenon. She responded via email.
Dr. Froehlich attributed the decline to two major factors: regulatory controls and increasingly cautious doctors. Specifically, she said, decreasing prescription rates “may be due to physician and public concern about these medications spurred by a number of FDA advisories issued in the mid- to late 2000’s, including the black box warnings on selective serotonin reuptake inhibitors (SSRI) and atomoxetine, and other advisories regarding psychostimulant-associated side effects.” Continue reading →
For all those freshman just settling into dorm life this fall, college can be exhilarating, mind-blowing, the best years of their lives. But many parents don’t realize that their children are also facing a potential double whammy. Not only must new students navigate an entirely unfamiliar social, emotional and intellectual landscape, but they’re also entering a time in their lives — the ages between 18 and 21 — when many mental illnesses, from anxiety to depression to eating disorders, peak.
This week, The Checkup, our podcast on Slate, explores the mental health of college students. Here’s one sobering statistic: up to 50% of college-age kids have had or will have some kind of psychiatric disorder. That’s why we’re calling this episode “Meltdown U.” (To listen to The Checkup now, click on the arrow above; to download and listen later, press Download; and to get it through iTunes click here.)
Consider some more scary numbers:
–80% of college students who need mental health services won’t seek them
–50% of all college students say they have felt so depressed that they found it difficult to function during the last school year
–Suicide is the second leading cause of death among college-age youth – over 1000 deaths per year.
We asked Dr. Eugene Beresin, M.D., a child psychiatrist at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, to offer some guidance on what parents should know about helping their college-age kids cope with the high stress of undergraduate life. Here’s his advice: Continue reading →
PET scan of a normal brain (NIA/Wikimedia Commons)
A diagnosis of depression is usually followed by months of uncertainty and experimentation. Should I try talk therapy first? Are medications the answer? If so which ones, and how long will I have to wait to know if they’re working?
But a new government-funded study suggests there may soon be a way to decide by looking at brain scans.
If the part of the brain called the insula is overactive, the patient should be prescribed medication, the study indicates; if the insula is underactive, than cognitive behavioral therapy, a type of talk therapy, may be better.
This power to predict, if confirmed by other research, will help avoid months of trial and error treatment, and – though brain scans are costly – might save money in the end, by getting the patient effective care much faster, said Diego Pizzagalli, director of the Neuroimaging Center and the Center for Depression, Anxiety and Stress Research at McLean Hospital. He was not involved in the study.
Published in today’s issue of JAMA Psychiatry, the study also reinforces the idea that depression is not one condition, as it’s currently defined in the “bible” of psychiatry – the newly published edition of the Diagnostic and Statistical Manual.
Instead, Pizzagalli said, it’s a wide-ranging set of symptoms that experts have decided should be called depression. Psychiatrists are currently debating whether such symptoms – or the underlying biology – should be used to define psychiatric conditions.
“What we are learning through our work is that basically the diagnosis of depression does not map one to one to biology,” said Pizzagalli, also an associate professor of psychiatry at Harvard Medical School. “Using neuroimaging we can differentiate between subgroups of patients in important ways.” Continue reading →
Casey was diagnosed with canine compulsive disorder. He’s now on Prozac. (Courtesy)
When Casey, a 6-year-old German Shepherd, gets anxious, she chases her tail.
But it’s not the kind of endearing, once-around-and-it’s-done kind of tail-chasing we’ve all seen. Left unchecked, Casey circles around and around, pursuing her tail until she can bite it. Then, even when the blood starts flowing, the dog is driven to continue the chase.
“It’s upsetting,” says Paula Bagge, a Hopkinton, Mass. business owner who has been living with Casey since puppyhood. “And it’s damaging. She hurls herself around the house, and it’s like a big bloody paintbrush spraying the walls.” Once, Bagge tied the dog’s leash to a coffee table in an attempt to control the chasing. But Casey, who weighs about 85 pounds, just started dragging the coffee table around with her. Now, she’s on Prozac.
Dogs, it turns out, can have obsessive-compulsive disorder, just like people. And in a new study, Dr. Nicholas Dodman, a professor of clinical sciences at the Cummings School of Veterinary Medicine at Tufts University, found that structural brain abnormalities in dogs, in this case Doberman pinschers, with canine compulsive disorder (CCD) are similar to those of humans with OCD.
In an earlier study, Dodman, a leading researcher on repetitive behavior in animals, found a specific gene associated with canine OCD.
Studying anxiety disorders in dogs, Dodman says, may ultimately help scientists come up with better therapies and medications to treat OCD and related conditions in people. Current drugs for OCD, such as SSRI’s (or for dogs, a beef-flavored form of Prozac) are notoriously ineffective for many sufferers. Indeed, Dodman says, only around 43 to 60 percent of people suffering from OCD show a postive response from an SSRI; the average reduction of symptoms in people taking these drugs is only about 23 to 43 percent. “Certainly not a panacea,” he says.
So, to further this research, Dodman spends time thinking about bears who pace obsessively, for instance, or parrots unable to stop preening and picking their feathers and beagles who overeat to the point of exploding,
Dodman calls the latest dog-brain imaging study, conducted in collaboration with researchers at McLean Hospital, in Belmont, Mass., “another piece of the puzzle, another brick in the wall.”
He says while more research must be done, it’s becoming increasingly evident that dogs with OCD are a great model for exploring human psychopathology: they show similar behaviors, respond to drugs in comparable ways and now, at least in this small study, seem to have the same brain abnormalities as people with the condition. “When you know what your dealing with it’s much easier to create targeted approaches,” to treatment, Dodman says. “If you don’t know what you’re dealing with it’s just kind of like going with your sense of smell.”
OCD afflicts about 2 percent of the population and often goes untreated or undiagnosed. People suffering from the disorder, marked by intrusive thoughts and repetitive behaviors such as hand washing, locking and unlocking doors, counting, or repeating the same steps, feel these impulses as uncontrollable. And the compulsive rituals, often triggered by stress or trauma, can be incredibly time-consuming, interfering with daily life.
Famously, Lena Dunham, the star and creator of the HBO series “Girls” came out with her own OCD on air, with repetitive tics, obsessive counting and painfully compulsive use of Q-tips. Continue reading →
The CDC has just released a report on the prevalence of mental illness among American children. It notes: “A total of 13%–20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994–2011 has shown the prevalence of these conditions to be increasing.”
Yet as that prevalence increases, treatment options are decreasing, writes Lisa Lambert, executive director of the Parent/Professional Advocacy League, which advocates for Massachusetts families with mentally ill children. Below, she discusses one particular pending loss, of Cambridge Hospital children’s psychiatric beds long especially valued by families. The hospital announced last month that it would consolidate two units with 27 beds into just one with 16 beds. It cited tight budgets, declining utilization and cyclical demand. The details are still in play.
By Lisa Lambert
When Aiden was seven, it seemed like he would never be safe.
At home and in his second-grade classroom, he repeatedly talked about killing himself. He barely slept, raced from one spot to another and threatened to harm his younger sister. His parents stayed glued to his side, barely taking time to eat, shower or sleep.
One day, his mother caught him lighting a fire in his bedroom. Aiden ended up in the emergency room, and later in a bed in Cambridge Hospital. The staff had seen young patients like him before and they knew what treatment would work and what kind of follow-up care a seven-year-old needs. Without that hospital stay, his mother says, ”We don’t know where our family would be.”
Lisa Lambert of PPAL (Courtesy)
No one likes the idea of admitting a young child to an inpatient psychiatric program. It is a last resort, something to be avoided at all costs. Parents will tell you, however, that when they’ve exhausted all the options, Cambridge Hospital has provided the best possible care. Now, it seems that a major piece of that care is coming to a close, unless a miracle happens.
Last week, the Department of Public Health held a hearing to receive comments about closing the Cambridge Hospital child psychiatric unit and eliminating beds. Nurses stood shoulder to shoulder to tell stories of families they’ve helped and of their pride in the wonderful care they’ve given. Parents came to say that this place was a lifesaver and without it, their children would never have improved.
The Child Assessment Unit is one of a kind, they all said, where parents can visit anytime and even stay overnight. Since PPAL is a grassroots organization, we surveyed families about this and want their voices to be part of the public conversation. Continue reading →
This combination of undated photos shows Tamerlan Tsarnaev, 26, left, and Dzhokhar Tsarnaev, 19. (AP)
From the moment the two Boston bombing suspects were identified, acquaintances and strangers alike have speculated that the older, ex-boxer brother had dragged the younger, mellower brother into badness. The Boston Globe’s Deborah Kotz offers a round-up today of such psychological theorizing, including a comparison to the 2002 Washington sniper case in which 17-year-old Lee Boyd Malvo fell under the influence of an older father figure.
Personally, my favorite theory comes in this Huffington Post diatribe: “Are The Boston Bombers Just Douchebags?” But epithets, however satisfying, cannot stem curiosity. And one of the more interesting possible elements of emotional explanation comes from Harvard psychiatrist Harold Bursztajn, who raises the possibility of a psychiatric diagnosis called “Shared Delusional Disorder” — long known in literature as a “folie à deux,” French for madness shared by two.
The diagnosis is not new to the upcoming DSM-5, the psychiatric “bible” of diagnoses. But it is, Dr. Bursztajn said, the only diagnosis in the official compendium that is, at base, “relational.” He defines Shared Delusional Disorder as a situation in which one person in a close relationship, usually the dominant one, develops a delusion and pulls the weaker person into it. It is considered rare, but is probably under-diagnosed, he said, because it tends to involve paranoia and concealment.
Dr. Harold Bursztajn (Courtesy)
“The delusions are concealed, and can be concealed more successfully because there’s someone else to share them,” said Dr. Bursztajn, co-founder of Harvard Medical School’s Program in Psychiatry and the Law. “You have company in your delusion, so you don’t need to tell anyone else. Good psychodynamic training is all the more vital to treat a disorder that is fundamentally relational and which involves concealment, because if you don’t know how to help people overcome their shame and defensiveness and fear about how crazy they are, then people won’t show you.”
Shared Delusional Disorder commonly shows up as Munchausen by Proxy, in which a parent becomes delusionally concerned that their child has an illness, and the child begins to believe it as well.
“One person has the delusion,” Dr. Bursztajn said, “and the other person is dependent, emotionally or physically. The dependent person feels that a condition for being loved is to buy in to the delusion, so they buy in to it and then the two of them have a system going…The two people lose touch with reality and form a bond against either a common enemy or, in the case of Munchausen by Proxy, it’s against nature itself and against the human condition, which is that we’re all fragile.”
As a young woman, I was told more than once that my severe respiratory symptoms were perhaps “psychosomatic,” caused by stress or anxiety. Being sick enough to be in the intensive care unit was challenging enough; having my credibility called into question while I was struggling simply to breathe made the situation that much harder.
When biopsies confirmed that I had a rare genetic lung disease called primary ciliary dyskinesia, I had “proof” that my physical problems were just that—physical.
Unfortunately, not every condition lends itself to biopsies and concrete diagnostic tests, and that ambiguity leaves a hazardous gap that could soon be widened by a new psychiatric diagnosis.
Next month, the American Psychiatric Association will release the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. Critics have found plenty to complain about in this new edition of what’s considered the mental health diagnostic bible, including its redefinition of depression, but one of the most contentious changes is the inclusion of Somatic Symptom Disorder (SSD).
In short, the SSD diagnosis makes it much easier to diagnose physical symptoms as mental illness, and diminishes patients’ ability to report normal emotional responses to the upheaval that physical illness can cause.
To get a sense of why Somatic Symptom Disorder is a flawed diagnosis, consider this: Patients meet its criteria if they have at least one symptom disruptive to daily life for at least six months and at least one of the following:
• Disproportionate thoughts about the severity of their symptoms
• Heightened anxiety over their symptoms
• Spending too much time and energy on their health concerns
Does this sound like mental illness? Perhaps, depending on who is doing the listening and categorizing. But it also sounds a lot like the trajectory of many chronic illnesses, and that’s the problem.
The diagnosis ‘increases the chance they will be cast aside as histrionic’
No group has more to lose with the introduction of Somatic Symptom Disorder than patients who live with chronic pain conditions, a disproportionate number of whom are women.
Women are three times more likely to manifest autoimmune disorders than men, for example; they’re four times more likely to be diagnosed with chronic fatigue syndrome and nine times more likely to be diagnosed with fibromyalgia. Continue reading →
I asked Dr. Steven Schlozman — assistant professor of psychiatry at Harvard Medical School, staff child psychiatrist at Massachusetts General Hospital, and author of “The Zombie Autopsies” — to explain such skepticism and describe how he’d propose spending $100 million on the brain.
By Dr. Steven Schlozman
Dr. Steven Schlozman
I’m actually giddy about the President’s proposal. Remember, I’m writing here as a clinician and an educator. I have not been battered by the false promises of the past in this particular arena. To fully appreciate my optimism, do this:
Imagine that you are an anatomy student in the dark days of the 12th century. You look out your window at the primitive road that passes your quarters. The plowed fields in the distance help to distract you from the vexing mystery that sits now on your desk.
There, on your wooden dissecting table, sits a recently removed human brain.
What a mess.
You see, you’ve figured out the heart. You’ve held it and squeezed it and using nothing but observational perseverance, you’ve gleaned that it is intended to pump blood, and that the blood only goes in one direction. You know an awful lot about this organ.
We physicians really don’t truly understand brain circuitry and yet we alter it in our patients every day.
You’ve done okay with other organs as well. You’ve blown air into cadaverous lungs and you’ve measured the extent to which human bladders are wonderfully impermeable. You are, in fact, pretty comfortable that our lungs move air and that our bladders hold liquid.
But what about that brain? You’ve picked it up, squeezed it, turned it over and over in your hands and you’ve tried to understand just what in God’s name this organ could possibly do. There are great big blood-carrying arteries that feed the brain, as well as great big blood-carrying veins that empty it. Perhaps the brain is for cooling the blood? Continue reading →
Two health-related points struck me in this disturbing but exceedingly smart piece in the current New Yorker about the “darker side” of Aaron Swartz, the gifted young Internet activist who hanged himself in his Brooklyn apartment in January. (The “dark” health aspects of the story were so powerful that I called an expert to find out more about the potent connection between disorders of the gut and the brain. See below.)
First, the depth of Swartz’ physical distress and heightened sensitivity to everything from food to music is astounding. Reporter Larissa MacFarquhar writes:
He disliked all vegetables and refused to eat them except in extremely expensive restaurants, such as Thomas Keller restaurants. He had ulcerative colitis, a serious digestive disorder similar to Crohn’s disease; he also thought that he was a “supertaster,” experiencing sensations of taste more intensely than regular people. Partly for these reasons, he ate only foods that were white or yellow. He ate pasta, tofu, cheese, bread, rice, eggs, and cheese pizza. He was phobic about fruit and wouldn’t touch it. He rarely drank alcohol and was careful to stay hydrated. He went through four humidifiers in his apartment in Brooklyn. He said that he left San Francisco because the air-conditioning was bad. He was a supertaster in matters other than food: things always seemed much better or worse to him than they did to other people.
[From Swartz' own writing]: I recently had to sit through a performance of Bach’s Well-Tempered Clavier at the Chicago Symphony Orchestra. . . . At first it was simply boring, but as I listened more carefully, it grew increasingly painful, until it became excruciatingly so. I literally began tearing my hair out and trying to cut my skin with my nails (there were large red marks when the performance was finally over). (2006)
The second issue that seemed particularly relevant to the entire tragedy is the severity of Swartz’ ulcerative colitis, a type of inflammatory bowel disease that affects the colon and rectum, with symptoms that can range from highly uncomfortable to seriously painful. In the piece, MacFarquhar quotes one of Swartz’ friends discussing the link between ulcerative colitis, depression and suicide:
A doctor relative last night told me that he’d had some very painful experiences with patients with ulcerative colitis committing suicide. Apparently co-morbidity with depression is common. I’ve been thinking about it a lot for the last twelve hours. I know during the scare in 2007 he had gotten very, very sick from his U.C. He definitely didn’t seem depressed right before his death, nor for a long time previously. He wasn’t doing normal depressed-people things (like withdrawing from friends and family), let alone suicidal-people things (like giving away his stuff). However, he did commit suicide, which weighs pretty heavily on the other side of the scale. My doctor relative told me that some of his ulcerative-colitis patients seemed to be doing much better until the moment when they suddenly committed suicide, and that there’s some speculation that U.C. can alter liver functioning, which in turn can cause other medicine to cause impulsive behavior like suicide.
Ben Wikler, a friend
I spoke with Suzanne Bender, a psychiatrist at Massachusetts General Hospital and the psychiatric liaison to the pediatric gastro-intestinal service at MGH. Every Thursday, Dr. Bender sees children and adolescents with GI problems that have not responded to typical treatments, and have also caused emotional distress. She says many of these patients only get relief from their GI symptoms once coordinated care is provided, between GI and Psychiatry.
Dr. Steven Schlozman is an assistant professor of psychiatry at Harvard Medical School and a staff child psychiatrist at Massachusetts General Hospital. He is also the Co-Director of Medical Student Education in Psychiatry. His first novel, “The Zombie Autopsies,” was published in 2011, and his affinity for zombies might explain his mind-numbing rage at being stuck on hold all the time. Readers, have you had muzak musings of your own lately? Please share in the comments below.
By Dr. Steven Schlozman
I am a physician practicing in Boston. I do my best to get my work done as carefully and efficiently as possible.
I am writing to you right now, in real time, as I enter my…wait for it…38th minute on hold with Blue Cross/Blue Shield in my attempt to gain approval for a treatment that my patient absolutely needs. No one who knew the details of this case would argue otherwise; not politicians, or business specialists, or cost efficiency specialists, or medical school professors, or anyone really. Neither would anyone deny that the treatment that I am trying to procure for my patient is costly. Finally, no one would deny that it is legions more costly to not treat my patient with the treatment for which I am now sitting on hold and trying to procure.
Help. I love being a doctor. But this isn’t doctoring.
Still, here I sit. I sat initially for 26 minutes, at which point the very pleasant muzak stopped and a recorded and maddeningly soothing female voice told me that I would “have to call back later.” Then the line went dead.
So I called back later.
I called back exactly 12 seconds later, and that was now 42 minutes ago. I mean, 42 minutes, in real time, as I write this letter. I have patients in the waiting room who will understandably expect me to get to them soon. I also know that there are those who will tell me that this is what I signed up to do for a living.
But they’re wrong. I did not sign up to do this for a living. There are no courses in medical school about how to spend one’s time on hold while patients need your help.