psychiatry

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The Upside Of Admission To The Psych Unit: A Doctor’s Inside View

By Helen M. Farrell, M.D.
Guest Contributor

I met J in the Emergency Department. Dark red blood was oozing out of self-inflicted deep lacerations to her forearms. The surgical team was consulted and the cuts were debrided, cleaned, stitched and neatly bandaged. J was patched up. But she was not healed. Her wounds ran deeper than a surgeon’s instruments could access.

Together, we had a thoughtful conversation that included a review of her suicidal thoughts, intermittent hallucinations and innermost feelings. These vacillated unpredictably between anger and worthlessness. I informed J that she was going to be admitted to the psychiatric unit for her safety and treatment.

“Locked up?!” These are typical words expressed by patients who learn that they are going to be admitted involuntarily to the psychiatric unit. When J heard this news, her own tear-stained face scrunched up in an expression of horror. After several minutes of pleading, she finally resigned herself to the plan.

A nurse came into the room and took J’s phone. She took her sweater, her belt and the laces from her shoes. J stripped down into a standard hospital gown. It is common for patients to make one last plea and many have told me that they fear the psychiatric unit is analogous to prison.

J is representative of the many patients whom I treat on a day-to-day basis. She is a composite of those actual people who suffer from serious mental illnesses ranging from psychotic and mood disorders to personality disorders that require hospital level care.

Not Your Mother’s Psych Ward
The days of psychiatrists wantonly locking up patients like J against their will are long gone. They have been replaced by a legal process called civil commitment that firmly puts patients’ rights first. Yes, J was being admitted against her will, but she would retain her power to make treatment decisions, summons legal counsel, and even have a hearing with a judge. These safeguards apply to patients like J who are mentally ill and at risk of harm to themselves or others as a direct result of mental illness.

We know about the extreme cases of mental illness — those who involuntarily get locked on a psychiatric unit. An estimated one-quarter of the United States population will suffer from mental illness. But what about those people whom we never hear about? Far too many people, victims of stigma, neglect treatment and suffer in the isolating silence of darkness. They are compelled to withdraw because of fear and shame.

Beyond Shock Therapy

Driving much of that stigma is the fantasy of what happens behind that infamous locked door. Images from “One Flew Over the Cuckoo’s Nest” fill people’s imaginations, as do fantasies of the “shock therapy” room, which many incorrectly think is a place of punishment and not treatment. Continue reading

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One Doc’s Oreos-And-Batman Perspective: TV Doesn’t (Necessarily) Make Kids Fat

(Donnie Ray Jones/Flickr)

(Donnie Ray Jones/Flickr)

By Steve Schlozman, MD

Here are three recent headlines that got me thinking about kids and fat:

“Watching one hour of TV per day increases risk for obesity by 50%”

“Watching TV for Just an Hour a Day Can Make Children Obese”

“Study makes surprising link between TV time and childhood obesity”

Oversimplifications? Um, yes. Each of these headlines greatly simplifies (dare I say, incorrectly simplifies) a critical social and health issue. Personally, I don’t think TV is the sole evil culprit here. It’s far more complicated.

The medical community has long known that the amount of TV that a child watches correlates with obesity. We can even make some leaps from these data towards implicating causality. Unless your little ones happen to be doing aerobic exercises while they tune in to their cartoons, it’s easy to see how passive watching can equal active weight gain.

However, be wary of oversimplification and especially of the “one-size-fits-all” policy statements that these headlines often generate. The study authors here do, in fact, suggest further limiting TV exposure based on the existing American Academy of Pediatrics guidelines for young children as a means of controlling the rate of obesity in this country. (Currently, the AAP recommends limiting screen time to one to two hours or less for children over the age of 2, and discouraging screen time altogether for those who are younger.)

So, here’s the big question: Is the recommendation that TV time be further limited an entirely appropriate conclusion?

Beyond The Headlines

The answer, like many answers to social policy questions, is both yes and no.

What we know for certain is that we can’t really discern from the headlines what we ought to do, though there is ample reason to believe that most American rarely go beyond the headlines. Thus, we run the risk of jumping to more draconian conclusions than might be appropriate simply because we don’t have or take sufficient time to examine the flood of information.

How do we guard against this leap to oversimplification?

Here are a few key questions:

•Was there a large and diverse population studied?

There have been solid links between lower socioeconomic groups and some ethnic minorities and increased television time, as well as between lower socioeconomic groups and obesity.

The causes for both of these issues are of course multi-factorial. Fatty foods and higher calorie foods are cheaper. TV can function as a babysitter in households where parents are busy working and living paycheck to paycheck. However, the study in the headlines above, conducted by the Department of Education in conjunction with physicians at the University of Virginia, was indeed both large and diverse.

Over 12,000 children starting kindergarten were enrolled in the investigation, and a year later follow-up data was available for more than 10,000 of these children. These data included height and weight, as well as statistical analyses to account for differences in race, gender and socioeconomic effects. In other words, the numbers here are sufficiently large and diverse for us to feel comfortable drawing at least preliminary conclusions.

Causality, Really?

But beware, always beware, of flashy headlines. A Google search yielded all of the headlines above with equal weight, and yet one of the headlines clearly implicates causality. “Watching TV for just an hour a day can make a child obese.” (My italics.)

However, this study does not in any way suggest causality. There are a number of potentially unrelated factors that also happen everyday that might be associated with obesity, but not function as a cause of obesity. These could include behaviors like longer baths to cool down. We don’t know until we do the study whether longer baths would be associated with obesity. In other words, always be wary of blanket statements of causality with regard to the complexity of human behavior.

•What about the ample availability of screen-based material on demand? Perhaps the fact that children can often watch both what they want and when they want it affects their activity patterns in negative ways. We could ponder the fact that TV content, even for kids, has arguably (though not in all spheres) gotten better and of higher quality. There is even evidence that TV watching can improve behavior among kids, and this evidence also comes from the American Academy of Pediatrics. Does that mean we ought to make a policy statement advocating that TV should be less compelling?

Confessing My Bias

Things get even messier when we take the necessary step of examining our own personal biases. In my case, that examination includes a shameless confession regarding the ways my own penchants might complicate my interpretation of these data. Continue reading

Outpouring On Beloved Prouty Garden Continues: Traumatized Kids Need It

The fountain in Prouty Garden at Boston Children’s Hospital (Jesse Costa/WBUR)

The fountain in Prouty Garden at Boston Children’s Hospital (Jesse Costa/WBUR)

News this week that the Prouty Garden at Boston Children’s Hospital can be bulldozed continues to draw impassioned pleas to reconsider the garden’s fate. Here, Dr. Elliott B. Martin, Jr., a psychiatrist at Newton-Wellesley Hospital and Assistant Clinical Professor of Psychiatry Tufts University School of Medicine, adds his thoughts. (This is the second powerful letter we’ve received from defenders of the garden. We also welcome letters from the other side.)

I am writing in hopes of continuing the narrative around the fate of the Prouty Garden at Boston Children’s Hospital. I have been involved now for several months in the effort to save the therapeutic space, and the letter yesterday from Ms. Ellen Gilliam has inspired me to build upon her story, in hopes that others will add their own chapters.

I, too, have worked at Boston Children’s Hospital, as a physician, specifically as a psychiatrist. Until recently, the best kept secret at Children’s Hospital had been that there is in fact an inpatient psychiatric unit there. At any given time the hospital cares for some of the most grievously traumatized children you can imagine. These are kids, ranging from seven to seventeen years old, who have suffered ungodly physical and sexual abuse, at times since infancy. These are kids who have suffered from neglect, at times to near death. These are kids with profound depression, who have tried to commit suicide, very often many times over.

Therapeutic options in such cases are extremely limited, often amounting to time, containment, support, and most importantly, love. Many, if not most, of the physically ill children at the hospital at the very least know the love of their families. For the psychically wounded there is precious little love. As we would often observe on the inpatient unit, very few people sent get well cards to the psychically ill. The clowns never came there. The celebrities, on their visits to sick children, were carefully shuttled past the double-locked doors designed to be disinviting.

In this environment two therapeutic modalities stood out as having had immediately tangible, positive effects on these children. The first was the weekly visit from the therapy dog, and the second were the daily supervised excursions to the Prouty Garden. For kids otherwise confined day and night to a tiny, cordoned off piece of hospital property these fifteen to thirty minute trips were their only connection to the greater world, the ‘world outside’, as one horrifically abused seven year old boy once described it to me. To see these kids playing in the garden one might even mistake them for “normal’ kids. To see them interact with children in wheelchairs, with children wheeling IV poles, with children sentenced to die and whose parents had nowhere else to cry, one might think they were even more than normal, that they were, at least for a few minutes, special. Continue reading

Out Soon: First Official Consumer Guide To ‘The Bible Of Psychiatry’

The DSM-5, widely known as the "bible of psychiatry," is close to 1,000 pages and not exactly user-friendly. (Wikimedia Commons)

The DSM-5, widely known as the “bible of psychiatry,” is close to 1,000 pages and not exactly user-friendly. (Wikimedia Commons)

On average, says Dr. Paul Summergrad, the outgoing president of the American Psychiatric Association, he gets three or four calls a week that go something like this: “Hi, I’d love to chat — we haven’t talked in a while — but I’m calling about a personal problem — I’m worried.”

Almost always, Summergrad says, “It’s about a parent, an aunt, an uncle, a brother, a sister, a child — usually an adolescent or young adult who’s at the age of onset of these conditions, and they’re trying to figure out what to do.”

Summergrad, who’s also psychiatrist-in-chief at Tufts Medical Center, doesn’t mind a bit. “It’s actually the best job that I have, taking those calls,” he says. “That’s one of the most important things I ever do, because I’m trying to get people to the right sources of help.”

Now he has one more source to recommend: On May 1, the American Psychiatric Association is officially releasing its first-ever consumer guide to the DSM-5, the compendium of mental disorders that’s referred to in virtually every news story ever written about it — including this one, now — as “the bible of psychiatry.” The new consumer-oriented book is called “Understanding Mental Disorders: Your Guide To The DSM-5.”

The new consumer guide to the DSM-5 (Courtesy APA)

The new consumer guide to the DSM-5 (Courtesy APA)

The DSM-5 — DSM stands for Diagnostic and Statistical Manual — took more than a dozen years to develop and sparked controversies over some psychiatric disorders as it was compiled, drawing criticism both within the field and from without. But it was finally published in 2013, the latest version of the go-to reference on psychiatric diagnosis and treatment.

No one would call it user-friendly, though; it’s a thick tome of 991 pages in the paperback edition, and written for clinicians and researchers, not laypeople.

So the new consumer guide, Summergrad says, “is a way of trying to provide some help and guidance and understanding for either the individuals themselves, for their family members, or for other caregivers.”

It’s also intended for tables in the offices of primary care doctors, psychiatrists and psychologists, he says, to explain diagnoses in language for laypeople.

As one of those laypeople myself, I felt a little confused. The consumer guide, like the DSM itself, is organized in categories of diagnoses: psychotic disorders, bipolar disorders, anxiety disorders, and more. Continue reading

Predicting The Next Mental Health Crisis: Sometimes We Just Can’t Know

Chris/flickr

Chris/flickr

By Steve Schlozman, M.D.

When tragedies hit, it is in our nature to ask why. The co-pilot in the horrific Germanwings crash had serious mental health problems, according to reports. How could no one have known how serious his challenges were? How could no one have predicted this terrible outcome?  On its surface this line of questioning seems even a bit ludicrous.  After all, even in the murky face of mental illness, the potentially deliberate and fatal nose-dive of a commercial aircraft seems impossible to imagine.  Nevertheless, this is exactly the question that we’re seeing over and over in the coverage of the crash.

How could we not have known?

The fact is, however, that this particular question glosses over a profoundly uncomfortable quandary that is by no means unique to psychiatry. For all of modern medicine, predictions are surprisingly fraught with difficulty.  For all of medicine’s miracles, for all of its technological wonders and advances, medicine remains a quintessentially human endeavor.  You might even argue that phrases like “medical miracle” are indeed part of the problem.  This more we grant medicine undue and mystical prowess, the more resistant we grow to the grueling trial and error that characterize everyday medical practice.  Doctors are wrong all the time.  That’s a fact.

Nevertheless, physicians are asked to prognosticate. That’s the verb form of “prognosis.” As patients and families, we look to our doctors daily for prognostic estimates.  (Emphasis on estimates.)  These estimates are really hypotheses necessarily based on incomplete data. Rare complications and twists of fate befuddle even the best.

For psychiatry this truth can be especially hard to swallow.  A neurologist might not be able to predict every migraine, but it is the rare migraine that results in tragedy.  Still, remember that psychiatrists cannot read minds. Like all physicians, psychiatrists will try their best to understand what is the cause of suffering.  And, as with all clinicians, psychiatrists will sometimes be right and sometimes not.  Medicine remains an art even as the science continues to improve.

The fact that someone suffers a psychiatric disorder, even a recurrent psychiatric disorder, is not remarkable when compared to the rest of medicine.  The same occurs with ulcers, asthma, allergies, orthopedic injuries, sinus infections and so forth. Most medical illnesses are chronic and many are intermittent. No medical professional can predict with absolute certainty when an episode is going to occur or how severe it may be. To be fair, physicians can and do identify triggers, but the intensity of a presumed reaction is outside anyone’s ability to predict.

And this is where society gets especially flummoxed. No one would argue that the art of medicine is infallible. No one would suggest that medical practice is right 100% of the time. But faced with tragedy, we are much more comfortable as a species pretending that our predictions are foolproof and that our mishaps are exceedingly rare.

Why can’t we always know? Medicine is post-modern. We cannot know because we can’t. Continue reading

The Medicated Woman: A Pill To Feel Better, Not Squelch Emotions

By Alicair Peltonen
Guest Contributor

I am a medicated woman. I take 50mg of Sertraline (the generic form of Zoloft) a day. I don’t take it to be more tolerable to my husband. I don’t take it because I’m embarrassed by my emotions. And I definitely don’t take it to quietly fit into a polite societal mold. I take an anti-depressant every day to quell my anxiety simply because it feels better. I feel better.

I grew up in a talk therapy household. My father began group therapy for anger management issues in 1984, when I was 10, breaking a cycle of rage and avoidance that tends to swallow people whole, particularly men. He would come home feeling calmer and then he would implore my sister and me to explore our feelings and talk about our problems. Begrudgingly at times, I learned to think analytically. And thankfully, I learned that asking for help is not only acceptable, it’s downright healthy.

I started seeing therapists here and there in my 20s and then regularly several months after my first daughter was born. Medication had never been suggested by any of my previous therapists but this time was different. I couldn’t shake the feelings of inadequacy, the certainty that my daughter didn’t like me and I was just a glorified dairy cow. Post-partum depression is a hell of a thing.

(Rachel Zimmerman/WBUR)

(Rachel Zimmerman/WBUR)

When my therapist suggested I see a psychiatrist to discuss the possibility of medication, I went home and cried for an hour. I felt ashamed, defeated, embarrassed, weak. Even though I had seen medication transform my father from a man who growled and dragged to one who laughed and hugged, it still stung to feel like I couldn’t pull myself together.

But, remembering my father’s bravery, I thought I should at least give it a try. If I didn’t like it, I could always stop taking it. The first pill was swallowed through tears. And each successive pill went down easier. For a full year, I could go days without yelling or wanting to break things and entire weeks without crying. And I felt better.

After a year, I decided to go off the medication. Things had been much better and I wanted to see if I could “go back to normal.” And things did go back to normal. But it turns out my normal wasn’t very comfortable.

There have been many discussions and articles recently asking if modern psychiatry is over-medicating women. A recent op-ed in the New York Times by psychiatrist Julie Holland suggested that many of the symptoms for which women are treated with antidepressants are natural and healthy. “We have been taught to apologize for our tears,” she writes, “to suppress our anger and to fear being called hysterical.”

Here’s the thing, though. Breaking down into uncontrollable tears because you stubbed your toe and it’s the straw that broke the stress-camel’s back doesn’t feel good. Continue reading

Toward A Less Invasive Mode Of Deep Brain Stimulation

Imagine this futuristic tableau: A severely depressed person walks into her doctor’s office, sits in a specially designed chair with a coil around her head, and with little more than an IV injection, undergoes deep brain stimulation to treat her deep, dark psychological illness.

Well, that’s not going to happen any time soon, but engineers at MIT are working on the building blocks that could make that fictional scenario a reality.

They’ve developed a method — a proof-of-concept, really — to stimulate brain tissue using external magnetic fields and injected magnetic nanoparticles that resemble small bits of rust. This technique allows for direct stimulation of neurons, which could someday be an effective treatment for a variety of neurological diseases, like Parkinson’s, and even further in the future, for severe, treatment-resistant psychiatric disorders like depression, without the need for highly invasive brain implants or external connections. The research is published in the journal Science.

(Allan Ajifo/Flickr)

(Allan Ajifo/Flickr)

Current treatments have been effective in reducing or eliminating tremors associated with Parkinson’s but involve major brain surgery to implant wires that are connected to an outside power source.

Polina Anikeeva, an assistant professor of materials science and engineering at MIT, says the new research suggests a much less invasive possibility. I asked her to describe the research in an accessible way and here’s what she said:

First, I want to clearly say that we are still very far away from any clinical or even pre-clinical application, this is a first proof-of-concept study, looking at the possibility of using these materials to stimulate neurons deep in the brain.

What we’ve done is to give a simple injection of nanomaterials (iron oxide) that look like small bits of rust [but aren’t actually rust], deep into the brain. This allows us to deliver stimulus using a magnetic field, which is converted into heat by the little rust particules. Now we have a system where a magnetic field is applied from the outside and with a simple injection of the materials we can deliver the stimulas deep in the brain without the connectors and without the implants. We don’t have to be invasive in order to do the stimulation.

Continue reading

Related:

Growing Burden: Toll Of Major Depression Now Put At $210 Billion A Year

(Wikimedia Commons)

(Wikimedia Commons)

For more than two decades, Boston economist Paul Greenberg has been calculating the costs of depression — the mood disorder, that is, not the economic downturn.

His latest study, now out in the Journal of Clinical Psychiatry, finds that major depression is costing the American economy $210.5 billion a year — boosted dramatically by the toll of the recent recession. And rates of depression particularly shot up among people over 50.

I asked Greenberg, head of the health care practice at the Boston economic consulting firm Analysis Group, to elaborate. Our conversation, lightly edited:

First, what would you most highlight from your latest findings?

There are many highlights but I’d focus on two. The first is that the costs of depression are large and growing. And the second is that costs of depression are borne in the workplace in a very dramatic way. There’s no employer that’s exempt from the costs of depression. And I think both the magnitude of costs generally, as well as the costs that are specific to the workplace, are worthy of further attention, further thought, further research.

What are a couple of the specific numbers that you find most striking?

Let’s start with the overall finding: We find the costs of depression to be approximately $210 billion per year. One of the interesting aspects is that only 40 percent of those costs are actually attributable to depression itself.

Could you explain that?

That means that 60 percent is attributable to elevated costs that, in the data, don’t show up as directly connected to depression, but they’re associated with depressed people to a greater extent than with non-depressed people.

Economist Paul Greenberg (Courtesy)

Economist Paul Greenberg (Courtesy)

To be more concrete, on the mental-illness side, there are an awful lot of co-morbid anxiety disorders, a lot of co-morbid PTSD-associated costs — those are examples where the same person who suffers from depression tends to have a higher likelihood of also incurring costs in these co-morbid categories.

But should those costs really count toward depression, when it’s technically another disorder that’s causing them?

Fair enough. That’s part of the age-old question of to what extent is this cause and what’s effect. Take the example of someone who suffers from cancer. It could be that in some instances, there’s an elevated cost of depression when you suffer from cancer. That’s one causal pathway where the depression likely follows the physical disorder. But in another instance, it could be that back pain or sleep disorders or migraines – those are examples of elevated physical disorder costs that accrue to depressed patients, likely as a result, at least in part, of the depression.

Here’s why it matters. If we’re more successful at treating the depression, there’s little or no hope it will alleviate any of the cancer costs. But if we’re more successful at treating depression, there’s a great opportunity to alleviate some or even a large part of those back pain, sleep disorder and migraine kinds of costs that are currently co-morbid with depression. Continue reading

Blue/Black Or White/Gold, And Why Care? A Neuropsychiatrist Examines ‘The Dress’

Sometimes it just seems like the whole world has gone crazy. Like when your colleagues, all serious people, cluster for precious minutes around a computer screen debating the color of a dress. And you see that, online, many other serious people are doing the same thing — say, at On Point or The New York Times.

So though I was curious about the science behind the recent viral phenomenon known as “The Dress,” my first question for Boston-area neuropsychiatrist Dr. Jon Lieff was a more mundane “Why?” To quote one top Slate commenter, “How is this a thing?”

Not that it’s a bad thing. The dress phenomenon “informs people that perception is not what it seems,” Dr. Lieff says. “We think we see reality when in reality, what we see is what the brain wants us to see. And that leads us into philosophy…”

But let’s not go into philosophy just yet. (And you can read Dr. Lieff’s thoughts at more depth on his website, Searching for the Mind.) Let’s talk instead about why this of all optical illusions swept the Internet.

His bottom line: “Our brain is correcting for an imagined light source. That’s the problem.”

And what’s unusual about it: “This doesn’t usually happen with an illusion: In any crowd, you have half the people saying one thing and the other half saying another thing. And because of the type of illusion it is, once it’s fixed, your brain is going to keep you on the blue side or the white side. I’m sure you’ve seen other kinds of illusions where it flips back and forth.  This is different. Once people choose their sides, they’re saying, ‘This is it, and I’m the right one and you’re the wrong one.’ So it’s captured the imagination, but in truth there are hundreds of these occurring all day long, that people don’t realize.”

“An example: if you’re watching a waterfall on the TV and your hand is on the desk, your hand thinks the desk is rising up. Continue reading

On ‘Radio Open Source,’ An Intimate Look At Decades Of Depression

I’ve never met the Cambridge-based writer George Scialabba, but now I can’t stop thinking about him.

About his personal psychiatric records, from his decades of treatment for depression, so courageously shared in a recent piece he wrote in The Baffler: “The Endlessly Examined Life,” subtitled “A Most Chronic Depression.” And about his extraordinary recent interview with his friend, Christopher Lydon, on “Radio Open Source.” You can hear it in the podcast above.

Writer George Scialabba (Courtesy Radio Open Source)

Writer George Scialabba (Courtesy Radio Open Source)

The conversation is interspersed with dramatic readings of excerpts from George’s medical records, and it includes a bit of kind encouragement from one who knows:

One of the things that hurts most about depression is that you don’t really believe that it’s ever going to go away, get better. It just doesn’t seem like something with a plausible cause. So you can’t imagine what the remedy is. So people should tell you: “Look, eventually, everybody gets a little better. Some people are still mildly depressed, but virtually no one is acutely depressed for decades and decades — their whole life. It’ll get a little better, and probably a lot better. So hang on.”

So many of us know depression personally — one in 10 Americans, by an estimate that must set the bar very high — that I expect this powerful, double-platform exploration of George Scialabba’s experience will elicit very varying personal responses. “Radio Open Source’s” post about the interview includes just one comment, at last look, but it’s a gorgeous one, including this:

Well, you would think that this subject is not where you want to go in this particular winter of 2015. But it’s not about depression. Or not about only that. What it’s really about is what happened in spite of it or because of it; what happens climbing out of it, or trying to. I have had to learn and will probably have to learn again that we are not only our particular illness. It’s the illness, the suffering, the pain, which you can never convey (but need to try) even to the most sympathetic, that pain itself that is the door through which you walk to somewhere else. But also I think one needs to have something to grab onto — maybe the rope of creative expression and reaching out. Something.

One brief personal reaction: I like George’s theory that depression may be the result of faulty emotional “shock absorbers.” But I was most struck by the possibility that, after he ended his intense involvement in the religious order Opus Dei, he never fully recovered because he needed that involvement, perhaps that faith, to face life. He had a great big Human Condition problem more than a personal psychological problem. Just a thought. But it’s what I find most echoing in my mind. That, and the fact that his psychiatrists seemed to mean very well, and some surely did help him, but they came nowhere near a solution to the enduring mystery of his long emotional suffering.

Read excerpts of George’s medical records in the Baffler piece here, listen to the podcast above, and please share what echoes most for you.

Further listening: “Radio Open Source: The Untethered, Untenured Mind