Bernards Voices

The toll from soaring rates of prescription drug abuse, including both psychiatric medications and drugs for pain, has begun to dwarf that of the usual illegal culprits. Hospitalizations related to prescription drugs are up fivefold in the last decade, and overdose deaths up fourfold. More high school seniors report recreational use of tranquilizers or prescription narcotics, like OxyContin and Vicodin, than heroin and cocaine combined.

via An Addiction Expert Faces a Formidable Foe – Prescription Drugs – NYTimes.com.

This article is more a profile Dr. Nora D. Volkow, the neurologist who heads the National Institute on Drug Abuse, than it is about the science of addition. It also touches on the politics of merging two bureaucracies within the federal National Institutes of Health: N.I.D.A and the National Institute on Alcohol Abuse and Alcoholism.

Abuse of prescription drugs presents a different kind of problem than illegal drugs: they have to be available for the medical benefits they bring, but be strictly controlled.

For instance, Dr. Volkow’s group showed several years ago that when cocaine addicts watched videos of people taking drugs, dopamine levels surged in the part of their brains associated with habit and learning, correlating with the intense drug cravings the subjects began to experience.

Her research and that of others has also shown that even after addicts are successfully detoxed and long clean, their dopamine circuits remain abnormally blunted. Substances that elevate dopamine levels in normal subjects had notably muted responses in ex-addicts.

This observation, experts say, may explain the intense difficulty addicts have staying clean, as the ordinary rewards of daily life may have little effect on the recovering brain. Only the drug of choice will send dopamine levels high enough for any kind of pleasure.

And interesting policy point, obvious once pointed out:

To the average doctor, … the addict’s brain is impenetrable. All that is visible is irrational, illegal and sometimes threatening behavior. Surveys show most doctors prefer to keep their distance from addiction and addicted patients.

The number of prescriptions written for potentially addictive pain medications has soared in the last decade, reaching more than 200 million in 2010, Dr. Volkow said. Surveys asking teenagers where they get pills find that relatively few buy from strangers. Many have their own prescriptions, often from dental work.

“Students and residents have gotten the message that pain is undertreated,” said Dr. Mitchell H. Katz, an internist who directs the Los Angeles County Department of Health Services. “So they just prescribe higher and higher doses.” Meanwhile, he said, there is no evidence that treatment with opioids for more than four months actually helps chronic pain, or that higher doses work where lower ones fail. There is good evidence, however, that higher doses raise the risk of overdose and death.

Prof. Murray B Stein MD and Prof. Dan J Stein MD, in The Lancet, Volume 371, Issue 9618, Pages 1115 – 1125, 29 March 2008.

Abstract:

Our understanding of social anxiety disorder (also known as social phobia) has moved from rudimentary awareness that it is not merely shyness to a much more sophisticated appreciation of its prevalence, its chronic and pernicious nature, and its neurobiological underpinnings. Social anxiety disorder is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (eg, personality trait neuroticism) core phenotypes to identify risk loci. A range of effective cognitive behavioural and pharmacological treatments [SSRIs] for children and adults now exists; the challenges lie in optimum integration and dissemination of these treatments, and learning how to help the 30—40% of patients for whom treatment does not work.

Listen to the podcast (interview starts at minute 6:00).

My notes from the podcast–bolded items in abstract plus:

• like sadness vs depression, shyness vs social anxiety exist on a spectrum, and it is the “most shy person you know” where this disorder may interfere with their life, and is worth treatment.
• diagnosable in 5% of the population
• easy to diagnosis.  physician/therapists asks: “Does you shyness interfere with your life?”  A yes answer is a strong predictor.
• stigma:  eg. General Physicians often themselves consider it trivial

Also in the issue Simon Wessely provides a dissenting view, reviewing How shyness became social phobia by Christopher Lane.

Pathologising shyness, eccentricity, or sadness does few any favours—neither those who receive unhelpful labels, nor those with major mental disorders who need all the resources and research we can muster.

In the March 5th, New York Times, Gardiner Harris, reports that insurance does not pay enough to justify a psychiatrist providing talk therapy.

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

When Dr. Levin began his practice in 1972:

he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.

The article seems to deal, first, with the impact on the doctor–the loss of intimacy and connection he feels with his patients. But that it is insignificant, I feel, compared to the loss to the patients. Many studies conclude that medications, when necessary, combined with talk therapy provide the best results.

I’m not implying that Dr. Levin isn’t recommending talk therapy, he is, but finding a second doctor, either in-network, or paying for it out of pocket, or the patient filling out his own paperwork to get partially reimbursed for the therapy, just adds more and more obstacles to getting care. And many people don’t follow through. If you are suffering, maybe you’re depressed, anxious … just how many hoops are you going to jump through?

“Medication is important,” [Dr. Louisa Lance] said, “but it’s the relationship that gets people better.”

Harris makes a tricky little point below by conflating social workers and psychologists. Psychologists with PhDs or PsyDs have invested quite a lot of money as well, and do more training than social workers. I doubt they are very happy, actually I know from experience, that they aren’t happy with the reimbursement rates from insurers either.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Here is a related post, from March last year. And another post, from January last year.

On December 19, 2010, Trip Gabriel reported in the The New York Times that:

Stony Brook is typical of American colleges and universities these days, where national surveys show that nearly half of the students who visit counseling centers are coping with serious mental illness, more than double the rate a decade ago. More students take psychiatric medication, and there are more emergencies requiring immediate action.

Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.

A recent survey by the American College Counseling Association found that a majority of students seek help for normal post-adolescent trouble like romantic heartbreak and identity crises. But 44 percent in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago.

Stony Brook has seen a sharp increase in demand for counseling — 1,311 students began treatment during the past academic year, a rise of 21 percent from a year earlier. At the same time, budget pressures from New York State have forced a 15 percent cut in mental health services over three years.

The article then tells a good day-in-the-life story of the college counselor. The triage they do to make sure the serious cases get dealt with the right way. Many colleges have systems where the campus psych services give a few sessions to the students, but they are designed to refer the students out to a private practioner, just so that there will be enough hours left to deal with all the demand.

On recent day … two dozen volunteers in black T-shirts reading “Chill” stopped passers-by in the Student Activities Center during lunch hour.

“Would you like to take a depression screening?” they asked, offering a clipboard with a one-page form to all who unplugged their ear buds. Students checked boxes if they had difficulty sleeping, felt hopeless or “had feelings of worthlessness.” They were offered a chance to speak privately with a psychologist in a nearby office. Sixteen said yes.

The depression screenings are part of a program to enlist students to monitor the mental health of peers, which is run by the four-year-old Center for Outreach and Prevention.

Students monitoring the mental health of peers. This sounds similar to the Mental Health First Aid program that we’re starting with HOP.

“I don’t have motivation for things anymore,” the student said. “This place just depresses me the whole time.” [The student] had been unaware that students could walk in unannounced to the counseling center. “I thought you had to make an appointment,” she said. “Yes,” she said, “I’ll do that.”

We hear things like this all the time. Help is available. But people, like this student, are unaware just how easy it is to ask for help–if they are willing to ask. We recommend the NJmentalhealthcares helpline for that first call for help. It is staffed by professionals. They assess, and connect, the callers to the right services. And they offer a follow-up call in a week to make sure the connection is made. That is just the surface description of the job, but they become very personally engaged, like the counselors at Stony Brook who are discussed in this article, in making sure the callers get the help they need.

In today’s New York Times, Pam Belluck reports on a new study from the Archives of General Psychiatry, and efficacy of treatments for adolescent depression.

About half of adolescents who recovered from major depression became depressed again within five years, regardless of what treatment or therapy they received to get over their initial depression

In the study, nearly 200 adolescents, 12 to 17, received 12 weeks of fluoxetine (Prozac), cognitive behavioral therapy, both, or a placebo pill. (Those not receiving cognitive therapy met with a psychiatrist for basic support.) Placebo-takers who did not improve after 12 weeks could choose any of the other treatments.

Researchers had previously found that those receiving the Prozac-and-cognitive-therapy combination recovered faster from the first depression. So they expected those youths to be less prone to another depression.

But that did not happen. After 36 weeks, improvement for everyone was similar, researchers said, and by two years most completely recovered. But by five years, 47 percent suffered another major depression, no matter what treatment had helped them recover.

The researchers also expected that youths who improved almost fully during the 12 weeks would have less chance of recurrence. They did not, although those showing no improvement at all at 12 weeks were more prone to another depression after recovery than those who showed at least some progress during the 12 weeks. Teenagers who also suffered from anxiety were more likely to become depressed again.

I’ve posted (eg. in March) here many times before on depression: it is progressive, it is chronic, it needs to be attacked aggressively. In my family’s own personal experience it is devastating if not treated.

Dr. Curry said one limitation to the study was that researchers did not look at specific events in the youths’ lives to see if some encountered more stress than others.

I’ve also posted recently (and in August) that having the parents involved in therapy helps. That doesn’t appear to have been considered in this study. My personal theory is that the parents could use the therapy just as much as the kids. We learn so little about how to parent. We do it seat of the pants. And of course we parents may have issues all of our own.

In September 2, The New York Times’s Duff Wilson reports on prescribing psychotropic drugs on children.

The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3.

More than 500,000 children and adolescents in America are now taking antipsychotic drugs, according to a September 2009 report by the Food and Drug Administration. Their use is growing not only among older teenagers, when schizophrenia is believed to emerge, but also among tens of thousands of preschoolers.

“Psychotherapy is the key to the treatment of preschool children with severe mental disorders, and antipsychotics are adjunctive therapy — not the other way around,” [Dr. Lawrence L. Greenhill, president of the American Academy of Child and Adolescent Psychiatry,] said. But it is cheaper to medicate children than to pay for family counseling, a fact highlighted by a Rutgers University study last year that found children from low-income families, like Kyle, were four times as likely as the privately insured to receive antipsychotic medicines.

In addition, foster care children seem to be medicated more often, prompting a Senate panel in June to ask the Government Accountability Office to investigate such practices.

Ms. Warren conceded that she resorted to medicating Kyle because she was unprepared for parenthood at age 22, living in difficult circumstances, sometimes distracted.

Letters to editor on above article.

In the August 3, 2010 New York Times, Richard Perez-Pena reports:

Patient advocates filed a federal lawsuit on Tuesday charging that New Jersey psychiatric hospitals routinely medicate patients against their will without a review by an outside arbiter, a practice that is banned in most other states.

Twenty-nine states require a judge’s ruling for involuntary medication, according to the suit, including New York, Connecticut and other large states, like California, Florida and Texas. Five other states leave the decision to an individual or panel outside the hospital. Some states also provide an advocate to represent a patient in a hearing on forced medication.

But in New Jersey, state rules allow a patient in a state hospital to appeal medication decisions only to people in the hospital. The lawsuit contends that the internal appeal process is routinely ignored and that psychiatric patients in private hospitals lack any opportunity to appeal medication regimens at all.

Phil Lubitz, associate director of the National Alliance on Mental Illness of New Jersey, said he did not see forced medication as a major issue, noting that it was extremely difficult to get patients committed in New Jersey, and that most who were presented “a danger to themselves or others.”

But Robert Davison, executive director of the Mental Health Association of Essex County, called New Jersey’s policy “beneath contempt.” “This state is way behind the times,” he said. “It suspends people’s civil rights without due process, and it’s troubled me for years.”

The Dec 16, 2006 Lancet podcast on Generalized Anxiety Disorder addresses the question: how should our medical system detect and treat anxiety?

GAD is defined by exclusion.   It is not a panic disorder—which is a sudden, severe, episode or attack, of anxiety.   GAD is not post traumatic stress disorder—which also has clearly defined source.  GAD, Professor Peter Tyrer says, effects 10 to 12% of the population at any one time.   It is chronic.  It persists.  It is described as free floating.  Everything a person does or thinks is tinged with anxiety.   Psychological symptoms include: tension, worry, inability to concentrate. The physical symptoms are a consequence of continuous autonomic arousal: palpitations, trouble breathing, chest pains, tingling, and feelings of unreality, depersonalization.

Depression and anxiety often overlap—in fact that combination is the most common mental illness a primary care physician would see.   And it isn’t that a primary care physical would be blind to anxiety—it is so common that they know it when they see it—but what is more rare is the decision to treat it, because they, like the general public, see it as a symptom and they look past it, wanting to get to the underlying problem.

But GAD treatment exists.   Not only are there drugs (sedatives, tranquilizers, anti-depressants) but also cognitive behavioral therapies that help the patient identify their distorted cognitions and conclusions they have about their symptoms.

Since anxiety is such a common ailment, economic and social concerns demand it be dealt with in primary care.  The big challenge facing the UK national health service is to:

… make the psychological treatments available, because these are the ones that are wanted by patients, and the evidence base suggests, because of the dependence problems with drug treatments, and these occur with all types of psychiatric drugs for treatment of anxieties, nothing really which is effective in treating anxiety has no problems at all when you stop taking it, but this doesn’t apply to the psychological treatments …

The psychological treatments are successful and their effects persist.   The drugs stop being effective when the patient stops taking them.

Here are some quick notes on his talk. I had to leave before he finished, but maybe Larry or Caroline, you can add some comments that I missed.

Dr. Rosenberg was very thoughtful speaker. He first walked us through his education, from undergraduate in Psychology, through medical school, and then three year residency in Psychiatry.

He talked about a wide range of presentations of depression–starting from the completely normal responses to external events–for example your house has a rotting foundation and you have no money to pay to fix it. There is no good outcome. You feel helpless. You can’t see the solution.

But there are gradually more severe forms of depression, and if the patient develops depressive mechanisms (depression is a coping strategy–just not a positive one) the problems don’t get addressed, they pile up, and compound each other. Then in the extreme form, Dr. Rosenberg described depression as a psychosis–losing touch with the reality around you–the reality, for example, that there are caring people who can and want to help you.

Talk therapy can help the patient understand, and then change, a coping strategy which is not really helping.

When should you ask for help? When you are depressed “a lot.” When things aren’t getting done. They’re piling up. Procrastinating at work–and then worrying all evening about the work you didn’t get done–that is sitting on your desk the next morning, waiting for you when you walk in the office.

Dr. Rosenberg talk about medications and their side effects. The medication doesn’t just treat the specific depression, for example, but it impacts many other parts of your mind and body. So you should be aware of that, and be watched carefully by a MD–particularly as you are adjusting to the medication and the dosage. (One scenario: meet MD, get meds. 5 days check-in with MD. 3 days later check-in with MD. 3 days later check-in with MD. This is the frequency, particularly in the beginning of taking the med.)

One cautionary tale about meds, is that in lifting the depression, you physically respond to the drugs faster than you mind does, so you may get more energy. But you apply that energy to negative behavior (suicide) before you mind catches up to your body. That is why he emphasized combining medications with therapy, and that he was very conservative in prescribing medication.

This is about the time I left the session.

The first, from the New York Times Magazine is an essay, Mind Over Meds, by a noted psychiatrist who was forced to rethink his approach to treatment, which has been heavily influenced by a growing trend in the psychiatric community that emphasizes drug therapy over psychotherapy/counseling. On Monday, May 10th, at 1:00 pm, Paul Rosenberg, MD, a psychiatrist affiliated with Morristown Memorial Hospital, will be speaking on “The Role of the Psychiatrist: How to Know When One is Needed”. It wil lbe interesting to hear his thoughts on this trend and to find out whether he, too, has felt pressure by managed care to shorten his visits with patients and to prescribe more anti-psychotic medication.

The second article Feeling Warehoused in Army’s Trauma Care Units: GIs Depict Life of Pills and Isolation, relates to the Mental Health Week presentation, “Time and Again: Reliving Trauma”, which will feature talks by Corporal Justen Townsend of the US Marines and Stefan Neustadter, MSW, LCSW, who has worked with military veterans for more than 30 years. Brenda Forte, LCSW, a specialist in the most current treatments for trauma, is also part of the presentation which is scheduled for Wednesday, May 12, at 1:00 pm. The article offers a disturbing portrait of the Warrior Transition Battalion in Colorado Springs, where, again, the emphasis appears to be on prescribing medication rather than providing needed support and counseling.

In the first article, Daniel Carlatt writes:

over the course of the decade following my residency, my way of thinking about patients had veered away from psychological curiosity. Instead, I had come to focus on symptoms, as if they were objective medical findings, much the way internists view blood-pressure readings or potassium levels. Psychiatry, for me and many of my colleagues, had become a process of corralling patients’ symptoms into labels and finding a drug to match.

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ”

Forces [other than modern Psychiatric training] are at work as well. Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists. Weekly therapy takes time and is arduous work. If a daily pill can cure depression and anxiety just as reliably, why not choose this option?

In studies by Helen Mayberg, a professor of psychiatric neurology at Emory University, depressed patients given cognitive behavior therapy showed decreased activity in the frontal lobe, the brain center that might be responsible for the overmagnification of life’s problems that leads to depression in some patients. And they showed increased brain activity in parts of the limbic system, a brain region associated with strong emotion. But Mayberg found that when patients were given medication, their brain activities changed in the opposite direction, stimulating the frontal lobe and damping down the limbic system. “Our imaging results suggest that you can correct the depression network along a variety of pathways,” she said.