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due to popular demand, a recommended reading list for patients, family, and friends of those diagnosed with a cycling mood disorder…..
I Am Not Sick, I Don’t Need Help! Helping the Seriously Mentally Ill Accept Treatment Xavier Amador with Anna-Lisa Johanson
Loving Someone with Bipolar Disorder Julie A. Fast, John D. Preston
Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression Frederick K. Goodwin and Kay Redfield Jamison
more to come…….
This article appeared in the new york times today:
OYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.
Farewell to the Couch
Articles in this series will examine recent shifts in medical care.
Share your insights on the changing medical profession with The New York Times and the Public Insight Network from American Public Media.
Dr. Matthew Levin, son of Dr. Donald Levin, is completing training to be a psychiatrist. The elder Dr. Levin said he hoped his son would not feel his ambivalence about their profession.
But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”
Like many of the nation’s 48,000psychiatrists, 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.
Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.
Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.
Then, like many psychiatrists, 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. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.
Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”
Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.
“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.”
With thinning hair, a gray beard and rimless glasses, Dr. Levin looks every bit the psychiatrist pictured for decades in New Yorker cartoons. His office, just above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has matching leather chairs, and African masks and a moose head on the wall. But there is no couch or daybed; Dr. Levin has neither the time nor the space for patients to lie down anymore.
On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions renewed, an encounter that took about 12 minutes.
Two years ago, the man developed rheumatoid arthritis and became severely depressed. His family doctor prescribed an antidepressant, to no effect. He went on medical leave from his job at an insurance company, withdrew to his basement and rarely ventured out.
“I became like a bear hibernating,” he said.
Missing the Intrigue
He looked for a psychiatrist who would provide talk therapy, write prescriptions if needed and accept his insurance. He found none. He settled on Dr. Levin, who persuaded him to get talk therapy from a psychologist and spent months adjusting a mix of medications that now includes different antidepressants and an antipsychotic. The man eventually returned to work and now goes out to movies and friends’ houses.
The man’s recovery has been gratifying for Dr. Levin, but the brevity of his appointments — like those of all of his patients — leaves him unfulfilled.
“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”
“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”
The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.
Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.
Farewell to the Couch
Articles in this series will examine recent shifts in medical care.
Share your insights on the changing medical profession with The New York Times and the Public Insight Network from American Public Media.
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.
Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.
When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists with whom he had worked were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.
“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”
He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”
“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”
Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group. To maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.
Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin’s office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.
“Medication is important,” she said, “but it’s the relationship that gets people better.”
Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful. His office assistants were so sympathetic to his tearful patients that they often failed to collect. So in 2004, he begged his wife, Laura Levin — a licensed talk therapist herself, as a social worker — to take over the business end of the practice.
Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.
“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”
She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said, words that echoed her husband’s.
Drawing the Line
Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.
“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”
Initial consultations are 45 minutes, while second and later visits are 15. In those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and family histories. He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview. Even so, patients sometimes fail to tell him their most important symptoms until the end of the allotted time.
“There was a guy who came in today, a 56-year-old man with a series of business failures who thinks he has A.D.D.,” or attention deficit disorder, Dr. Levin said. “So I go through the whole thing and ask a series of questions about A.D.D., and it’s not until the very end when he says, ‘On Oct. 28, I thought life was so bad, I was thinking about killing myself.’ ”
With that, Dr. Levin began to consider an entirely different diagnosis from the man’s pattern of symptoms: excessive worry, irritability, difficulty falling asleep, muscle tension in his back and shoulders, persistent financial woes, the early death of his father, the disorganization of his mother.
“The thread that runs throughout this guy’s life is anxiety, not A.D.D. — although anxiety can impair concentration,” said Dr. Levin, who prescribed an antidepressant that he hoped would moderate the man’s anxiety. And he pressed the patient to see a therapist, advice patients frequently ignore. The visit took 55 minutes, putting Dr. Levin behind schedule.
In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.
“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”
Dr. Levin, wearing no-iron khakis, a button-down blue shirt with no tie, blue blazer and loafers, had a cheery greeting for his morning patients before ushering them into his office. Emerging 15 minutes later after each session, he would walk into Ms. Levin’s adjoining office to pick up the next chart, announce the name of the patient in the waiting room and usher that person into his office.
He paused at noon to spend 15 minutes eating an Asian chicken salad with Ramen noodles. He got halfway through the salad when an urgent call from a patient made him put down his fork, one of about 20 such calls he gets every day.
By afternoon, he had dispensed with the cheery greetings. At 6 p.m., his waiting room empty, Dr. Levin heaved a sigh after emerging from his office with his 39th patient. Then the bell on his entry door tinkled again, and another patient came up the stairs.
Farewell to the Couch
Articles in this series will examine recent shifts in medical care.
Share your insights on the changing medical profession with The New York Times and the Public Insight Network from American Public Media.
“Oh, I thought I was done,” Dr. Levin said, disappointed. Ms. Levin handed him the last patient’s chart.
Quick Decisions
The Levins said they did not know how long they could work 11-hour days. “And if the stock market hadn’t gone down two years ago, we probably wouldn’t be working this hard now,” Ms. Levin said.
Dr. Levin said that the quality of treatment he offers was poorer than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. “But my office is like a bus station now,” he said. “How can I have an analytic calm?”
And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. “You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”
In interviews, six of Dr. Levin’s patients — their identities, like those of the other patients, are being withheld to protect their privacy — said they liked him despite the brief visits. “I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”
Another patient, a licensed therapist who has post-partum depression worsened by severalmiscarriages, said she sees Dr. Levin every four weeks, which is as often as her insurer will pay for the visits. Dr. Levin has prescribed antidepressants as well as drugs to combat anxiety. She also sees a therapist, “and it’s really, really been helping me, especially with my anxiety,” she said.
She said she likes Dr. Levin and feels that he listens to her.
Dr. Levin expressed some astonishment that his patients admire him as much as they do.
“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”
The Levins’s youngest son, Matthew, is now training to be a psychiatrist, and Dr. Donald Levin said he hoped that his son would not feel his ambivalence about their profession since he will not have experienced an era when psychiatrists lavished time on every patient. Before the 1920s, many psychiatrists were stuck in asylums treating confined patients covered in filth, so most of the 20th century was unusually good for the profession.
In a telephone interview from the University of California, Irvine, where he is completing the last of his training to become a child and adolescent psychiatrist, Dr. Matthew Levin said, “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”
As we all know, marijuana remains controversial culturally, socially, legally, and medically. A recent article/study I came across in a psychiatry online journal medscape:
A number of studies in recent years have revealed complex links between marijuana use and psychotic symptoms and diagnosable psychotic disorders like schizophrenia. Although a thorough review of this broad literature is beyond the purview of this brief communication, two avenues of research will be succinctly summarized, pertaining to (1) associations between cannabis use and clinical manifestations of psychosis, and (2) the biologic plausibility of the observed links.
Diverse studies suggest that cannabis use is associated with psychotic phenomenology. First, in addition to being the most abused illicit substance in the general US population, cannabis is clearly the most abused illegal drug among individuals with schizophrenia.[1,2] Furthermore, the initiation of cannabis use among those with psychotic disorders often precedes the onset of psychosis by several years.[1,3,4] Second, cannabis use in adolescence is increasingly recognized as an independent risk factor for psychosis and schizophrenia.[5-7] That is, several epidemiologic studies suggest that cannabis use is a component cause of schizophrenia.[8,9] Very recently, McGrath and colleagues[10] reported that early cannabis use is associated with psychosis-related outcomes (having a nonaffective psychotic disorder, scoring in the highest quartile of the Peters Delusions Inventory,[11] and reporting hallucinations) in a cohort of 3801 individuals assessed at age 18-23 years. Findings among 228 sibling pairs in that study reduce the likelihood that unmeasured confounding variables account for the results.[10] Third, cannabis use may interact with genetic factors to elevate risk for psychotic disorders. One sentinel study demonstrated that the catechol-O-methyltransferase Val158Met functional polymorphism moderates the effects of adolescent-onset cannabis use on the later development of psychosis.[12] Fourth, preliminary research suggests that cannabis use before the manifestation of psychiatric symptoms may be associated with an earlier age at onset of psychotic symptoms,[13] and perhaps even an earlier onset of prodromal symptoms.[14] We found that simply classifying first-episode psychosis patients according to their maximum frequency of use before onset of psychotic symptoms (ie, categorizing into none, ever, weekly, or daily use) revealed no significant effects of cannabis use on risk for onset, but analyzing the change in frequency of use before onset (using time-dependent covariates), revealed that progression to daily cannabis use was associated with age at onset.[14] Fifth, aside from studies linking cannabis use and psychotic disorders, an increasing body of research suggests a potential association between cannabis use and schizotypal symptoms, or psychosis-proneness, in the general population.[15,16]
Several lines of evidence support the potential biologic plausibility of these links between cannabis use and psychosis. First, exogenous (eg, Δ-9-tetrahydrocannabinol) and endogenous cannabinoids (eg, anandamide) exert their effects (such as modulating the release of neurotransmitters including dopamine and glutamate) by interactions with specific cannabinoid (CB1) receptors that are distributed in brain regions implicated in schizophrenia. Second, several studies have shown an increased CB1 receptor density in brain regions of interest in schizophrenia, including the dorsolateral prefrontal cortex and the anterior cingulate cortex.[17,18] Third, other studies report elevated levels of endogenous cannabinoids in the blood and cerebrospinal fluid of patients with schizophrenia.[19-21] Fourth, acute, controlled administration of Δ-9-tetrahydrocannabinol causes both patients and controls to experience transient increases in cognitive impairments and schizophrenia-like positive and negative symptoms.[22] In summarizing these and many other findings, Fernandez-Espejo and colleagues[23]have suggested that the endocannabinoid system is altered in schizophrenia and that dysregulation of this system, perhaps induced by exogenous cannabis, can interact with neurotransmitter systems in a way so that a “cannabinoid hypothesis” can be integrated with other neurobiologic hypotheses (eg, those involving dopamine and glutamate).
In sum, a growing body of clinical and epidemiologic research suggests significant but complex links between cannabis use and psychosis. Concurrently, ongoing neurobiologic research is revealing findings in the endocannabinoid system that appear to support the biologic plausibility of such links. It should be noted that much of the research conducted to date does not allow for causal determinations. Ongoing research of varying designs will undoubtedly enlighten the field.
parents are always asking me about the effects of tv and computer games on their children. Please read this article:
http://news.yahoo.com/s/afp/20101011/wl_uk_afp/healthmindchildrentelevisioncomputer
note the following article appearing in today’s LA times:
http://www.latimes.com/health/la-sci-marijuana-20101010,0,3819276.story
We are on the verge of passing the most important piece of social welfare legislation in decades….though imperfect, this bill takes important steps toward ensuring that health care is treated as a basic civil right that every American is entitled to.
Read an informative article that appeared in the New York Times Sunday Magazine in September, 2008, on the controversy surrounding the diagnosis and treatment of bipolar disorder in children.
http://www.nytimes.com/2008/09/14/magazine/14bipolar-t.html?_r=1&scp=1&sq=bipolar%20kids&st=cse
INFORMATION FROM INDUSTRYNovember 21, 2008 — Contrary to recent research, new evidence shows that therapeutic doses of stimulant medications, including methylphenidate (MPH)- and amphetamine-based drugs, which are widely used to treat attention-deficit/hyperactivity disorder (ADHD), do not cause cytogenetic damage in children.
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After 3 months of continuous treatment with MPH- or amphetamine-based medications, no significant treatment-related increases were observed in any of 3 standard measures of cytogenetic damage among 47 children 6 to 12 years of age.
“Our results demonstrated that standard therapeutic levels of either methylphenidate or mixed amphetamine salt (MAS) products in our study did not increase measures of chromosome damage in white blood cells of children who had been treated continuously for 3 months,” study author Kristine L. Witt, MSc, from the National Institute of Environmental Health Sciences, toldMedscape Psychiatry.
With principal investigator Scott Kollins, PhD, from Duke University Medical Center, in Durham, North Carolina, the study is published online November 19 in the Journal of the American Academy of Child and Adolescent Psychiatry.
Cancer Scare
Investigators at the University of Texas MD Anderson Cancer Center in Houston, raised red flags when, in a 2005 study, they reported cytogenetic damage in the lymphocytes of 12 pediatric ADHD patients after 3 months of continuous MPH-based drug therapy (Cancer Lett. 2005;230:284-291).
These reported alterations consisted of increased frequencies of standard measures of cytogenetic damage, including sister chromatid exchanges (SCE), structural chromosomal aberrations (CA), and micronuclei.
“This raised concern among members of the medical community and families of children receiving MPH-based therapy because increased frequencies of CAs and micronuclei in peripheral blood lymphocytes are associated with an increased risk of cancer,” the authors of the current study write.
However, after publication of the 2005 study, the research community raised questions about the validity of findings based on, among other things, the small sample size and, most important, the fact that there was an absence of SCE data recorded for 6 of 11 children.
More recent research prompted by the 2005 study suggests that MPH does not cause genetic damage. However, despite the growing evidence that MPH-based stimulants are safe, said Ms. Witt, the investigators felt that the “enormous public-health significance of the issue” warranted further investigation.
Methylphenidate-based products have been prescribed for more than 50 years, but use of these drugs has increased sharply since 1990, as the number of children and adults diagnosed with ADHD has risen. In 1996, MAS, another stimulant medication, was also approved for the treatment of ADHD.
Larger, More Comprehensive Study
According to Ms. Witt, the primary goal of the current study was to determine whether the results of the study by the MD Anderson Cancer Center researchers could be independently replicated in a similarly designed trial with sufficient statistical power to detect an increase in genetic damage.
However, said Ms. Witt, given the fact that MAS products are also widely used to treat ADHD and there are currently no cytogenetic data on these drugs, they also decided to test MAS medications in addition to MPH.
The study examnined 63 children, aged 6 to 12 years, diagnosed with ADHD who had not been previously treated with stimulant medications. Baseline blood samples to determine cytogenetic measures were taken in each child, and a second sample was collected after 3 months of continuous treatment.
Of the total study group, 34 subjects were randomized to receive MPH and 29 to receive MAS. A total of 47 children completed the full 3-month treatment schedule.
There were no significant differences between the 2 treatment groups with respect to age, sex, race, body weight, height, or ADHD subtype. The groups had similar ADHD symptom levels at initial screening, and children in both groups responded equally well to the study medications.
Results “Completely Negative”
At the end of the study, the researchers found no cytogenetic changes in any of the study participants, including those children who left the trial early.
“These products do not induce genetic damage in white blood cells of children, and that is reassuring because those changes can be associated with an increased risk for cancer down the road, said Ms. Witt.
“This is a straightforward, simple study with a straightforward design meant to reproduce another study, and [our] results clearly did not reproduce the earlier findings and, in fact, are completely negative,” she continued.
Ms. Witt added that the 3-month study duration is sufficient to detect primary induction of cytogenetic change. She said there have been some studies looking at 6-month exposures to MPH, measuring the single micronuclei end point, and these have been similarly negative.
Typically, children on stimulant medications are long-term users and, therefore, said Ms. Witt, studies looking at the impact of long-term exposure with respect to other outcomes would help reassure parents and the medical community.
The study was supported by the National Institutes of Health. Dr. Kollins reports receiving research support and/or honoraria/consulting fees from Athenage, Eli Lilly, Psychogenics, Pfizer, New River Pharmaceuticals, Shire Pharmaceuticals, National Institute on Drug Abuse, National Institute of Mental Health, National Institute of Neurological Disorders and Stroke, and Environmental Protection Agency. Study author Allan Chrisman, MD, from the Duke University Medical Center, reports receiving honoraria and was on the speaker’s bureaus for Shire Pharmaceuticals and McNeil-PPC. The other authors have disclosed no relevant financial relationships.
J Am Acad Child Adolesc Psychiatry. Published online before print November 19, 2008.
