Mental Health Blogs

Archive for July, 2009

When we talk about enmeshment, and we’re not doing that now, but just so you should know, when we talk about enmeshment it’s really about fearing strangers. Parents are afraid that other people will steal their kids away from them emotionally. And they need them.

You need to know that to tie this post together.

I don’t know where I learned it, or if it’s a Jewish thing, or if someone taught it to me in school or I read it in Ann Landers, but I believe that everything you learn in life will come in handy someday, somehow. You use it all along the way.

Now that’s a world view, realize. Basically what you get on a blog is a world view, the way someone looks at life. And because world views have to be generalizations, exceptions don’t exactly fit. Here, for example, I’m saying that everything we learn in life comes in handy, meaning will be useful one day. Yet there are many things kids learn growing up in abusive homes that they wish they never learned, never had to know.

But even this, even having suffered, can come in handy. Abused people belong to a huge club, and empathy for this club is a handy thing to have, a human thing to have. Sometimes I wonder if anyone gets through life abuse-free. I don’t think so. Of course, there’s abuse. And there’s abuse. Ask any Holocaust survivor.

Let’s get to something happy, though, talk about how sometimes things tie together and how cool that is.

THE STORY

For years now I’ve heard people in therapy complain that it’s hard to clear their heads of intrusive thoughts, not necessarily traumatic memories, just junk thoughts, to-do lists, mainly, and things we forgot to do or should do, maybe know we’ll never do. We experience our busy lives, racing minds full of responsibilities and “musts”, most self-imposed, as irrepressible chaos. Too much data. Too many words. Pressure for time and energy, a sense that there just isn’t enough of either.

On my last post I didn’t even tell you that riding to work from the hospital, which should have been an idyllic bike ride, the junk thoughts in the brain would not quit.

Forgot to do this. Forgot that. Didn’t respond to this. Didn’t buy that. Need to write this. Need to send that. Need to clean this. Need to order that. Have to call her. Have to call him. Oh, and let’s not forget her. And him. And him and her. And her and him. And her mother. His sister. Her sister’s doctor. A third cousin once-removed. That cousin’s teacher.

Sure, I’m exaggerating. But all I wanted to do was to enjoy the weather, see the robins peck for worms, enjoy the sunshine and the sky. It was a nice day.

But it doesn’t work that way. Trapped on a bike with nothing to do but enjoy the ride. Couldn’t do it.

Crazy. What’s a therapist to do?

I did what works for me, drudged up an age-old anti-anxiety strategy, simple but reliable. I count. I think it started while clock-watching in fourth grade waiting for the bell to ring for recess, timing how long I could hold my breath. Something about that underwater drill at swimming lessons over the summer, gets into your head.

One, two, three, four. . . as high as I could go.

What counting does is focus just enough attention to a task that the rest of the noise in our heads has to take second to it. You can’t think about other things and still count. You can’t really sing and think about other things, either. So singing works, too, but I didn’t like any of the songs that came to my head that day on the bike. Barbra singing Smile just didn’t cut it.

Counting, singing, humming. These function as Western mantras. I know this because although I’ve never taken a formal meditation class, I still learned a little about it, and not from the Beatles, either. It’s just another one of those things you learn along the way, assuming you’re let out to do that.

I had just graduated high school (a semester early—couldn’t wait to get out of there). Every morning I took the train downtown to Roosevelt University. All kinds of people go to Roosevelt and although I was a commuter, I’d sit and try to get to know other students sitting in front of the big picture windows that overlook Michigan Avenue and the lake.

Somebody gave me a mantra in a clandestine way, like someone who is selling drugs.

Nam myho ren ge kyo. (rhymes with or sounds like palm-m’yo ho-wren-gay-key-oh!).

It’s a Buddhist chant. I think. I pick up languages quickly, or did then, is more accurate. All the way home on the train. . .

Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo, Nam myho ren ge kyo,

I think it’s your basic surrender your issues to some Higher Power, a Buddha, probably, maybe someone named Nam. The exact translation according to a YouTube video implies this. No idea if it’s true or not.

So the crazy thing is that if you repeat a phrase like Nam myho ren ge kyo often enough, you never really forget it, even if you never chant it again, even if you only chanted it in your head all the way home from school that one time. And when a patient asked me for a mantra, many, many years later, asked did I know any mantras, I had one to pass along. Such a bag of tricks, why wouldn‘t I have a mantra?

I’ve done this only once, passed the mantra along, but I did it with a disclaimer, one that you’ll get right now, that

There is no way in ___ that I can swear that this mantra helps anyone.

And if people are Jewish or Christian they’re probably better off saying Psalms. Pick a line, any line from King David’s poetry and tunes. Can’t say if these will help those of you who practice Islam or any other faith. You’ll have to use your own discretion, look into your liturgy.

Although I couldn’t then and still can’t swear by the efficacy of the mantra, I do know that the turning it over intervention can be useful.

Whatever your problems are- just give them to a Higher Power, ‘cuz seriously, you don’t need them, and the Universal Boss will take them, so give ‘em over already

This idea helps millions who work 12 Step programs to relinquish control. And we know that psychologically, when we surrender, when we relinquish control, something relaxes in the brain and everything feels a little better– under ordinary circumstances. I know there are exceptions.

So this is one way of clearing the disk. But there’s nothing like doing something we like, something that requires concentration, to help us forget the rest of the chaos, to put it off for a little while, maybe even indefinitely. When we’re busy exerting ourselves to the degree that it requires concentration, there’s no pathway open to junk thoughts. Think basketball or tennis, probably not golf.

There’s focus and distraction at our jobs, too, or should be. We either take charge or take orders, but if we’re in the moment, doing the task, paying attention, putting out, we might be able to shred the junk thoughts, although they do seem to reassemble, do they not, rally at inconvenient moments? But temporary relief beats no relief at all.

Helping someone can work, too. The spinning settles down when we’re useful, maybe helping someone load or unload some groceries, or mowing a neighbor’s lawn. You have to be careful not to scare anyone while offering to help, seriously. We’ve grown suspicious, as a society, of those who do this. There must be an ulterior motive.

We can clear our heads with a good walk, you know. The walk has to be long enough to go over every conceivable iteration of a problem, spill them all to the wind, every one of them, or release them to whomever is kind enough to walk with us, to listen.

And there’s nothing like a good puzzle, not a jigsaw, you can still think and do that, but maybe a crossword or a scramble. My mother does the scramble with my sister-in-law and I’m jealous of this, but it’s okay. It works for both of them better than it would work for me. And some of you, I know, like video games.

It isn’t like talking in therapy, no question, using these mini-interventions– helping someone, taking a walk, counting, turning it over, humming, concentrating on our work, playing games. But when people start offering you things like mantras for free, think about it. Can you trust someone who does that, gives you a mantra for free?

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I have a family member who has an infection in his nail. The treatment for the infection is a pill that is taken for 3 months (with some liver function monitoring). It’s not a fatal condition. He went to the doctor, got the bloodwork, waited for the results, then got a call from the doctor that he could start the medication and had the doctor call in the prescription to the pharmacy (CVS) next to his work. The pharmacy told him the medicine requires preauthorization. Even though there is not an alternative medication. The pharmacy called the doctor. The doctor filled out the preauthorization form. The form was sent in and it was rejected. The doctor called to say it was rejected and she didn’t know why or what to do. She said the medicine is available at Walmart for $4 and offered to call it in there. She waited while the number for Walmart was located. She phoned the medicine in. She called back to say it was done. My family member didn’t get the medicine at the pharmacy next to his office (where it cost $70 as cash, but likely has a negotiated lower cost to the insurance company plus his cash co-pay) and instead he drove 20 minutes each way to Walmart to pick up his $4 medication. The insurance company then spent the money on a 2 page personal letter and a stamp to inform him he wasn’t preauthorized because the physician did not document that the condition was painful or uncomfortable and did not document that over-the-counter topical medications had been tried (they haven’t been, but note, they take months to try and are known to be ineffective). The infection looks groddy, will not get better without treatment, and can spread, so treatment seems reasonable to me. There are no less expensive prescription treatments for this conditions and essentially no other options.

So let’s see: 6 phone calls by the doctor
3 phone calls by the pharmacist (to the insurance, to the doc, to someone to say the preauth was denied)
A 2 page letter spit out by a computer but with some personalization as to patient name and drug name
A postal stamp and the involvement of several postal employees
40 minutes of driving by an executive with a top notch private health plan.
And the $4 prescription was had.

And we’ll guess this amount of rigamarole saved the insurance company money by essentially bullying him into paying cash elsewhere rather than asking the doctor to fill out an appeal form and fax in “supporting documentation” for the appeal. How much did they save for the 3 months of medication they denied? Well $12 if they bought their meds at Walmart. If the insurance company actually paid the top cash price minus the copays, they saved an absolute max of $165 for 3 months at $70 (so $210) minus the $15 generic copays. My guess is it was somewhere inbetween, so was it worth it in terms of doctor time, pharmacist time, care manager time at express scripts, secretarial time for the appeal letter, mail carrier time, gas, and an hour of some busy’s guy’s life spent running around to get a script he could have gotten on his way back from lunch?

I don’t have the answers, but I do know our system is broken. Many say it’s broken only for the certain people….and really my family member got his medicine, and if the story got any more complicated, he would have just paid the $70, it’s just the idea that they throw you through all these hoops because they can.

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I’m going to write about a story I saw on-line about a depressed mother who poisoned her small child. It’s a terribly tragic story, and please keep in mind that I only know what I read in the article Here, and I’ve never examined anyone involved. The question being asked at the trial is that of whether the mother, who was depressed, was legally sane and knew it was wrong to kill her child, and that’s not what I’m going to write about. I didn’t pick a graphic to go with this blog post, because I couldn’t think of any photo that would be appropriate to such an angst-ridden topic.

I’m pulling a few sentences from the newspaper article to use as a springboard for discussion:

They said Sparrow told a nurse practitioner she was considering using sedatives to kill herself, her daughter and her dog, but that medical professional did not contact the authorities or otherwise try to get Sparrow committed to a psychiatric hospital.

After hearing Sparrow had just stopped taking the antidepressant Prozac for fear it was causing the suicidal thoughts, the nurse practitioner let her go home with the instruction to come back if she didn’t feel better…

I was struck by two things in the recounting of the story as I read it: that both the patient and the nurse practitioner thought her suicidal thoughts came from the Prozac (and both, perhaps, trusted they would stop with the cessation of the medicine— obviously I don’t know that’s what they thought, but it’s implied in this particular recounting of the story), and that a homicidal mother was apparently allowed to leave a clinic without being evaluated by a psychiatrist, I think. So my comments are general, because I don’t trust a press account to be all-inclusive, and perhaps things transpired that didn’t make it in to print.

When Prozac first came on the market, there were some concerns that it made people suicidal, and these concerns were dismissed. With years (oh, more than a decade) researchers revisited this idea and concluded that people under the age of 26 have a low incidence (1-2%) of violent thoughts caused by anti-depressants, and so we have the Black Box Warning about such thoughts. Does all the publicity about how the possibility of suicidal thoughts can arise from the medications narrow peoples’ thinking? If we think a medication has caused a suicidal idea, does this prevent people from exploring other options? Perhaps the medication isn’t working, or perhaps the depression has gotten worse and has broken through. Perhaps something else has transpired that increases risk. And if the medication is the culprit, what do we know about how long one has to be off it before such violent thoughts stop and the risk is gone? I think the answer is that we don’t know.

I don’t know if the woman described above saw a doctor the day she was in the clinic, or what exactly she said to the nurse practitioner. I don’t know if the outcome would have been any different if she’d been committed to a psychiatric facility. What I do know is that when any story has a tragic ending, it’s hard to wonder if more couldn’t have been done.

We pass so-called scope-of-practice laws— should psychologists prescribe? Should nurse-practitioners practice essentially independently? The fuss goes into the legislative battles before-the-fact, one fought primarily by legislators and lobbyists, not clinicians. We don’t generally look backwards and ask if poor outcomes are more more likely to occur in settings where we’ve dropped our standards and we don’t seem to ever ask if we should revoke those decisions. I’m not saying we should— but perhaps we should ask more questions.

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In an email today, Jim Gottstein, president of the Alaska-based PsychRights group, announced the opening of the new Soteria-Alaska project. The project is modeled on the now-defunct Soteria House in California. Explains Gottstein:

“The original Soteria House proved that outcomes for people diagnosed with schizophrenia could be dramatically improved if a psychosocial approach was used instead with neuroleptics used as a last resort and stopped as soon as possible when they were used.”

While there was some controversy about client outcomes at Soteria House, which closed in 1983 due a lack of funding, I’ve long felt the model looked promising enough for it to be tried again. The US spends many billions of dollars a year in taxpayer funds through Medicaid and Social Security disability and other programs for the care and treatment of people diagnosed with schizophrenia but we are seeing terrible clinical outcomes for some people including greatly reduced life spans due to the effects of medications. That kind of situation argues that some other system of care and rehabilitation should be tired, at least on a pilot basis, to see if other approaches might not work as well or better.

The Alaska project opened with two clients, but plans to accept others as soon as its state license is approved. I congratulate everyone involved in the effort to make the new Soteria a reality. I hope it works.

There are several other Soteria-style projects in Europe. A lengthy report on the original Soteria House authored by its founder Loren Mosher can be found here.

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Wyeth yesterday announced its second quarter results and once again failed to detail sales of its new and heavily-advertised anti-depressant Pristiq. The company only noted in its announcement that the drug had “higher sales,” but offered no sales data. That’s better than earlier this year when the drug hardly garnered a mention in earlier financial reports.

What this means is that the metabolite of Effexor–which rang up over 700 million in sales in the second quarter–isn’t generating enough sales figures to even be worth mentioning to investors. So much for the creepy wind-up doll ads.

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Second quarter financial results are out today for Bristol-Myers Squibb and the results for its atypical antipsychotic Abilify are astounding: worldwide sales of the drug reached $643 million in the quarter, an increase of 22 percent over the previous year. US sales were $518 million, a startling 29 percent increase over the second quarter of 2008. All of which is proof that the company’s Abilify as an anti-depesant advertising has paid off handsomely for BMS.

As for patients, well that’s another story.

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Last evening, President Barack Obama delivered a press conference in an attempt to salvage health care reform. It didn’t work. His answers to questions were rambling at times and far too professorial at other times (and still lacked some much-needed details) and I walked away from the whole affair fairly confused about where reform efforts are headed. It seems to me that the President and many in his own party are at-odds with one another and that doesn’t often spell success.

I fear that health care reform is headed either for failure–which would really disappoint folks like me who have no insurance–or it’s headed toward a watered down plan that will cover some but not all without insurance and that President Obama and the Democrats will call it victory.

It’s a measure of just how frustrated people have become that even MSNBC was criticizing the President last night–and that’s the first time I’ve seen that on the Obama-loving network. That tells you something.

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The Wall Street Journal is reporting today that Eli Lilly is in “advanced discussions” with attorneys general from several states–presumably ones like Utah and Connecticut–who’ve sued the drug maker, alleging that the company illegally marketed its antipsychotic Zyprexa. There’s not much news beyond that.

Lilly has already settled about $2.7 billion in claims relating to Zyprexa and pled guilty to a criminal charge in federal court in January.

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I’ve been following with much interest patient reports concerning the new anti-depressant Pristiq, actually little more than a metabolite of Effexor. Yesterday, a reader commented:

“I took Pristiq for 3 months and it has been the worst 3 months of my life! Side effects started during 3rd week and included severe nausea, dizziness, fatigue, headaches, night sweating, irritability, weight gain (+15 pounds), vivid dreams, head noises (ch ch sound), and confusion/concentration issues. Have intermittent episodes of these symptoms and have missed lots of work. Withdrawal is even worse (on day 4) and completely bed-ridden. If anybody else is experiencing this, please fill out MedWatch form to complain to FDA at https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm This drug should never have been approved!”

I think I’ll just let all of that speak for itself.

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A new study in the Journal of Clinical Psychiatry identifies that many thousands of veterans in the VA system are being given antipsychotics for the treatment of depression, a finding that is startling and unsettling. CL Psych had some thoughts on all of this the other day.

From the study:

“RESULTS: Altogether, 20.6% of veterans with MDD received antipsychotic medications, and 43% of those who did received them at the higher doses recommended for schizophrenia. GEE models showed that younger age, male gender, psychiatric comorbidities, duration of diagnosed MDD, and more intensive mental health service use were all associated with greater likelihood of receiving antipsychotics and with less likelihood of receiving them at conventional antipsychotic doses.

“CONCLUSION: Antipsychotic medications were commonly used in the treatment of MDD prior to FDA approval, especially in the presence of comorbid mental illness and longer term MDD. Further research is needed to evaluate the long-term safety and efficacy of these medications in combination with antidepressants.”

Keep in mind this study covered people in the VA system in 2007 and the most widely used antipsychotic for depression within the VA system was Seroquel. But Seroquel isn’t approved for treating depression (it is approved for bipolar depression), so this is a very high level of off-label use by the VA and sure makes me curious if there’s been any off-label marketing going on by AstraZeneca, which was dinged by the FDA last December for off-label marketing of Seroquel for depression, or what circumstances led the VA to adopt Seroquel and other antipsychotics for use in depression when the available evidence suggests that these drugs are neither particularly safe or efficacious in treating depression.

In other words, I smell a rat.

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