Stop discriminating against people who take psychiatric medications

            Many people criticize psychiatric disorders for being vague and arbitrarily defined.  I hear people say depression is just a matter of degree.  They claim to have periods of sadness so why medicate people?  They say that psychiatric illness is not like medical illness because they can’t get a simple blood test to prove its existence.

            My response is to point out that the most common medical syndromes for which people take medications are just as arbitrarily defined.  This includes, diabetes, hypertension and heart disease.  Autopsies on soldiers reveal evidence for atherosclerotic disease in 20 year olds.  What degree of vascular occlusion merits medical treatment?  Should a stent be put in an artery that is 50%, 60%, 70%, 80% or 90% occluded?  Does the patient have to be symptomatic to have a procedure done?

            What is the glucose cut off for a diagnosis of diabetes?  For treatment with medications?  It used to be over 200.  Now it is 120.  As more evidence for future complications became evident, the optimal blood sugar levels began to get lower and lower and include patients who had no overt symptoms.  The same is true of cholesterol levels.  Millions of people take statin medications and have no symptoms other than a blood test out of a statistically defined range.  Many of these people suffer severe side effects from the statins including muscle aches and depression.

            But somehow more criticism is given to doctors prescribing antidepressants to people who are suffering severely from depression and anxiety.  These symptoms greatly impair the patient including risk to loosing their jobs and relationships.  Every psychiatric disorder list in the DSM (Diagnostic and Statistical Manual) includes a set of criteria that requires the symptoms to be severe enough to cause impairment in function and not be due to another condition including medical illness.  This is not true of all medical illnesses for which medications are given.  Patients are given a blood pressure medication for having a blood pressure reading above an arbitrary cut off.  This cut off has been lowered over the years appropriately reflecting knowledge of risk factors.  Still the criterion is just a number without any other symptom needing to be present.

            Why are patients suffering from depression and anxiety chastised for accepting medications to treat it while others are not for taking blood pressure lowering, glucose lowering or cholesterol lowering agents?  Aren’t these patients as much to blame for their conditions due to lack of dietary discretion and exercise?  Vulnerabilities towards mental illness are at least as biologically and genetically based as other common medical conditions.  So it is about time this false argument against use of psychiatric medications is understood for what it is, it’s discrimination pure and simple.

I was on WNPR Colin McEnroe's show at 1pm on Tuesday March 15

I'm looking forward to being a guest on Colin's show tomorrow.  For those who are outside the listening area you can hear the show on WNPR.org.

Here is a link to the show
http://www.yourpublicmedia.org/node/11349

Comment on NYTimes article on death of psychotherapy for psychiatrists-is it so bad?

I say good riddance to the one parent model of Psychiatry (Talk doesn’t pay, so Psychiatry turns instead to drug therapy, March 6, 2011).  For too long psychoanalytic treatment models have been allowed to dominate the profession.  Major Psychiatric illnesses have a clear biologic basis and the treatment is extremely complex.  While psychopharmacology has progressed so has psychotherapy techniques.  I seriously doubt that anyone can be an adequate master of both.  The role of the modern psychiatrist is to be the director of a team, assessing, diagnosing, and providing appropriate psychopharmacologic intervention compatible with a multitude of physical concerns while collaborating with well-trained psychotherapists.  In the one parent psychoanalytic model, the psychiatrist is often derailed from finding psychotherapy coping techniques while switching hats to see if a medication change is in order.  The data needed to determine what medication is best overlaps little with the data needed to develop a comprehensive cognitive behavioral coping strategy.  Having a separate therapist who cannot prescribe medications forces the patient and therapist to devise strategies for coping while medications are given needed time to work.  This avoids harmful premature medication changes in desperate efforts to reduce symptoms.  This is not just a cost issue.  I have been using this model of collaborative treatment successfully for over 20 years and is the model of choice for hospitalized patients.  Do you expect your orthopedist to provide your physical therapy?  Both require highly technical skill sets.  Psychiatrists have complained about such “divided” treatment.  I see it more as the two-parent model collaborating while providing complementary interventions for the benefit of patient.
      In addition, psychiatrists complaining about not being paid for doing psychotherapy often belittle the skill of none physician therapists.  I personally received therapy from three different individuals, an MD, PhD and MSW.  I can say the most helpful was the MSW.  The patient's treatment experience and outcome is greatly enhanced by a collaborative effort as each can add insights to help the mutual effort.  This is true of every complex endeavor from flying a plane to surgery.

An alternative to gay marriage, no marriage

The New Jersey legislature in response to recent court rulings should consider getting out of marrying people.  Marriage begun as a religious institution and should remain so.  Civil governments should only issue licenses for civil unions that would between two, unrelated, consenting adults.  Marriage can occur between individuals in their chosen place of worship after having signed civil union agreements.  Existing marriages can be grandfathered by the state to be declared civil unions under a new law, and any existing laws pertaining to marriage can be declared to apply to any new civil union or “grandfathered marriage”.  The new civil unions would have all the rights, benefits and obligations of current marriage laws, except for any religious obligations or restrictions as to religion, gender, race, creed or color.  All divorces would involve application of any existing divorce laws to the new civil union where the word marriage is replaced by civil union.

            People of faith should not fear “the institution of marriage” being corrupted by the prospect of gay marriage.  Each house of worship can chose how it wants to deal with this issue.  Since the state would only recognize civil unions, state recognized gay marriage would become a non-issue.  Gays and straights would be accorded the same legal rights and protections under civil unions; religious and non-religious individuals would be free to practice their own beliefs without interference from the government as our constitution demands. 

With this modest proposal, hopefully all parties could end this divisive debate and live happily ever after.

Bipolar one, bipolar two, bipolar two and half, bipolar spectrum, and now for something entirely different

The case for a new diagnosis of cyclical mood disorder NOS.

 To the editor:  We have read the February 2006 edition focusing on the “Problems in the treatment of Bipolar disorder” with great interest.  One of the major issues in both study and clinical treatment is making a meaningful diagnosis.  This was touched upon in the editorial by Swann and in the research article of Perlis, et. al which compared features of unipolar to bipolar disorders.  However, we believe that there is a strong need for a new diagnosis, cyclical mood disorder, which captures a substantial number of patients who present with highly recurrent unipolar symptoms but respond poorly to antidepressants and preferentially to mood stabilizers.

There are three major reasons for the need for a new diagnosis.  The first is the poor response to treatment.  These patients based upon DSM IV criteria should only be diagnosed with major depressive disorder.  Non-psychiatric providers, following evidenced based protocols would be forced to go through innumerable futile or worse trials of antidepressants.  The second reason is stigma.  Even if a reliable diagnostic genetic marker were identified for bipolar disorder, this would stigmatize patients who have never manifested symptoms of mania.  This discrimination is currently evident in the Connecticut Bar Association’s, application that specifically asks applicants if they have ever been diagnosed with Bipolar disorder.  Internal medicine avoids stigma in several conditions by recognizing early syndromes as distinct from their more severe illnesses. For example patients with impaired glucose metabolism might be treated to prevent diabetes but are not given that diagnosis.

Finally, the validity of research studies necessitates accurate diagnosis.  The entrance of cyclical mood disorder patients into unipolar depression trials, unfairly introduces a bias against active treatment.  It may be the reason for failure of most medication trials in adolescent depression.  Early intervention with a mood stabilizer to a depressed young person may avert the appearance of bipolar symptoms and hopefully the associated morbidity and stigma.

We propose the neutral term “cyclical mood disorder, NOS” since it neither implies unipolar or bipolar diathesis.  Symptoms would include all the current criteria for major depression but have the additional criteria of a certain number of prior episodes.  These episodes might include subsyndromal episodes and have the frequency indexed according to age.  For example an adolescent may only require 2-3 episodes in two-year period, while a 30 year old require 5-10 episodes.  Research analysis can be done to choose an appropriate cut off frequency.  Ancillary criteria would include family history of bipolar, poor response to antidepressants without a mood stabilizer or “poop-out” of antidepressants after several months of good response with adequate dosage, prominence of atypical symptoms and energy dsysregulation.

We hope that introduction of this new diagnosis should inspire new research and advance clinical treatment.  Since it represents a reclassification of already diagnosed patients, it should avoid criticisms of creating diagnoses in to expand a population needing treatment.

Thoughts on the slaying of a psychiatrist in 2008

Cure The System, Treat The Patient

February 17, 2008

A recent incident in which one mental-health provider in private practice was slain and another seriously wounded in New York City [News, Feb. 14, "Doctor Hacked To Death In Office"] should stimulate outrage at the systematic dismantling of our mental-health system caused by cuts in funding for programs serving the seriously mentally ill.

Over the past few decades, thousands of individuals lost access to long-term treatment when states eliminated hospital beds to shift costs onto an overburdened Medicare and Medicaid system, pushing increasingly ill patients onto an ill-equipped private sector.

Private insurers have reduced hospital lengths of stays to dangerously short periods. Even if patients could afford to pay for longer stays, these hospitals had to modify their programs so that little if any therapy occurs.

Advances in psychiatric treatment have been dramatic and inspiring. Severe mental illness, however, is associated with actual loss of brain tissue. New treatments help to re-grow brain cells, but this can't occur if patients return to the same environments that triggered their episodes.

Our haphazard medical system pays for procedures costing hundreds of thousands of dollars to prolong someone's life for several months. But it denies payments for respite and psychiatric rehabilitation services at a fraction of the cost that may restore patients to normal levels of function.

The failures of this inequity are seen in tragedies reported in New York and in cities around the country. The irony is that society pays the costs in increases in crime, swollen prison populations and lost job productivity.

A useful review of Techno Colors

This book is a collection of essays, but they are not written in the academic style that one might expect. They are unified by simple language, a practical clinical approach, and by the author's sharing of many clinical pearls. Some of the essays are very personal and describe the challenges faced by the author in his education and professional development, going from residency to academia to private practice.
Primary care doctors will find the book helpful, especially the chapters dealing with panic disorders. In fact, his mother suffered from panic disorder and his descriptions of growing up and watching his mother's difficulties are touching. His humanistic approach to mental illness is manifest throughout the book.
He explains how his interest in painting and mixing colors helped him to develop his approach to sometimes treating psychiatric illness by using a combination of drugs. He refers to red and blue as his defining colors. Blue is associated with calming an anxious patient, red in adding fire and motivation to depressed patients. Purple was the blended color used to find a harmonious middle ground. On page 64 he actually shows the "color chart" of various psychotropics that he devised and which may be helpful to clinicians who understand his approach.
He mentions various drugs used in treatment of Attention Deficit Hyperactive Disorder (ADHD) and his personal experiences using them. He also describes neurotransmitter pathways; and how low serotonin levels can bring on compulsive activity, panic attacks, depression, and lowered sense of well being. The benefits of selective serotonin uptake inhibitors (SSRI) in helping to alleviate these symptoms are also mentioned.
Throughout the book his personalized approach is highlighted; for example he says that for a person with irritable bowel syndrome, with depression, using a drug that has constipation as a side effect may cure both their depression and their IBS.
The chapter on panic and anxiety has much practical information. Also discussed are evidence-based medicine and how they can be misleading. He finished with a detailed summary outlining how to treat depression that primary care doctors will find helpful.
Edward J. Volpintesta MD

Feeding my posting to Amazon's author's page

I think I've connected this blog to my Amazon's author's page.  If you are seeing this on Amazon and want to see old posts check out psychiatryintechnocolors.blogspot.com

Lawsuit against Merck for Propecia and panic disorder

I just read a new article anouncing that some people had filed a lawsuit against Merck Pharmaceuticals claiming that their medication propecia caused them to have panic attacks.  Since panic disorder is so common in the general population especially in a young population also most concerned about hair loss I can't see how a causal relationship could be made.  I have had young men start to panic about their hair loss as they worry about their attractiveness to women (even though many woman seem to think balding men are sexy).  Propecia is a low dose (1mg) of the prostate shrinking medication Proscar (5mg) and has significantly lower side effects.  Although, I know nothing about the specifics of this case and can't comment on the individuals I think there is a lesson to learn about seeking legal help as a diversion to getting real psychiatric care.

Patients who have panic attacks link these attacks to whatever happens at the time.  I've had patients associate a particular exit on the highway with their panic attacks and avoid it.  This is classical conditioning.  (See my chapter on Panic in my book http://www.amazon.com/s/ref=nb_sb_ss_i_0_14?url=search-alias%3Daps&field-keywords=neil+liebowitz&sprefix=neil+liebowitz)
It is unfortunate that there is such a stigma to treatment for psychiatric conditions that patients would rather blame anything else for causing their symptoms than realize that they need psychiatric treatment.  Panic disorder is very treatable, especially if dealt with early. The longer it goes the harder it is to treat.  Filing lawsuits  and blaming others only delays real effective intervention.

thoughts on Israel and the middle east

The purpose of my next book is to use reason to reinterpret our negative thinking and hopefully see things in a more positive light.  I had a patient ask what I thought of the recent turmoil in the Middle East and its effect on Israel.  Historical records reveal the Jewish presence in the area that is Israel going back thousands of years. The Jews were expelled and killed resulting in a diaspora.  Hitler's Holocaust led to recognition that Jews had no safe place to go and were not wanted in the rest of the world. Also that over the centuries they were displaced from their original homeland in the middle east.
 Growing up, learning of the Holocaust and reading Robert Frost's poem, Death of the Hired Man, I was struck by the line, "home is the place where, when you have to go there they have to take you in."  The Jews clearly didn't have this place until Israel.

The dictators in the Arab world have used the presence of Jews in Israel as a distraction from their subjugation of their people.  But you can fool only some of the people some of the time.  The closest to a rational argument against Israel has to do with the displacement of the local Arab population during the division of Palestine between Jordan and Israel.  Interestingly Jordan which was to be the Arab partition isolated the displaced refugees and only since the Israeli occupation of additional territory has the emergence of semi-autonomous Palestinian region emerged.  Interestingly, fellow Palestinian Arabs didn't feel they had a home either as monarchs and dictators chose to use them as pawns, kept in refuge camps rather than treat them like family.  Critics fault Israel for wanting to keep a Jewish state (I say homeland) likening it to apartheid.

I think that the closest analogy is to the creation of sovereign native nations within the United States after our Native American holocaust.  These were lands given to the former inhabitants of the area often displacing local residents.  No one suggests that Indian nations allow non tribal members to vote or call it apartheid.
One hopes that the citizens of the newly liberated Arab nations recognize the distraction that the Israeli conflict has been and reduce their interference of honest negotiating for a two state solution. In this case a new Palestinian state may emerge similar to the demilitarized sovereign Indian Nations in the US, creating a home for both families-Jews and Palestinians, who are clearly scions of the same stock.

So what does this do with psychiatry?  The anger associated with this conflict causes people to get depressed and leads to prejudice that hurts others.  When one sees things from a different perspective we can have more empathy for others reducing tension and grief.

Abridged versions of my book

By the way, I've created two abridged versions of Psychiatry in Techno Colors for the kindle.  Anxiety in Techno Colors has five chapters that deal with anxiety and panic.  I thought this would give helpful insights into understanding this terrifying condition.  It is about 40 pages of text and sells for $2.99 on Amazon.   Remember that a free Kindle app is available for hand held devices and a free Kindle previewer for computers. 
free kindle apps  The second abridgement is a little shorter and includes more of my memoir pieces more of a sampler sampler selling for only $0.99 the lowest price that Amazon would let me do.  Enjoy.

After the first post

Now that I've published my first book Psychiatry in Techno Colors, I've gotten excited about the next.  This book was mostly about my strategy for understanding problems and deciding on treatments.  My next book will focus on the supportive and interpretive statements that I've given patients to help them see things differently.  The tentative title is It could be worse.  This different is mostly in a positive way.  In psychiatry this may be called cognitive reframes.  I don't always reframe in a positive way.  Some individuals do self destructive things such as drug abuse or self harm and think that they are not really hurting themselves or others.  Here I might point out how non productive these behaviors might be.  At any rate I might use this blog to help others to "reframe" their problems.  I don't intent to provide free psychiatric help without examining you, as that would be irresponsible and against my malpractice coverage.  But I believe that as person who has cared for a lot of patients, I can provide hope and some direction. Please be advised that comments posted might end up in my next book!

book press release

Psychiatrist’s collection of essays aims to challenge misconceptions in field

 Neil Liebowitz’s “Psychiatry in Techno Colors” uses clinical vignettes to improve our understanding of major mental illness

FARMINGTON, Conn. – While psychiatry has come under attack for its alleged checkered past concerning over-reliance on medication, Neil Liebowitz, MD argues this claim is false in “Psychiatry in Techno Colors” (ISBN 1456316435). His book outlines why commonly held beliefs are distortions of reality. It further argues that a skilled psychiatrist can help a patient heal and return to a productive and happy life. This collection of essays ranges from understanding panic disorders to selecting depression medication, and each chapter concludes with a solution or strategy to resolve the dilemma. This book is written on a level intended to suit the general public, yet it also aims to provide enlightening insights and strategies for any clinician.

“My primary message is one of hope,” explained Liebowitz. “Hope that anxiety and depression can be understood and treated if patients and providers are better informed by an experienced clinician.”

The book’s messages include overcoming the psychiatry stigma, differentiating drugs of abuse from those that heal, failings of diagnoses and clinical trials, understanding how ADHD differs from bipolar disorder and understanding memory problems associated with medications.

Liebowitz founded the Connecticut Anxiety and Depression Treatment Center. He shares personal stories that illustrate some patient dilemmas and possible solutions for key psychiatric problems. From growing up on Long Island to residency training at Yale, to an academic career at the University of Connecticut, this doctor learned how best to understand psychiatric problems and properly treat them.

The author’s 28 years of practice have helped him develop strategies for conceptualizing patient problems.

“I feel that   mainstream psychiatry may miss the mark for many patients,” he said. “Psychiatry has been held back by wrong theories and an establishment that is slow to reconsider old notions.”

“Psychiatry in Techno Colors” is available for sale online at Amazon.com and other channels.