The world has been shocked by the terrible tragedy in Newtown, Conn., where a shooting in a primary school has resulted in the loss of 20 young children and six adults, in addition to the shooter and his mother. Our thoughts and hearts go out to their families, friends, and community, as well as to the professionals involved.
In the wake of a disaster of horrific impact and proportions, be it human-made or the result of catastrophic forces of nature (as climate change has brought all too frequently in recent times), many wonder about children’s responses to traumatic events and how best to support them. In addition, many children who themselves were not directly affected will be exposed to relentless media footage, potentially propagating distress and calling for helpful responses by parents, relatives and teachers.
How do children respond to trauma?
Children’s immediate reactions vary widely. Some children are visibly frightened, agitated or upset, while other children are more withdrawn, or on the contrary, can come across as very composed. In the latter instance, it is difficult for adults to judge to what extent a child has been affected.
Most children directly exposed or living in the impacted community will show stress reactions in the weeks following the traumatic event. Common reactions include nightmares, repetitive intrusive thoughts about what happened, avoidance of places or people related to the event, concentration difficulties, separation anxiety, heightened vigilance, irritability, and guilty feelings. In addition, the children involved in the shooting, in this case, will be mourning the loss of friends and teachers. For some young children, this will be the first time that they are confronted with death and its irrevocability.
Children will respond differently according to their age and capacity to put their experience into words. The National Child Traumatic Stress Network has depicted age-related responses, which vary from preschool children to adolescents. Younger children may behave in ways even more childlike than their years (called regression), with less control over their feelings or behavior or even control over their toilet functions. Older children may show their fearfulness with worries, withdrawal or physical problems like stomach pain and headaches.
An excellent summary for parents on the impact of a violent event such as the Newtown shootings is also available from the National Child Traumatic Stress Network. Also helpful is “After the Injury,” which can be useful for families of injured and traumatized children; it provides clear descriptions and short videos explaining post-traumatic stress reactions and their development over time, as well as a simple checklist that can assist parents in monitoring their child’s stress reaction.
What can we do to support children in the direct aftermath of a traumatic event?
An international consortium of trauma experts has identified the five essential actions to direct us in what we can all do to help survivors after a mass trauma. These actions apply to both children and adults:
1. Promote a sense of safety. Make sure survivors feel as comfortable as possible, and reassure them that they are safe now (provided that they are really safe).
2. Promote calming. For survivors who are overwhelmed by emotions, help them learn to breathe slowly -- with an emphasis on breathing out -- and to be aware of their body and surroundings.
3. Promote a sense of self and community effectiveness. Survivors need to be helped to return to taking control over their own lives and decision making. Taking up normal routines as soon as possible is a fundamental rule of post-disaster responses.
4. Promote connectedness. Social support is one of the most robust predictors of recovery. Help children and families turn to those they care for and trust to receive both emotional and practical support.
5. Instill hope. Most people, children and adults are resilient and will eventually recover from a traumatic event. Survivors who feel confident about their capacity to recover are more likely to experience a good outcome.
Based on these five essential actions, the National Center for PTSD and the NCTSN have developed and supported the use of Psychological First Aid (PFA) by mental health professionals and first responders.
How you can you talk about the shooting with children who were not there
With the extraordinary high levels of media coverage of this shooting, we expect that many children throughout the U.S. and internationally will become aware of this tragedy. Parents, teachers and other responsible adults will surely encounter questions about safety, even the meaning of death. Responding starts with letting children know that they are safe.
For example, young children may have difficulty understanding that repeated television coverage is not a new shooting. For this reason alone, you will want to limit children’s media exposure and answer their questions in an open and honest manner, without using frightening language. For young children, it may be helpful to explain death with analogies -- for example, as if they recently broke a toy that could not be fixed. The National Association for School Psychologists has a well-done brochure about talking with children about violence.
Effective treatments for long-term post-traumatic stress
The gravity of the tragedy in Newtown, Conn., indicates that a significant number of directly exposed children will experience significant post-traumatic stress reactions in the months after the shootings. Some may develop post-traumatic stress disorder (PTSD). Cognitive behavioral therapy (CBT) is a well-know therapy for children (and adults), and there is good evidence of its beneficial effects.
The tragedy in Newtown, and its predecessor violent events, should be a further wake-up call for efforts to reduce the risk of future devastation produced by these events. While there is balm for the grief, fear and psychological wounds of the survivors, there is no remedy for their losses. We must attend to the survivors and gather the resolve to take the steps needed to identify those who are at risk to perpetrate these awful acts and to reduce their access to the weapons of destruction by which they wreck their havoc.
Eva Alisic, Ph.D., who co-wrote this article, is with Monash Injury Research Institute, Australia, the National Psychotrauma Center for Children and Youth, The Netherlands, and is a member of the International Society for Traumatic Stress Studies. She blogs at www.trauma-recovery.net.
Dr. Sederer’s book for families who have a member with a mental illness, The Family Guide to Mental Health Care, will be published by WW Norton in the spring of 2013.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer’s website for questions you want answered, commentaries, movie and book reviews, and stories.
Originally published in the Huffington Post on December 16, 2012.
Mentioning the Bronx (the New York City borough that sits atop Manhattan, for those who may not know this city) can conjure up Fort Apache the Bronx, the film from 1981 (with Paul Newman and Danny Aiello) that portrayed the danger and desperation that then boiled in sections of the Bronx. I grew up in this borough, named after a Dutchman (Jonas Bronck) when the City was settled centuries ago, and indeed there were some pretty sketchy places. But there was another form of danger — one among youth that made it fearsome to be smart or wear glasses or tote a lot of books. My junior high school, PS 113, was like that, and I learned to sneak in and out to avoid the boys who were looking to bully and shame.
I took a citywide exam in the ninth grade (the last year of “junior high” — then the interval between elementary and high school) and, to my surprise, received notice that I was accepted into the Bronx High School of Science. Me and about 900 other New Yorkers. “Science” was one of several “exam schools” (like Stuyvesant and the LaGuardia High School of Music and Art) where smart city kids could go for free to a high school that surely rivaled the private schools that served the rich and privileged. My first reaction to getting in was that I didn’t want to go because my best friends were not accepted (though I knew others who were); that’s what I said to my parents, who — remarkably — did not fight me, letting me come around to accepting. That was 1959. That was when Jews, Italians, Irish and a few other “minorities” chiefly inhabited the Bronx and northern Manhattan. The vast diaspora of American immigrants, then as it is so today, sought to create a place in society that birth and connection did not provide. Education was the means then, as it can be today for aspiring generations.
Just recently, I attended my 50th (!) Science reunion. Badges showed our photos from the graduation yearbook, since these were the images that formed the emotional basis for knowing each other. Some 200 alumni, spouses and friends crowded into a Chelsea restaurant for an evening of dining on memories and realities. Drink in hand, I braved walking into the crowd. Start a conversation with someone, anyone, my wife said, and I did. There were only a handful of people I knew, but they all were my people, my classmates, my vintage, New Yorkers everyone, no matter where they live today.
Reunions select out two groups: those who do not want to put their lives on display and those who have died. A third group, those who did not want to or could not attend, are more of a mystery — take me, for example, since I had only attended one other reunion (the 25th). Seventy-one “Class of ‘62” graduates were listed “In Memoriam” in the evening’s program. There were only a few I knew personally, but the sheer number of those who had passed and the homage paid to them by friends who commented during the program was a reminder of how thin is the thread of life as we know it.
One fellow I knew well when we both were young had died over a decade ago. We were in the same junior high school class before we went to Science: He was my first startling experience with true genius, with his capacity to rapidly solve complex problems that, try as I might, took me forever; he left Science after one year to go to an Ivy League college, which he soon quit to develop his own (over time, successful) business. But he was gone, but by some grace I was not.
There was a show of hands when the emcee asked how many had artificial joints or stents? How many had taken LSD? Not that many, in answer to all three questions, though more positive responses to the first two questions. An online survey (after all, this is Science High) of the class taken before the reunion had 232 respondents and revealed that 83 percent were currently married (many more than once) and 81 percent had children; over 80 percent had graduate degrees (masters and doctorates); over 40 percent had career changes; over 40 percent were now retired, many said they never planned to retire, and one said he would retire 10 years after he died. An overwhelming number of alums felt very positive about the school, endorsing that it made a “consequential difference” in their lives. I could observe and consider that evening, when I listened to this information and looked around, what are the ingredients of successful aging: being smart, from families that valued assimilation, well-educated, and fortunate to have lived in a culture of meritocracy. We were the winners of the precious commodities of dignity, prosperity and community.
Bronx Science’s graduating class of 2013 will be substantially Asian. This reflects the changing demographics of New York and its ever-revitalizing immigrant communities. Whoever goes to Bronx Science today, or tomorrow, will discover that it is safe to be smart. They will see that learning, mastering knowledge and valuing thinking is a gift that keeps on giving. Imagine if that experience were one that could happen in any school in New York City, or other community in this vast country? Imagine if there were many more places like Science where it’s safe to be smart, and not just for the best students with the most intact and engaged of families. Now, that would be something to be proud of.
Dr. Sederer’s book for families who have a member with a mental illness, The Family Guide to Mental Health Care, will be published by WW Norton in the spring of 2013.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer’s website for questions you want answered, commentaries, movie and book reviews, and stories.
Originally published in the Huffington Post on October 22, 2012.
"Middle of Nowhere” is beautifully drawn and poetically written. It teaches about family, race, character and the often-unknowable arc of a life, without becoming pedantic or pretending to have answers.
The film opens in the middle of nowhere, setting the tone, as a bus arrives at a high-security prison set outside the perimeter of everyday life where society's pariahs are contained. Ruby (Emayatzy Corinealdi, whose beauty rivals Lena Horne and Halle Berry) has come, as have other devoted women, to visit her man who is serving time. Ruby radiates hope for her recently married husband Derek (Omari Hardwick, who fills the screen with the body of a NFL fullback, the face of a poet — which he happens to be outside the theatre — and a voice reminiscent of Denzel Washington); it is early on in his nine-year sentence, and she bursts with love, resilience — and self-deception. She is a registered nurse who had begun medical school. Forget about becoming a doctor if you need to earn money to pay for your husband's legal fees and child support from a previous marriage as well as dedicate yourself to the cause of his early release; plus, it is hard to get the on-call schedule to conform to regular visits to the prison, two hours away each way, and to be free for daily phone calls from her inmate husband.
The United States has the highest rates of incarceration in the world: Recent data indicate that about 1 in about 30 men and women over 18 (7.3 million people) were imprisoned or on probation or parole. Nine percent of black adults are in prison compared to about 4 percent of Latinos and 2.2 percent of whites. Black men have the longest sentences, which add to their high rates behind bars. Their plight is furthered as 35 percent of blacks are living in poverty, unlike whites at 13 percent. Children are not spared, creating generations of poverty as 38 percent of blacks under 18 are living in poverty, while the national average is 22 percent, leaving this still-prosperous country with little to be proud of.
Ruby is from a family of women. Her father is absent. Her mother, Ruth (Lorraine Toussaint), is living arduously on her own, painfully distanced by her two daughters. Ruby's sister, Rosie (Edwina Findley), is a tough-minded, single mother of a young boy, whose father is also nowhere to be found and whose only uncle is locked up. These three women are seemingly going nowhere with meager financial and emotional provisions and a boy who will absorb their pain, putting him at risk for an uncertain future. Welcome to too much of black America.
But Ruby has something special. She is smart — smart enough to get into medical school — and has not been bled of the hope that is critical to finding an exit from the virtual prison of poverty, dissipated families, violence, incarceration and ill health that blighted urban neighborhoods spawn, and that produce the lost lives and social burden that so deeply ail this country.
Prison changes people, and usually not for the good. Prison changes those within its walls, and their families. Derek, a non-violent felon, learns to survive inside by becoming a prison gang member and maintaining criminal contacts outside for the money this will provide his family. Prisoners' wives are called "women in waiting" who try to raise children with no money and no man. Their rates of physical and mental illnesses are high.
Ruby has her profession and occasions upon a man, Brian (David Oyelowo, whose credits include award-winning performances in the Royal Shakespeare Company), who makes her feel beautiful and not alone. The arc of her life begins to change as spousal betrayal and everyday opportunity collide and begin to lift her from her slavish rut. But her devotion runs deep to those whose life is compromised, as it is in her family and community. She becomes even more in the middle of nowhere.
Director, writer and producer Ava DuVernay (winner for Best Director at Sundance this year), is the grand painter and author of this cinematic tableau. It is the kind of fiction that Philip Roth said, to paraphrase, is not so, but so very true. After doing documentary work, DuVernay retrieved and developed this script which had sat idle for years. The narrative we observe on the screen thus combines the eye of a field worker with her gift for literary composition.
I wonder: Were the cast too beautiful? But who wouldn't want to look at Emayatzy Corinealdi all day, or her hulk of a husband, or the man who later declares that he wants to be part of her future? Or her sister, Rosie, who still has the luster of youth. Even their mother seemed to me more like a high school principal than a poor black woman. Maybe their attractiveness makes them more accessible to an audience like me?
“Middle of Nowhere” is yet another remarkable film supported by a Social Action Campaign from Participant Media (Company With a Conscience). Participant's films include “The Kite Runner,” “Charlie Wilson's War,” “An Inconvenient Truth,” “Good Night, and Good Luck,” “The Visitor,” “The Soloist,” “Waiting for ‘Superman,’” “Fair Game,” “Page One: Inside The New York Times,” “The Help,” “Contagion,” “The Best Exotic Marigold Hotel,” and the forthcoming “Lincoln.” Their campaign for this film aims to address prison phone rates (that can exceed $200 a month) that prey on the families and friends of those who are incarcerated. They have found another just cause, an example of how inequity breeds injustice.
Where do we find Ruby as time goes by and more years stare her in the face before Derek stands a chance of release? In the middle of nowhere. She is not able to leave him emotionally and also not able to sacrifice her life for him. But a serenity, different from what her sister and mother display, embraces her face. We leave her, or she us, at a bus stop. She says, with warmth and resolve, "Good morning."
This entry originally appeared in the Huffington Post on Oct. 12, 2012.
Visit Dr. Sederer's website (www.askdrlloyd.com) for questions you want answered, commentaries, movie and book reviews, and stories.
If you lost a limb, would you think twice about getting a mechanical prosthesis that could be operated with your thoughts? If you lost hearing or vision, you might want a cochlear implant or a visual prosthetic. What if you lost a chunk of memory, or lost your ability to tell reality from delusion, or were burdened with a relentless psychic trauma? Would you want a neuroprosthesis to restore (or enhance) brain function, or a smart pill to boost memory, or a microchip implanted in your brain?
From Frankenstein to The Terminator, stories abound that show how man's creative and innovative attempts to overcome his limitations through technology, no matter how well-intentioned, have the potential to backfire. Destructive consequences can issue as readily from acts of altruism as from those born of evil. Far more often, sadly, misfortune is the unintended result of hastily enacted and shallowly considered actions.
In a recent post, entitled "Neurotechnology: Science Fiction or Applied Science?" (Part 1), we noted several emerging neurotechnologies primed to transform the diagnosis and management of neurological and mental illnesses, yet also poised to challenge society's ethical norms and standards. Reading a person's thoughts, implanting machinery into man, and augmenting our neural processing powers with cognitive enhancers are all matters of neuroethics. They bring us face to face with questions about who has access to powerful new technologies and for what purposes. Neuroethics, however, has few laws, unchartered territories, and no sheriff.
Let's consider memory-enhancing treatments. Those with Alzheimer's disease need medications or other neurotechnologies to restore lost brain functions. Victims of TBI (traumatic brain injury) seek a medicine or procedure to erase disabling traumatic memories, those that sear into the brain after a disaster, in combat or from torture or abuse. But beyond such clearly defined therapeutic applications, imagine a military or global corporation seeking drugs or devices that sharpen focus and turbocharge mental operations. What is fair play -- and who decides?
There already is a growing market for off-label "cogniceuticals" -- drugs that promise to "fix" mediocre mental performance or mood. In the 2011 movie Limitless (see Lloyd's HuffPost piece "Limitless: Would the FDA Approve?"), Bradley Cooper's character achieves bountiful success from the fictional drug NZT, but not without near-disastrous consequences for those who take it, and for society at large.
Should doctors prescribe cognitive enhancers like NZT to boost a healthy brain, or implant artificial neurons or stem cells to further the performance of the healthy? Even before doctors get their chance, will the FDA be able to tell the difference between snake oil and the next magic bullet? What about those individuals who actually have an impairment but cannot afford treatment? Will there be a black market?
Ethicists consider these quandaries in terms of "distributive justice," or the principles used to guide the allocation of resources and services in society. What will it mean if market forces of supply and demand determine who will get what is needed and who will not? Will rationing of health care include questions of who should have access to a genius-level I.Q. or spared the mental agony of trauma?
Other applications of neurotechnology tempt us: What about brain scans that could assess a defendant's veracity? Might there be a scientific method to prove the insanity defense? Today's cutting-edge DNA fingerprinting already gives us an example of an advanced technology that's rife with legal ambiguities.
And what about your mind being read in your local shopping center or global market? Product "neuromarketing" -- corporate consumer psychoanalysis, if you will -- has advertisers using functional brain scanning to determine a buyer's unconscious reactions to the latest widget. And then the subliminal pitch developed clinches the deal. A Nielsen brain scan? Yes, and yours for only $299 from Emotiv, which already retails this neurotechnology to consumers. What should be the responsible conduct of researchers on retainer to global corporations or even to rogue governments -- and who will judge?
There is also the matter of an individual's privacy. Imagine if there were spyware that downloads your brain's account as if it were a Web browser's history. Figuring out how the mind works, reading the brain's thoughts, and determining future intentions are the ingredients of social control. This is not that far-fetched an idea.
This brings us, inescapably, to questions of human responsibility, personhood, and individual agency. Computer scientist Ray Kurzweil described, in 2005 in The Singularity Is Near: When Humans Transcend Biology, how man and machine enmesh: when computer information and neural technologies are intermixed with the "plastic" human brain to further human evolution. This is the premise of transhumanism.
Neural implants, from computer chips to optic probes, are already used for epilepsy and Parkinson's disease. Deep Brain Stimulators are being studied for the treatment of obsessive-compulsive disorder, refractory depression, Tourette's syndrome, and addictions, and even to curb obesity. Brain-computer interfaces are in development that will "fix" what might be dysfunctional neural circuits that produce human psychopathology and suffering. As cerebral implant technologies reprogram the brain, will they remake our identity? Will we manufacture the Cylons of Battlestar Gallatica? The HAL of 2001: A Space Odyssey? This is Asimov's "Frankenstein complex," where we fear (yet create) the mechanical man.
We know by now that the hubris of science will not be stopped. The allure is too great, the benefits too seductive, and the rewards potentially astronomical -- all making the risks easily dismissed. But risk must always be weighed against benefit. Progress from science, as has been said before, is science's "most important product." Yet means of mitigating risk can be installed as an equal part of our forward motion. There exist counter forces that prove just as powerful: human kindness, altruism, objectivity, and defiance against the myriad of forces bent upon manipulation and control. These are the old-fashioned protections that, if not lost, can save us from a future where the machines win.
The opinions expressed here are solely those of Drs. Erlich and Sederer, as physicians and public health advocates. Neither receives support from any pharmaceutical or medical device company.
The debate continues to rage about whether psychiatric medications work. This controversy especially has brewed about antidepressants and antipsychotic medications, some of the most widely used medications in the world. An important study just published in the British Journal of Psychiatry sheds light (not just makes for heat and wind) on this vital subject.
In a carefully constructed research study called a meta-analysis (where the results of many studies are examined to answer specific questions), the authors provide (in their words) "The first ... panoramic overview of major drugs." They looked at 48 different drugs used to treat 20 general medical diseases and 16 different drugs used to treat eight psychiatric diseases. The researchers concluded that the psychiatric drugs, overall, were as effective as those used in general medicine.
Their research approach was to select a specific disease and then look at rigorous studies on the response of that disease to medications commonly used to treat it. Examples for general medical diseases included:
-In chronic heart failure, how well were angiotensin converting enzyme inhibitors and receptor blockers, beta-blockers and diuretics in reducing death and how did digitalis do in reducing hospital admissions?
-How effective were proton pump inhibitors (PPIs) in controlling symptoms for acute reflux esophagitis and in maintaining control of those symptoms?
-How effective was aspirin therapy in preventing cardiovascular events and death?
-In the treatment of Parkinson's disease, how effective were drugs that increase brain dopamine?
-How well did steroids and beta-2 agonists control chronic asthma?
-What about the efficacy of chemotherapy for breast and lung cancer?
Some other common diseases (and their treatments) they reviewed included hypertension, hypercholesterolemia and rheumatoid arthritis. The researchers also asked, and answered:
-In people with schizophrenia, how well did antipsychotic medications reduce overall symptoms and prevent relapse?
-In bipolar disorder, how effective were mood stabilizers in acute mania and for relapse prevention?
-In major depression, how well did antidepressants (ADs) work for acute depression and for relapse prevention? (By the way, they found better for the latter, though the data is confusing for the former because ADs were used in mild and moderate cases where their performance is not as robust as it is with severe depression.)
-For people with Obsessive Compulsive Disorder (OCD) how did the serotonin reuptake inhibitors (SRIs) do in controlling symptoms? -How effective were psychostimulants on the symptoms of attention deficit hyperactivity disorder (ADHD)?
They also reported on treatments for panic disorder and Alzheimer's disease.
While some individual drugs for (a few) medical conditions outperformed the psychiatric drugs they studied (and a few did not perform as well!), as a whole the two groups were about the same in terms of their efficacy.
The authors also noted that the benefits of medications can accrue over time -- a reminder that continuous (ongoing) treatment makes more of a difference. This is a message for patients, families and policymakers alike.
All medications have side-effects and risks, not only benefits. Informed patients and their families need to carefully weigh, and discuss with their doctor, risks and benefits when making decisions about their health, including the use of medications.
It is important for those affected by psychiatric illnesses to see this research. When it comes to benefits, psychiatric medications hold their own when compared with general medical medications in the treatment of a great number of diseases that affect so many people.
References:
[1] Stefan Leucht, Sandra Hierl, Werner Kissling, Markus Dold and John M. Davis. "Putting the efficacy of psychiatric and general medicine medications into perspective: review of meta-analyses." The British Journal of Psychiatry 2012, 200:97-106.
Originally Published by Huffington Post on March 28, 2012.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
"Any sufficiently advanced technology is indistinguishable from magic." --Arthur C. Clarke
In fact, advances in neurotechnology are capitalizing on the brain's remarkable sleight of hand.
Neurotechnology refers to the applied science of understanding the brain, consciousness, thought, and higher-order activities of the mind. Neurotech's brainchildren are today's mental magic. Such fantastical items include electrode-laden "thinking caps" or Transcranial Direct Current Stimulation (TDCS) to enhance human concentration; neuroimages of our dream lives, and perhaps even our waking thoughts; remote artillery weapons that soldiers can fire at a combatant by mind control; and video games operated by the player's thoughts. These aren't a sci-fi creation; now they're real.
Advancing from science fiction to applied science is a fast-growing, $8-billion business, with investments from commercial, military, and academic interests. This might seem to be good news for countless sufferers from neurological (e.g., Alzheimer's and other dementias, Parkinson's disease, Multiple Sclerosis, stroke, etc.) and mental disorders (e.g., depression, PTSD, OCD, mania, etc.). But for every scientific step forward, there is the chill of possible diabolical applications -- where there's neural firing, there's apt to be the smoke (and mirrors?) of self-serving and questionable ethics.
This is the first of a two-part series examining emerging neurotechnologies and their potential value. In the second post to follow, we will consider their ethical and practical conundrums.
The diagnosis and treatment of behavioral health conditions has yet to fulfill the promises of the 1990s, the so-called "Decade of the Brain." Since then, technological wizardry has transformed our markets, if not our lives. The next iProduct comes with lines of consumers snaking around the block. But for the people who just want to feel well, diagnostic and treatment advances in psychiatry and neurology still lack a magic bullet.
Here's the good news: With neuroimaging advances, the brain is a veritable neural Google Map. Functional MRI (fMRI) neuroimaging, as well as PET and CT scans, now allow medical scientists to observe a highly detailed landscape of the brain that reveals locations where mental diseases emerge, where behavioral therapies might do their job, and how a drug can find entry into the brain. It can even pinpoint the brain's "funny bone" -- or which neurons light up when we laugh at a joke.
An fMRI scan uses an electromagnetic field to navigate the brain, much in the same way a compass has guided travelers for millennia. One notable neuroimaging explorer is Dr. Helen Mayberg, a neurologist who identified a tract of brain tissue deep within the frontal cortex known as "Area 25," a region that is likely a "nerve center" for depression. When a depressed person responds to treatment with antidepressants and cognitive behavioral therapy (CBT), neuroimaging reflects a corresponding response in Area 25.
Beyond imaging to pinpoint neural landmarks and monitor responses to therapeutics is repetitive Transcranial Magnetic Stimulation (rTMS), an example of using applied science to treat depressed (and anxious) people. Resembling a large wand, rTMS is an FDA-approved treatment for depression in which a low-frequency electromagnetic pulse is applied to specific areas of the brain through the scalp, never directly touching the brain; it is performed safely in your doctor's outpatient office. Research demonstrates that rTMS improves mood -- and without the side effects of medication or using electroconvulsive therapy (ECT). Moreover, rTMS may help lessen the intrusive thoughts of obsessive-compulsive disorder, improve the painful apathy associated with certain psychotic disorders, and diminish chronic pain due to migraine headaches and phantom limb syndrome.
Broaching the realm of science fiction, rTMS may even have an effect on our thoughts and morality. When the wand is waved over the brain's right temporoparietal junction, it seems to exert a neuronal "superego" force! In one study, research subjects responded to a morality play where they were asked whether Cain should slay Abel. Chillingly, rTMS was able to dampen study participants' ability to judge right from wrong. Remember the brainwashing of Laurence Harvey in The Manchurian Candidate?
rTMS is not alone. Modern electro- and magneto-encephalography can now detect tumors, find stroke sites, and localize areas prone to epilepsy. Deep Brain Stimulation (DBS) utilizes a surgically implanted probe -- a brain "pacemaker" -- that stimulates brain regions instrumental to Parkinson's disease and depression. Brain-computer interfaces (BCI) are poised to enable a person's thoughts to operate a computer that could drive a wheelchair, operate a pain pump, or communicate for people who can think but not talk.
Advanced drug delivery systems are being developed to zero in on diseased brain sites or turn on genes that could promote cell growth -- and do so with little damage. Smart drugs or "nootropics" that selectively boost the neural circuits of memory and cognition are another budding frontier. And why not have an amnesic pill to erase bad memories or disabling trauma? Perhaps most incredible is the field of optogenetics, where specially engineered, light-activated (or inactivated) neurons are implanted in the brain to control anxiety. This work is underway with mice, a few cortical steps away from man. Beam me up, Scotty.
As science makes a reality of what has been science fiction, we will face questions of how to best apply neurotechnologies. Should these advances be limited to helping those who have illnesses? Or should they bolster the performance of a wartime soldier, enable a C student to get straight As, or supercharge corporate CEOs? Should an MRI or an EEG be used for lie detection or "brain fingerprinting"? If a magnetic wand can influence human morality and tip right to wrong (or vice versa), then what mischief lies ahead in using neurotechnologies to perform Jedi mind tricks on unwitting victims?
In part two of this article, we will look at how the value of neurotechnologies may go astray in the hands of mere humans.
The opinions expressed here are solely those of Drs. Erlich and Sederer, as physicians and public health advocates. Neither receives support from any pharmaceutical or medical device company.
Originally Published by Huffington Post on March 21, 2011
Once again, the American Academy of Pediatrics is demonstrating its clinical leadership. Two recent, groundbreaking reports -- "The Lifelong Effects of Early Childhood Adversity and Toxic Stress" and "Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health" -- by the Academy boldly declare what has been known but too hidden from sight: Namely, that brain and emotional development is profoundly disrupted by childhood adversity and trauma.
The pediatric academy quotes Frederick Douglass who said, "It is easier to build strong children than to repair broken men."
Toxic stress, or early environmental trauma, has been proven to disrupt normal brain development and trigger genetically predisposed diseases. The tragic results include impairments in the ability to regulate emotions and learn, to adapt socially with others and produce, in adolescence and adulthood, lifelong physical and mental disorders, including heart disease, asthma, arthritis, obesity, diabetes, cancer, depression, substance abuse and PTSD. Trouble staying and succeeding in school are also common, as are brushes with the law.
Adverse Childhood Events, or ACEs, were initially studied by Kaiser Health of Southern California and then by the World Health Organization (WHO) World Mental Health Survey Initiative. ACEs include:
1. Direct psychological abuse 2. Direct sexual abuse 3. Direct physical abuse 4. Substance abuse in household 5. Mental illness in household 6. Mother treated violently 7. Criminal behavior in household
The greater the number of ACEs, the greater the risk of developing a chronic disease, or multiple chronic diseases. From post traumatic disorder research we know the greater the severity and frequency of the trauma the more like it will burn itself into the brains neural circuitry.
The mechanisms by which early childhood adversity lays its toxic roots are numerous and complex. The manifestations are as specific as youth engaging in impulsive and dangerous behaviors (well beyond normal adolescent risk taking), including reckless (and drunk) driving and unprotected sexual behaviors, which can result in sexually transmitted diseases and teenage pregnancies. The mechanisms are as fundamental as the unregulated and ongoing release of stress hormones, including cortisol and adrenaline, which weaken body defenses (compromising the immune system's ability to protect from infection and cancer or to turn our immune systems against us in the form of autoimmune diseases), raise blood pressure, promote plaque formation in arteries, and are linked, neurologically, to depressive and post-traumatic stress illnesses.
The specialty of pediatrics was first to develop "medical homes" (popularized today with federal enabling legislation) designed initially for the young with serious and chronic illnesses whose proper care needs to be monitored and clinically managed by one responsible (accountable) doctor and clinic. Pediatricians have long used screening tools to track childhood development and more recently many have introduced depression screening (and treatment paths) as basic tenets of good care. Their declaration, through these recent reports, of the impact of childhood trauma is a rallying call for what heretofore was another example of "don't ask, don't tell."
There are many proven approaches to these problems. Among them are:
- Home visits by nurses to mothers identified as being at high risk for emotional problems (e.g., Dr. David Olds' Nurse Home Visiting Program)
- Primary care screening and early intervention for depression in moms
- Pediatric screening and early intervention for depression and addictive disorders in youth
- Parental skills training programs (e.g., Positive Parenting, The Incredible Years, Bright Futures, About Our Kids)
- Youth support programs (e.g., Big Sister, Big Brother, after school programs)
- Pediatric medical homes that holistically support child development and deliver health, mental health and wellness services
- Trauma-focused mental health programs (for youth already affected)
The health of our youth, today and into their futures, can be protected. We can prevent the diseases and disabilities that result from childhood adversity and trauma. State and national budgets can be protected from decades of preventable health, correctional and social welfare expenditures. By following the wise counsel of the American Academy of Pediatrics, and other professional and policy groups, early experience need not be destiny for countless children, their families and their communities.
Originally Published by Huffington Post on February 2, 2012.
Depression is an arch enemy if you suffer from one of many chronic, physical illnesses. It appears all the time, as an unwelcome intruder, in people with diabetes, heart and lung diseases, cancer, Parkinson’s disease and asthma. It impairs our ability to recover from these, and other, medical problems. Depression escalates health care spending for other medical disorders unless it is detected and treated.
Consider this: Depressed patients are at twice the risk of developing cardiac and artery disease (CAD) and stroke. They are four times more likely to die within 6 months after a myocardial infarction (MI or heart attack). They are three times more likely to be non-compliant with treatment – a reflection of how the illness diminishes our ability to or interest in taking care of ourselves as well as its harmful effects on the body’s stress response, immunity and hormones. As a result, those people, for example, with diabetes and depression average four times greater health expenditures. Individuals with major depression make an average of twice as many visits to their primary care physicians as do nondepressed patients – though not for their depression but for a myriad of other symptoms which are explainable when the depression is uncovered.
Goodness, these are troubling statistics. This state of affairs is not because there are bad doctors (though there are some of those just like in any profession). It is because depression has not yet gained a needed foothold in the standard operations of every primary care doctor's office. We have not yet begun to screen for depression and set as a clinical standard the proven ways of effectively detecting and treating depression in general medical care settings.
Primary care practices have become the principal sites of medical care where adults with common mental health problems in this country (and throughout the world) go for care. These individuals seldom announce they are there for a mental condition. But good medical practice will readily reveal it. Moreover, most patients prefer to have their health and mental health care delivered in one place, by the same team of clinicians. This is called integrated health and mental health care.
Depression also will hurt you at work. It reduces the productivity of our businesses through absenteeism and presenteeism (showing up but not being able to do much). Data from the “National Expenditures for Mental Health and Substance Abuse (MHSA) Treatment” indicates that the U.S. spent $104 billion on mental health and substance abuse treatment in 2001. In 2005 total spending on mental health and substance abuse services was $135 billion. While depression clearly has a significant economic impact on society, the estimated total costs of depression in the US (in 2001) were $44 billion, in 1990 dollars. However, the majority (72%) of costs incurred by society are indirect costs in the form of reduced productivity, absenteeism, and mortality – not the direct costs of care. Medical care costs (inpatient emergency and outpatient medical and/or psychiatric care) comprised only 25% and medications were only approximately 3% of overall costs. In other words, it costs more to NOT treat depression than it does to treat it.
Depression is today the leading cause of disability (by Years of Life Lost, YLLs) and the 3rd leading contributor to the global burden of disease (DALYs 2008). Projections are that by 2030 neuropsychiatric disorders will be the leading contributor to the global burden of disease (these conditions include depression, bipolar disorder, schizophrenia, epilepsy, alcohol and drug use disorders, Alzheimer's and other dementias, Parkinson's, MS, PTSD, OCD, and panic disorder).
Moreover, depression is highly associated with suicide. Estimates are that as many as 90% of completed suicides occur in people with an active mental disorder, depression in particular. An estimated 60% of people over 55 years old who took their lives were in a primary care doctor’s office in the month before their death: otherwise known as a missed opportunity to detect and intervene.
What About Quality of Care For Depression in Primary Care Today?
The answer is short and troubling: The quality is poor.
• Less than half the people with depression are properly diagnosed
• Less than half of those get any treatment.
• In total, one in eight (1/8) people with depression receive “minimally adequate care” (defined by minimal therapy visits and/or appropriate medications).
Yet treatment is effective: As many as 75% of individuals with depression will improve with appropriate diagnosis, treatment, and ongoing monitoring.
What Can Be Done?
A lot. In fact, a very specific approach to treating depression in primary care can achieve remarkably beneficial effects. This approach is well represented by the “Collaborative Care” model developed by the University of Washington. The success of Collaborative Care has been studied and now replicated in 40 (!) studies, including
in rural areas as well as in ethnically diverse and impoverished populations. The core elements of Collaborative Care are:
• Screening for depression (and in some instances other mental and alcohol and drug disorders): this involves the use of a screening tool that provides a depression score that improves when the condition improves.
The PHQ-9 is an example of a depression measurement tool.
• Measurement-based, stepped care: The abnormal score, once the diagnosis is established (the doctor, not the test, makes the diagnosis), is followed over time. Evidence-based depression care paths direct the treatment. If a defined care path is not followed or does not result in improvement then changes in treatment are made.
• An ‘activated’ patient: Patient education and engagement in their own wellbeing is an essential component.
• A care manager: The discipline of this person is far less important than their unrelenting attention to helping a patient engage and remain in treatment and self-care.
• Psychiatric consultation to the primary care physician: This means an active, weekly review of cases that do not improve, not waiting for the PCP to call.
• Training of clinical and administrative staff.
• Ongoing performance measurement and quality improvement of the delivery of integrated care.
In December, 2010, a game changing article was published in the New England Journal of Medicine by Dr. Wayne Katon and colleagues. This article showed that the collaborative care approach not only improved depression, it significantly improved blood pressure, diabetes control and lipid levels. For patients and doctors, this is the Holy Grail: an approach that benefits health and mental health!
Doctors are good learners. If they need to do something they will learn to do it. If you measure their performance they learn how to do it even better. We see that with rates of immunization, mammography, reducing surgical complications, and evidence-based treatment of a host of common and serious diseases like diabetes, asthma, and heart disease. But general medical physicians have yet to tackle depression (even though it is ubiquitous in their practice) because it has not been systematically measured and monitored.
Collaborative Care can be done. It will take clear standards of care, training, and ongoing quality improvement. Not doing it carries a price we cannot afford: human suffering, morbidity and mortality, as well as great family and economic burden. At first, leadership medical groups will need to show it can be done. Then others will find the determination and the ways to follow-suit.
Work Underway in New York State
A collaboration between the NYS Department of Health and the NYS Office of Mental Health is underway to progressively implement Collaborative Care in primary care settings. ‘Early adopters’ will identify how to succeed and demonstrate that patients and providers can take pride in their achievements. These state agencies will seek the aid of the University of Washington and the Institute for Healthcare Improvement to provide training in Collaborative Care and to scale it up across NYS Stand by for more information that will emerge in the months ahead on this initiative to integrate health and mental (behavioral) health.
Conclusion
There was a time when you or a loved one would have gone to a family doctor and you would not have had your blood pressure measured. A time when we did not measure blood sugar (much less the ongoing measure of glucose control, the hemoglobin A1c), or cholesterol. A time when care paths were places to walk in shaded glens, not treatment protocols. Not so today.
Some day we will look back and wonder how we did not measure and treat depression, and other behavioral health disorders, in primary care? We are starting on the transformation road now. It will be uphill and bumpy. So is all change.
A legendary, if notorious, character said: “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them.” He was Niccolo Machiavelli; he lived in the 1500s. Times may have changed, but not what it takes to get something done.
But it was Mahatma Gandhi who said in a more recent century, “…first they ignore you, then they laugh at you. then they fight you, then you win.”
Originally Published by Mental Health News in Spring 2012 Vol. 14.
The debate rages on about DSM-5, the
latest diagnostic manual of psychiatric disorders due for release next
year by the American Psychiatric Association (APA).
Arguments
abound about what disorders should be included (and what should be
listed within each respective disorder, like autism or psychosis) and
what should not be included; what is science and what is opinion (when
kindly considered "opinion"); what stigmatizing dangers may exist from
diagnosis; and the sheer volume of conditions that will find their way
into the printed pages of this manual. Conspiracy theories, favorite
headline grabbers, claim that the APA is in bed with Pharma companies.
Others see a psychiatrist cabal that seeks wheelbarrows of money from
the sales of this next edition.
A diagnostic manual of mental
disorders cannot be eluded. Clinicians need specific ways of declaring
what they observe to be one condition or another so they can speak to
each other and to patients and families. Researchers need reliable
diagnoses to study whether treatments work, and the course and prognosis
of diseases. Every insurance entity, including Medicare, Medicaid,
United, Aetna, BC/BS, Kaiser and countless others, requires a diagnosis
for payment -- just as they do for heart and neurological conditions,
asthma, diabetes, cancers and all the other maladies that impact the
human race. International classifications of diseases, as well, must
harmonize with the DSM to inform global public health practices and
research. The DSM is not going away.
As the winds of controversy
swirl something is going on that you might want to know about, and that
might -- might -- settle some of the contention. The APA is field
testing the DSM draft to see how it works. Now that's a good idea.
The DSM-5 Field Trials
The
draft DSM-5 is being tested in real-world clinical settings. Two
studies will examine how the diagnostic criteria work with those who
will actually use and be impacted by DSM-5, namely patients and
clinicians.
The first, and larger, of the two field trials
involves 11 Academic Medical Centers (AMCs) in the United States and
Canada. These sites were selected from 65 applicants based on their
capabilities to recruit and study a diverse group of participants (e.g.,
children, adults, and seniors as well as ethnicities). This trial will
allow the APA to compare the prevalence (rates of a condition in a
population) of the disorders among AMC patients who would be given a
DSM-IV diagnosis with those who would be given a similar diagnosis using
the new criteria in the DSM-5.
The second type of field test
involves Routine Clinical Practice Settings (RCPs). This DSM field trail
will specifically examine small group or solo practices. The field work
will involve a random selection of general adult psychiatrists and
specialists in geriatric, child/adolescent and addiction psychiatry, and
those that consult to medical colleagues as well as psychologists,
advanced practice psychiatric nurses, licensed counselors, licensed
marriage and family therapists, and licensed clinical social workers.
This study will especially focus on how feasible and useful are the new
criteria as well as the manual's measures of severity of illness.
The
field trials will concentrate on conditions that are new (e.g., autism
spectrum disorder), or that are significantly different than the
preceding manuals (e.g., personality disorders), as well as conditions
at the forefront of public concern such as post traumatic stress
disorder. The field trial participants, however, will have all the new,
proposed criteria for their use and input.
In addition to the
proposed diagnostic criteria, the field trials will assess "severity
measures" and cross-cutting symptom lists (new to the manual).
Participants will use a severity rating scale and measures for a
clinician to record symptoms such as anxiety, depressed mood, substance
use, or difficulties with sleep or attention that occur across a wide
variety of diagnostic conditions. In everyday practice clinicians see
people, for example, with depression who also suffer with anxiety, or
individuals with bipolar disorder or PTSD who have insomnia. The field
trials will assess whether the severity measures and symptom lists
provide useful information and capture clinical change over time, which
is essential to how clinicians determine response to treatments.
Previous
DSM III and IV field trials did not ensure that participating
clinicians were not affiliated with the manual's development; in fact,
previous field trials were done by the experts who drafted the manual.
The current DSM-5 field trials also use a larger and more diverse sample
of participating clinicians and patients. These actions were taken to
help to reduce bias and improve the generalizability of the findings.
Patients and clinicians also have an unprecedented voice in shaping the
proposed manual and its measures.
What happens then?
The
results of the field trials will be reported at the APA annual meeting
this May and shared with professional and consumer groups for their
feedback. Reports will also be published in peer-reviewed scientific
publications. The field trials and feedback received from patients,
consumer advocacy groups, and the public will inform further revisions
to diagnostic criteria or severity and symptom measures.
There
has been a lot of smoke from the DSM fires. The field trials should help
all concerned see through the smoke and into the embers of advancing
the complex and continuous process of improving what we know about
diagnosis in psychiatry.
Originally Published by the Huffington Post on February 6, 2012
I have had a lot of jobs, maybe more than most people of even my vintage. In the workplace, as well as in other domains, my basic premise is that leadership is earned. It is not granted by role or rite of passage. Once achieved, leadership is not sustainable without continuous proof of concept: what did you do today, or at least yesterday? In other words, leaders must demonstrate their value in a ceaseless and tireless way. For physicians, in a world dominated by administrators and insurance plans, our leadership may best be rendered through what is called “expert authority”—where a physician’s unique and extensive knowledge of diseases and therapeutics, and of human nature, serves as the basis of his or her authority and the platform for leading.
Expert authority, like the leadership it seeks to exercise, must be earned. It is earned by having the capacity to know what works medically and why; translating the complex into the comprehensible; speaking clearly and concisely and in language meaningful to others; having the emotional intelligence to understand and respond to the concerns of others, particularly patients and families; and working well in teams and being able “to manage your boss.”
Be grateful to those who do good work. Find opportunities to thank them and enable them to shine. Find ways for them to do more. Don’t be afraid to push people; they usually need it. When you do, make sure that you let them know you believe in them, and then support them. Don’t be afraid to set high standards; no one I know has died of hard work.
Measure, measure, measure. Establish metrics that are understandable to your mother. Because when your efforts meet the undying forces of clotted interests, as they surely will, you will need to prove that what you are doing is working. Then despite any criticism that is raining down on your efforts, you can resolutely point to the evidence that what you are doing is working (and kindly acknowledge their concerns).
Enjoy the journey. The Spanish have an expression: se hace camino al andar—the road is made by walking it. You will be surprised by where you go and by the places you will discover, in yourself and in the community you call work.
Originally Published by Psychiatric Services in February 2, 2012
Great post. I was checking constantly this blog and I'm impressed! Extremely helpful info specially the last part I care for such information much. I was seeking this particular info for a very long t...
Lloyd I. Sederer, M.D., is Medical Director of the New York State Office of Mental Health (OMH), the nation's largest state mental health system. As New York's “chief psychiatrist”, he provides ...Read More
Keys to Leadership: The Physician Executive's Top Ten List