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Sunday, December 12, 2010

How are you feeling today?

It's that time of the year and my office is packed. The holidays are often worse with my patients who suffer from mental disorders. Recently, I saw my patient whom I've been following for a long time. She has schizophrenia and has been doing well. She hasn't had paranoid delusions or hallucinations for years now. I love seeing the progress she has made, and that I was able to help her get well.

Yesterday when I saw my patient, I asked her to sit with me. When we got comfortable, I asked her, "How are you feeling today?" She said, "With my fingers." I laughed...

Thursday, December 2, 2010

Scrat...musings on ADHD


My office assistant Patricia said, "You've got a live one." I thought Okkkkkkay..., as I readied myself for my next patient. When I stepped out to greet him, he jumped, I mean really jumped! He was extremely nervous and kept looking around, like he was leaving something behind. When we sat down face to face, his voice was squeaky and thin. He looked thin. He reminded me of the character Scrat, the squirrel from the Ice Age movie. He told me he had been using Adderall for his ADHD and after increasing the dose found that his concentration seemed to be worse. He wanted me to help him find something else that
might work better. I said, "Sure, but first we have to stop your Adderall, you're tweaked."

Attention Deficit Hyperactivity Disorder is seen in both children and adults. My practice is limited to 15 yrs and older. The reason is because medications used for ADHD can stunt growth if used before puberty. I think it's better to leave that kind of treatment to child psychiatry specialists. I see a lot of adult ADHD and have people frequently seeking treatment in my office for poor concentration issues.

The medications of choice for ADHD are stimulants like Ritalin and Adderall. These drugs are highly effective but a real pain in the ass for me and for the patient. The reason--because they are highly addictive, and tolerance and dependency develop rapidly--just ask my boy Scrat. He was even having a hard time peeing, he had so much Adderall going on. Because these drugs are highly scheduled DEA drugs, it means a monthly visit to my office. No refills can be prescribed with these drugs. These drugs need to be taken everyday, not just sometimes. Nonetheless, I frequently see patients requesting these pills. In my practice, I prescribe only the long acting or extended release stimulants at low doses. Long acting drugs have less tolerance and dependency issues, are simpler to use, have fewer side effects and are less likely to be abused or diverted by other people. Vyvanse, Adderall XR and Ritalin LA are my favorites.

There are non-stimulant medications for ADHD which I always try to switch my patients to. These drugs have no dependency or abuse issues and can be prescribed with refills. I see these stable patients every 3-4 months instead of monthly. These medications include Strattera and Provigil, which I use abundantly. There are just fewer side effects, improved ADHD symptom profile and often improved mood as well. Adderall and Ritalin don't capture mood disorders occurring with ADHD. Non-stimulant medications can treat depression and anxiety often occurring with ADHD. Other second line ADHD medications include Wellbutrin and desimipramine, which I occasionally use.

My patient Scrat did get better after we tapered him off Adderall. We started Strattera, where now his concentration is fine without all the side effects. He can sleep and has regained some lost weight. He's not jumpy either. Last week when I saw him, he told me he felt much better. He also said he wasn't looking for acorns anymore.

Tuesday, October 26, 2010

Enough

I've been procrastinating. The last time I posted was over 6 months ago. Not that I didn't want to, at least not really. Sure, I've been busy and life has been tough. Listening to my patients these last 6 months it's obvious it has been tough for a lot of people, not just me. I can honestly state there were days when I wasn't tired and I really didn't have anything else to do. I would think about blogging and then sort of do nothing...nothing.

Well, not really nothing. I would sort of think about what I would write, I'd come up with a phrase, then I would think that's dumb, then I would think of another phrase and then think that was dumb too. I would do this for hours, on and off...sometimes all day. I would get stuck. I would procrastinate.

Recently I read an article in Google news that indecision is a characteristic of intelligent people and ambivalence can generally be helpful. I instead believe that procrastination and associated
indecisiveness usually cause dysfunction that result in lost moments or opportunities.

Procrastination is a subconscious self defense mechanism that's supposed to minimize anxiety. For me the anxiety was trying to come up with perfect phrasing. This is irrational, there is no perfect phrase. I lost time, the most precious opportunity I have of here and now. Procrastination is a psychological abnormality probably resulting from dysfunction in the prefrontal cortex regions of the brain. We actually see this area light up on PET scans when people are having these same kind of circular thoughts. Although subconsciously I believed I was better off putting off my blogging, I instead got more anxious. This often translated into vague feelings of being less than or defective or a loser.

It's easy to see how these behaviors and thoughts can result in poor self esteem. Most if not all of us procrastinate, it's how the human brain is wired. It becomes important to realize that these unconscious blips usually diminish our ability to function. We need to improve our insight even if it's days, weeks or months later.

At least I was able to blog today. Later when I notice I'm procrastinating again, I'll be able to say enough already!

Tuesday, April 13, 2010

Serotonin smile

Yesterday one of my patients told me she was much better with
her new medication. "I have a serotonin smile."

One of the reasons I went into psychiatry is because it can be
so funny! Everyday I laugh at something. I'll try to share these
as I go along.

Sunday, April 11, 2010

Major Depression as a Brain Disorder

As I  posted earlier, Major Depression Disorder (MDD) is serious-you can die from it. A comment posted on my last blog stated psychological pain is just as real as chest pain and should be treated. I concur and am happy to tell you MDD is highly treatable. Lets say you saw your regular medical doctor, started medications 6 weeks ago and you still feel depressed. Now what?

At this point psychiatric treatment is the next step. I would obtain your history, review your symptoms and develop a diagnosis with a treatment plan. For MDD, I would start an antidepressant and then discuss psychotherapy goals. The treatment for MDD is an antidepressant and psychotherapy. To do one without the other is a waste of time, plain and simple. Because most of the patients I see haven't done both together, their depression is chronic, everyday for what probably seems like forever.

All antidepressants work, it's a matter of using one that alleviates your symptoms and causes no side effects. This is actually easy for me to do. I can usually gauge and see a response within 2 weeks. Antidepressants restore normal brain function, they do not create any artificial states.

While we wait for full antidepressant response, psychotherapy is started with goals delineated. For MDD, cognitive behavioral therapy (CBT) is standard. Once better coping skills are learned treatment usually winds down. Yes, for most people treatment ends, you're cured. It is a rare patient in my office who does treatment forever for MDD. Usually a year, give or take, is all it takes. Amazing huh? The comment from my last post has it right, ditch any stigma about shrinks and get better.

Tuesday, February 2, 2010

Mental Diseases versus Mental Illnesses

Recently one of my last patients of the day told me "I feel so much better." I was writing, not directly looking at her and I said "What did you think, you weren't?" When I looked up at her, there were tears in her eyes. "Honestly," she said, "I thought that I was crazy, you know, mental illness, something is wrong with you if you're mentally ill...you're defective. You're never better."

This was just one more point of realization for me. In my last post, I used the term mental disease as opposed to mental illness. The term illness is archaic and references ideas of deviance, defect or crazy. No physician colleague of mine says heart illness or kidney illness; it's heart disease or kidney disease.

I specialize in the treatment of mental diseases which I define as abnormal thoughts, emotions or behaviors that interfere with daily life function. An abnormal heart beat would lead to ischemia (lack of oxygen) to vital organs, which would affect everything in your daily life. Normal heart beats are essential to normal function of the entire person. Normal brain function, like wise, is necessary for a healthy life.

Psychiatrists can diagnose and effectively treat abnormal thoughts, emotions and behaviors. Abnormal emotions such as constant worry or sadness, abnormal thoughts like obsessions and abnormal behaviors such as poor sleep or weight gain are highly treatable and curable.

I don't think most people would think that they were awful, defective people if they were diagnosed by their doctor with high cholesterol. In fact, most people would start cholesterol lowering medication and try to cut back on fatty foods and exercise. Hypercholesterolemia is usually a chronic condition that can be improved with treatment that is necessary for a healthy life. We all know this.

It's the same for the diseases that I treat. Medication can alleviate the actual abnormality and psychotherapy rehabilitating you to normal function.

I say this because a poll in Business Week showed most workers fear stigma or a change in their work status when seeking mental health care versus seeking treatment for other diseases such as diabetes. This poll was news in conjunction with a new law that requires parity or reimbursement for mental health. This law now requires that psychiatric treatment be allowed and reimbursed by insurance at the same rates as medical illnesses like heart disease treatment.

Disease is disease. If you're sick it's your responsibility to get well. With mental diseases, treatment is highly effective, safe and affordable. There is no such thing in psychiatry that you don't get better, like my patient found out earlier. Mental illnesses are not character defects, they're diseases; get treatment.

My next post will start to cover these topics.

Friday, January 15, 2010

Differences Between Psychiatrists, Psychologists and Psychotherapists


I am not a psychotherapist. I am a psychiatrist. Psychotherapists are non-physician mental health providers. They include psychologists, licensed clinical social workers, and marriage and family therapists. Because they are not physicians, they cannot prescribe medications. Let me emphasize, psychologists are not physicians. Most of my patients don't seem to know the difference. As a physician, I am able to diagnose any medical illnesses that present as mental symptoms. For example, a patient with weight gain, decreased energy and loss of interest in her favorite activities is consistent with a diagnosis of Major Depression. This patient I recently saw complained that these symptoms had slowly progressed over the last 2 years and had not gotten better with several months of weekly psychotherapy. There was no previous medical history. I ordered labs (which a psychologist cannot do) and found low thyroid hormone, a condition called hypothyroidism. I then referred her to an internist friend of mine. Later, follow up with her revealed no symptoms of depression, her energy and mood had improved, and she had lost weight with thyroid replacement. I discharged her from my practice, cured.

I am a medical doctor who specializes in the treatment of mental diseases, just like a cardiologist specializes in the treatment of heart diseases. Psychiatry treatment includes diagnosis, medications if necessary and psychotherapy. I perform medical testing if indicated and admit patients to hospitals like other medical doctors. I can also submit to courts petitions for involuntary treatment. Non-physician psychotherapists and psychologists can only do psychotherapy and not the other functions of mental health assessment, like a physician who specializes in mental disorders can. Most of my patients are very surprised that most mental disorders can be diagnosed and treated very easily. Most of my patients are very surprised that mental health is health.

Dr. Phil is not a psychiatrist. Refer to Wikipedia for a good definition of what a psychiatrist is. Any non-physician psychotherapist discussing medications is practicing beyond the scope of their training. All psychiatrists are trained in all aspects of psychotherapy. In my office and I believe for most psychiatrists, psychotherapy is usually referred to non-physician mental health providers. It's just plain cheaper. The reality is most people and most insurance plans will not pay $300 or more per hour, per week for a psychiatrist. Honestly, I wouldn't pay that either. I also believe good psychotherapy can be done with other psychotherapists. I usually relegate myself to making a diagnosis, establishing a treatment plan and referring patients to psychotherapists for goal oriented treatments. These plans are aimed at restoring health and function in the easiest, quickest way possible. This biopsychosocial approach is beyond what non-physician mental health providers can do. Once a treatment plan is started, I make sure all the goals of the treatment plan are achieved to restore health and normal function.

I hope this narrative provides clarification. Next I'll be posting on how psychiatry treats mental diseases.

Saturday, January 2, 2010

Unhinged vs Unplugged

The week before Christmas, I saw 75 patients in my office. 10-15 were new patients and the majority of these patients had know idea about what I do. In the end, I'm glad they had the nerve to come. I don't think I'd go to a doctor's office without having some idea of what to expect.

Most were relieved to find out they suffered from simple mental diseases that are highly treatable. However, the misinformation that most of my new patients relayed to me was down right crazy. In my practice I don't see crazy very often--seriously.

Most people thought I do "Soprano" psychiatry where I'm sitting in a plush office with a patient asking deep
probing questions about their childhood for 1 hour. Others thought I do "Tom Cruise" psychiatry and give out pills in some haphazard fashion on request. The fact is most psychiatrists don't do either.

This blog I'm hoping will dispel these myths and bring some common sense and straight forward explanations about what psychiatry is and is not, what it does and doesn't do, what it can and can't do. Mental diseases and all aspects of treatment will be discussed, clarified and simplified. Current information and standards of psychiatric treatment and disease management will be emphasized. In short, I'll try to put some sanity into defining psychiatry as my medical specialty.

Prior to Christmas I did feel unhinged. Now I feel better. Psychiatry unplugged is how I'm starting the New Year!