What’s MDD?

March 1st, 2013 by gelenberg No comments »

I chaired the APA workgroup that authored the third edition of the treatment guideline for major depressive disorder (MDD), published at the end of 2010. MDD is a typical DSM-3 (and beyond) diagnostic category—a behavioral syndrome, which doubtlessly encompasses many biologically distinct diseases. (Hence the varied responses of patients to our ministrations.) But even while we eagerly await the dawning of the era of personalized, genomically informed medicine in psychiatry, we can still assess each depressed patient with a careful differential diagnosis—considering substance abuse, medical and neurologic diseases, and personality disorders, among other possibilities.

This came to mind when a resident presented a case to me. The chief complaints were lack of energy and interest—certainly key components of MDD, but easily reflecting a host of other diagnoses. When I saw the middle-aged man, he had mask-like facies, bradykinetic features, and a resting tremor. On examination he displayed muscular rigidity. We referred the patient to a neurologist, who confirmed a diagnosis of Parkinson disease. The patient’s psychiatric complaints responded favorable to the antiparkinson regimen, as did his motor signs. We will soon taper his SSRI. It didn’t take long, and it sure helped this man.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

“Inheriting” A Patient

February 27th, 2013 by gelenberg No comments »

Cases presented to me recently at another medical school and within my own department highlight a common clinical problem: picking up (“inheriting”) a patient previously under another doctor’s care. In resident clinics, it is commonplace, as residents advance through their training.

I shudder at how often I see complex pharmacologic “cocktails,” with at least one agent from every psychiatric drug category—sometimes two or three in a category. Truly there are some patients who benefit from polypharmaceutical regimens—as they do in hypertension treatment and other medical specialties. But more often, no one can say why the patient is taking these medicines at these doses: not the chart, the patient, the family, or other caregivers. Commonly, providers inheriting such patients go into “autopilot”—continuing the regimen without understanding it. It’s quicker and has less hassle. A resident recently told me how she worked to understand, then disentangle a complicated multi-drug regimen, then explain it to the patient, family, and other staff. By the end of the session, she was exhausted!

When a physician assumes care of a new patient on a complex treatment regimen, I recommend slow and cautious but methodical diligence. Ask everyone for input on the regimen, review the clinical record, and try to contact previous clinicians. At an initial visit, put confidence building and establishing trust first, but mention that the regimen is complex and might conceivably be less than optimal. Suggest future conversations toward simplifying the regimen, and document the discussion. And over time, consider cautious tapers—one drug at a time—with careful observation for adverse outcomes.

It is time consuming. And emotionally draining. And when a patient or family is adamant against change, I take their wishes seriously. But if I assume medical responsibility for care, I am responsible—not the doctor or doctors who created the regimen in days past.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

Personalize This

January 17th, 2013 by gelenberg No comments »

The future of psychiatry, and indeed all of medicine, will emerge as we unravel the double helix of the genetic code, the proteins DNA commands, and the epigenetic factors that allow our environment to influence genetic expression. Today, I caught a brief glimpse of that future.

I just attended the ceremonial opening of the Penn State Hershey Institute for Personalized Medicine, one of a handful of high technology centers that will pave the way to a new era in health care. This multimillion dollar facility was enabled by federal, state, and private funds, and the inaugural event was attended by a U.S. senator and many United States, Pennsylvania, and university dignitaries. The Institute consists of laboratories that can quickly and relatively inexpensively map individual genomes, a tissue repository for samples from thousands of patients, and an information technology hub.

When I was a medical student in the 1960s, virtually all children with leukemia died. Today, almost all survive. The difference has been discoveries about the mysteries of individual cancers and how to target treatments to their unique signatures. Not only has survival increased, but when cancer treatments can be personalized, doctors can apply less toxic medicines than the systemic poisons we have used for decades.

I am committing significant discretionary funds from my department to leverage our new center’s technology to achieve breakthroughs in psychiatry. Instead of blasting every cell in the body with increased levels of serotonin, someday we should be able to target interventions to distinct pathophysiology underlying diseases of impulse, mood, and thought. As in other medical specialties, we will bank tissue samples from psychiatric patients, establish diagnoses, track symptoms systematically over time, record responses to treatments, and use computer programs to link biology to pathology and ultimately to cure. It is an exciting time.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

Run For Cover

December 18th, 2012 by gelenberg No comments »

Lawmakers and other politicians have been ducking and running for cover from the NRA and gun lobby for more than a decade. Perhaps after the slaughter of first graders in Connecticut—many little feet trying vainly to run for cover from an assault rifle—that may change.

In the shooting’s aftermath, I heard pundits and politicians call for better “mental health screening.” Say what? We have no valid instruments to predict which mentally ill people are likely to erupt in random violence. Unquestionably, we can improve our system of care for people with mental illness. Outpatient commitment laws can use judicial powers to assure a higher rate of adherence to treatment for many at-risk individuals. And state systems are sorely in need of more funds and better leadership, with accountable management and best practice standards.

But we really need better gun laws. Semi-automatic assault-style weapons, with high-capacity ammunition clips, make no sense for sport or self-defense. Background checks and other restrictions will help. An angry or psychotic person can wreak havoc with a baseball bat or knife, but rapid-fire firearms can kill and maim large numbers of defenseless innocents in seconds.

Monday is my clinic day. This week it followed the Newtown killings by three days. A mother of young children, whom one of my residents treats for an anxiety disorder, feared sending her kids to their elementary school and was considering home schooling as safer. A woman in her 70s re-experienced dormant grief. A mother of a disturbed youngster felt anticipatory guilt, as she identified with the shooter’s mother. Patients with PTSD felt re-traumatized, with resulting recurrent symptoms.

The residents and I did our best. We consoled, offered advice and perspective, suggested limiting exposure to continuous television scenes of carnage. We counseled on ways to explain the events to children.

We helped our patients grieve. And along with our own families, friends, and colleagues, we grieved. Many tears have been shed since last Friday’s senseless loss of life. How many more children must die before our state and federal governments take reasonable steps to enhance public safety?

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

When Passion Trumps Practicality

November 19th, 2012 by gelenberg No comments »

My department at Penn State reaches out regularly to medical students who may be interested in careers in psychiatry: movie nights, mentorship, electives, and much more. A few days ago we held an open question-and-answer lunch, in which three faculty members and a senior resident fielded questions from a couple of dozen students from all four years. We munched on take-out Chinese food and chatted.

One student asked about careers in psychiatry, unmet needs, and subspecialties. He was reasonably trying to sort out his options. I knew that if I told him what had been the facts over my 40 years in practice, and what the world looks like today, he would make his calculations and decision for his practice over the coming 40 years. But the world of U.S. healthcare is anything but static. The changes coming over the next few years will be huge.

I am certain that psychiatry—and our subspecialties even more—will remain short of manpower. But who can say what tomorrow’s psychiatrists will do, what their hours will be, how long they will spend with patients, or what they might earn? I would say the same for the choice of specialty, whether surgery, medicine, pediatrics, or any other. Science and technology will bring major new developments, and the healthcare delivery infrastructure is undergoing a sea change.

What I am sure of is that there will be patients. People will be scared, in pain, confused, and uncertain. They will require ministrations, explanations, treatments, and comfort. The safest course for young doctors looking forward is to follow their passion, to chart their paths by what they most want to do—independent of practical, economic, and lifestyle factors. The joy in medical practice will remain forever—if they can follow their own hearts.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

And Now: Healthcare Reform

November 7th, 2012 by gelenberg No comments »

Last summer the U.S. Supreme Court upheld the Affordable Care Act (ACA). Yesterday’s re-election of President Barack Obama virtually guarantees that ACA will be implemented. The process will be long, complex, with countless moving parts. Many of its features require interpretation, further enabling policies from the HHS Secretary, individual state actions, and a myriad of detailed steps. But the continuing escalation of healthcare costs is unsustainable—especially when we are not buying improved care for our citizens. And we can now see a path forward.

Within a few years, almost all who reside within our borders will be eligible for medical care. Mental and behavioral diagnoses will be covered. With the increased focus on efficiencies, behavior will become paramount: enhancing patients’ understanding of their conditions and care, securing their buy-in to treatments, prompting them (often electronically) to take medicine, come to appointments, and more. Recognizing and effectively treating depression, for example, will improve outcomes and save costs in treating diabetes, heart disease, and many other chronic illnesses. I sincerely hope the chronically mentally ill will begin to receive the medical care that has often been denied them—with safe integration of brain treatments and those for other body organs.

Doctors will experience a sea change. The premium for surgery and invasive procedures will give way to preventive and long-term management foci. Information technology will play a growing role in every aspect of health care. Teams of professionals will be integral in the new order.

It will take a long while to “get it right.” The journey will require patience and efforts at every level. But I am convinced we will get to a better place.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

The Obesity Epidemic

October 26th, 2012 by gelenberg No comments »

It’s growing. And we’re growing. A news article in the October 17th JAMA summarizes a report from the Robert Wood Johnson Foundation on obesity in America. At our current rate of growth, by 2030 more than half of adults will be categorized as obese in 39 of our states. In 2011, Mississippi had the highest obesity rate and Colorado the lowest.

And echoing the blog I wrote on October 18th about health care costs, the price tag of treating obesity-related diseases will be $66 billion additional dollars. Productivity losses could be between $390 and $580 billion. America’s expanding waistlines will create additional cases of type 2 diabetes, coronary heart disease, stroke, hypertension, and arthritis. We are on track to see the incidence of diabetes in adults over age 20 rise from 11% to more than 31%. Obesity could contribute to more than 400,000 additional cancer cases over the coming two decades.

Psychiatrists see patients whose underlying disorders and life styles contribute to weight gain, and many of our medicines contribute additionally. BTP will soon report on work with metformin (Glucophage and others) to attenuate some of this problem, but at the forefront should be efforts to encourage healthy eating choices and portion control, exercise, and modest but important lifestyle changes, such as walking rather than riding and preferring stairs over elevators.

Walking down a street—more often in some parts of the country than others—I see visual evidence to support the data about the increase in obesity. The clinical facts are overwhelming, and the economic figures are sobering. Attention must be paid.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

The times they’ll be a-changing

October 18th, 2012 by gelenberg No comments »

I think the figure I heard yesterday about the amount the United States spends on health care today was $2.6 trillion annually. That’s a lot of zeros! And hard to get my mind around. What it does tell me is that no matter who wins control of the White House and the two chambers of Congress, our current system must and will change dramatically. One expert who addressed our group said that unless the rate of health care cost growth is arrested, the cost of care per employee will exceed wages over the next decade or so. That cannot and will not happen.

Some colleagues advocate for a single-payer system, which might be our ultimate destination. The Affordable Care Act is relatively conservative but will definitely bring big change. Even if conservative forces prevail politically, the market will force change. The change will inevitably involve greater focus on efficiency, effectiveness, evidence-based treatments, and long-term management of patients with chronic illness. Behavioral and psychiatric conditions will ascend in importance. Information technology—for medical records, communication among clinicians and with patients, decision support, and patient education and adherence—will take on growing importance.

Change is inevitable and imminent. Psychiatrists and other physicians must stay attuned and prepared for the implications of change on their lives and practices.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

Duane

August 3rd, 2012 by gelenberg No comments »

My father-in-law, Duane Bryers, passed away recently—weeks short of his 101st birthday. We held a memorial at his Tucson home for family and close friends. For me, Duane personified resilience and the benefits of a positive attitude.

As a psychiatrist, I have spent much of my career studying depression and treating people who suffer from it. I understand the concept of CBT, as it encourages depressed people to reconceptualize their views of themselves, the world, and their futures. In recent decades, scientists in a range of biological disciplines have advanced concepts of resilience, reframing a problem like depression from a dichotomy of normal versus pathological to a spectrum, in which some people are predisposed to dark and negative thoughts and emotions, while others see the proverbial glass as half full or more.

Duane always looked on the bright side of everything. He made his own luck. His positive attitude was infectious. The greatest blow I ever saw him take was the loss of his beloved wife of 30 years. Dee was younger, and we assumed he would precede her. But when she left him alone, he grieved, then moved forward by initiating a new phase of life in his 90s—buying a new house and new furniture. A very gifted artist, Duane spent hours every day at his easel. Until a few years ago, he continued to create beautiful new paintings and sell them for serious money.

In time, neuroscience will shed light on the biological and experiential bases that allow some people to innately see the positive and embrace a can-do attitude, while others are easily daunted and discouraged. Sometimes, when a bad event challenges me, I think of Duane and his smile.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

People Kill People

July 23rd, 2012 by gelenberg No comments »

It was a bumper sticker years ago: “Guns don’t kill people. People kill people.” Like most clichés, it’s true, but incomplete. Knives and baseball bats also can be employed by people intent on murdering others—but they can’t do as much damage so quickly.

Who didn’t pale in horror at the news out of Aurora, Colorado, news about innocents, including children, gunned down at random in a movie theater? The suspect had an arsenal of modern weapons, some capable of spewing 60 rounds a minute, all purchased legally, along with high-powered ammunition, much from the Internet.

The immensely powerful NRA used to be about access to hunting, about teaching children gun safety. The “R” is for rifle, not assault-style semi-automatic weapons, of no legitimate use in hunting.

Today we cannot know if the shooter is mentally ill or an angry man intent on random vengeance and creating mayhem. But we do know that mental illness will not be vanquished for decades or even centuries, and rage, drugs, and alcohol will be with us at least as long. If senseless tragedies are to be limited in their scope, we must push back against today’s easy access to weapons of mass slaughter.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry