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

Mission and People

June 24th, 2012 by gelenberg No comments »

I awoke this morning to front-page news about two criminal convictions—both concerning sexual abuse of children by trusted authorities, both in Pennsylvania, my home state, where I now live again. One involved a church leader in Philadelphia, the other a highly regarded assistant football coach at Penn State, where I am on faculty. The stories are jarring and disturbing and have made headlines around the world. The stories also carry lessons and reminders.

When I served in the U.S. Army, I learned (as all officers were taught) that nothing transcends the mission and the people. Society sets up many authorities, social structures, codes, and hierarchies: the military, law enforcement. civil service, the courts, religion, universities, medicine, and many others. People higher up in such hierarchies often enjoy privilege, elevated status, wealth, and recognition. Society imbues these people with trust and many perquisites and, in return, expects a code of conduct—such as dedication to one’s mission and people. Still, it is common for people and organizations to lose sight of these sacred trusts and focus instead on self gratification and taking care of one’s own: for example, police sometimes protect other officers before the public; doctors often protect our colleagues and trainees above our responsibility to their future patients.

It is reassuring that, after generations of neglect, society is now investigating and punishing the abuse of children. But physicians, educators, the clergy, and many others who benefit from elevated status in our community carry a range of obligations and expectations. We need to renew our vows every day in our own worlds—reminding ourselves of those who are vulnerable and depend on us. It comes back to our mission and our people.

-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

NCDEU 2012

June 13th, 2012 by gelenberg No comments »

I just attended the annual NCDEU meeting—this year in Phoenix, AZ. NCDEU stands for New Clinical Drug Evaluation Unit (formerly ECDEU, Early Clinical Drug Evaluation Unit) These are now meaningless acronyms, but it was originally a symposium of clinical psychopharmacology researchers funded by NIMH. NIMH has recently relinquished “ownership” of the meeting to the American Society of Clinical Psychopharmacology, but it, along with its sister institutes NIDA and NIAAA as well as the FDA, retains a partnership stake and roll [?a role] in the program.

No one was certain how this meeting, which many of us are devoted to, would survive the transition from NIMH’s leadership. But this year’s program, with ASCP in the lead, was a sparkling success: in attendance, participation, enthusiasm and—most of all—groundbreaking science.

Meetings evolve. ECDEU/NCDEU began as a methods-focused conclave in the early days of biological psychiatry. Over the decades, it evolved to incorporate understanding of brain function, psychosocial interventions, and combined treatments. NCDEU became a unique assembly of industry, government, and university scientists, regulators, teachers, and clinicians. The papers, posters, and panels contained cutting-edge information, but much of the spark came in the informal conversations, from which flowed new research ideas and collaborations.

This year’s agenda included news on innovative treatments and new data on old techniques and agents. A bold new diagnostic methodology, the NIMH Research Domain Criteria (RDoC) is shifting the focus from DSM categories to dimensions and traits, in the hope of mapping disorders to biological underpinnings and the human genome. Whether—and when—this will bear fruit in furthering understanding of brain disorders and creating new and personalized treatments remains to be seen. It could take years or even decades to unfold.

-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

 

Overall, the information imparted at NCDEU 2012 was invigorating, and the energy in the meeting has never been higher. With the disclosure that I sit on ASCP’s board and have an abiding passion for its mission and NCDEU’s future, I encourage my faculty members and BTP readers to think about ASCP membership and attending NCDEU. BTP (and the Journal of Clinical Psychiatry) are partners with ASCP, which is a dynamic and growing organization. Coming away from this year’s meeting, I am very optimistic about psychiatry’s future.

A Little More Time for Sex

April 3rd, 2012 by gelenberg No comments »

In the early 1990s, I was intrigued by the nature and degree of sexual side effects engendered by the then-new SSRI antidepressants. These adverse reactions differed from sexual problems associated with tricyclics and MAOIs. Several of us in Arizona created the ASEX scale to track these side effects, and I participated in trials of antidotes and journal reviews of the problem.

Twenty years have passed. A few days ago I chaired a “roundtable” discussion on depression for primary care doctors with my colleagues and friends Michael Thase and Erika Saunders. When we spoke about sexual side effects of serotonergic antidepressants, Michael mentioned the benefits of counseling patients to expect sex to take more time. Here was an obvious and low-tech solution I had never thought of.

I doubt many people book time for sex in their Outlook calendars. Still, couples in stable relationships know roughly how long they need. (For teenagers, the unit of measurement can be seconds.) Few couples will begin a 30-minute encounter if, for example, they’ll need to drive to an appointment or expect the baby to awake in 15 minutes.

So when we start a patient on an SRI antidepressant, suggesting that the patient and partner allow and anticipate more time (and sometimes more stimulation and creativity) can transform what otherwise would be anorgasmia into delayed orgasm.  I recall a middle-aged female patient of mine who observed, “I can get there, but I have to work harder.”

This is good, safe, practical, art-of-medicine advice. Thanks, Michael.

-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

 

Grief and Depression

March 16th, 2012 by gelenberg No comments »

If you read the popular press, you are aware of the controversy about dropping the bereavement exclusion from the diagnosis of Major Depressive Disorder in DSM-V. The Lancet published an editorial in their February 18th issue decrying what they called the classification of grief as a mental illness. The same issue carried a moving Perspective by Dr. Arthur Kleinman, who described the recent death of his wife, his own bereavement, and his warning against “medicalizing” grief.

Freud struggled with the separation of grief and depression. His elegant monograph Mourning and Melancholia bears re-reading today.

The thought of turning natural grief into an illness and treating it with drugs is anathema to me. Grieving truly is a normal, personal, intimate process. It requires friends and loved ones and, as Freud describes, it is a gradual, healing path of saying good-bye and moving forward with the rest of one’s life.

But sometimes loss triggers the pathological mood state of depression. I have seen patients whose normal grief went off track and ground to a halt when the pall of depression descended on them. When they were treated with antidepressants or psychotherapy, they were able to resume the healing process, move forward in grieving, and find their place again in the world.

I am no expert in nosology. But as a clinical psychiatrist, I do hope the framers of the next DSM will find a path between the extremes—neither medicalizing a normal process, nor making it impossible for a grieving person who then develops depression to legitimately receive proper treatment.

-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

 

I and Thou

March 8th, 2012 by gelenberg No comments »

I often sit in on our psychiatry residents’ visits with patients. During one recently, I was reminded of reading Martin Buber when I was in college. Good doctors—certainly good psychiatrists—must establish what Buber called an I-it relationship with patients: objectively collecting, synthesizing, and hierarchically organizing data, maintaining appropriate boundaries and neutrality, formulating a working diagnosis and treatment plan. But without simultaneously establishing an I-thou relationship—involving an ineffable mélange that includes love, empathy, and spiritual connectedness with a companion soul—the clinical encounter is cold.

At a pragmatic level, cold encounters usually result in patients who don’t return, non-adherence to treatment recommendations, and little clinical benefit. Practitioners who can’t put aside checklists and allow a free flow of emotion and experience often “miss the boat” and may not help a fellow human in need.

A while back a resident was evaluating a patient. Going through his standard questions to rule in or out major depression, he asked the patient about her sleep. She said she hadn’t slept very well since a recent incident with her husband. The resident checked a box about insomnia and went on to questions about suicidal thoughts. When he had finished, I followed up and asked the patient about her marriage. The tears flowed, vital information emerged, and our formulation of the problem and treatment recommendations changed.

DSM-III, IV, and presumably V have brought reliability to psychiatric diagnoses. Someday genomics presumably will add validity to our nosology. We should follow the rules of the DSM to ensure clear communication and fidelity with best-practice treatment guidelines. Measurement-based care and evidence-based medicine are watchwords of modern practice and to be honored every day.

But there is a vital role for I-thou, which in no way conflicts with a scientific and objective approach. It’s the human part of the complex equation of two people sitting with one another. In his daily physician’s prayer, the twelfth-century physician and philosopher Moses Maimonides wrote, “In the sufferer let me see only the human being.” Amen.

-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