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.
Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
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





Can Too Much Work Make You Depressed?

January 30th, 2012 by gelenberg No comments »

Last week two reporters asked me to comment on an article in the open-access journal PLos ONE.

Citation: Virtanen M, Stansfeld SA, Fuhrer R, Ferrie JE, Kivima¨ki M (2012) Overtime Work as a Predictor of Major Depressive Episode: A 5-Year Follow-Up of the Whitehall II Study. PLoS ONE 7(1): e30719. doi:10.1371/journal.pone.0030719


The study, by Virtanen and others, followed 2,123 British civil servants for 6 years. It found that workers who put in an average of at least 11 hours per day at the office had roughly two and a half times higher odds of developing depression than their colleagues who worked a standard 7 or 8 hours. The association of long workdays with depression persisted even after the researchers took into account potentially confounding factors such as job strain, the level of support in the workplace, alcohol use, smoking, and chronic physical diseases.

Psychiatrists know that many factors contribute to a person’s becoming depressed. These days we assume genetic and early-life variables set the stage for depression later in life. But immediate factors play a role too. Working long hours for an extended period takes away time to unwind, to seek comfort and pleasures in recreation, friends, and loved ones. Then there is the element of control. In the Virtanen study, the length of the workday didn’t have a perceptible impact on the mental health of higher-paid, top-level British civil servants —employees such as cabinet secretaries, directors, team leaders, and policy managers. I have the good fortune of choosing when I work extra and on what projects. It’s more fun and less adverse

When we consult to individuals or employers, we’ll want to keep this study in mind. Individuals at risk for depression should be cautious about long stretches of overtime work—if they have a realistic choice. And supervisors will want to take a long view: get extra work accomplished, but don’t burn out your most valuable workers.

-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





Online All The Time

December 30th, 2011 by gelenberg No comments »

Mostly I love the digital revolution. I have tools at my fingertips that make life easier, give me instant access to almost infinite data, and keep me close to loved ones. But there are many downsides.

Impaired driving is an obvious one, as people negotiate turns in traffic with their hand pressed to an ear, eyes focused on infinity. And we’ve been hearing lately about “impaired doctoring,” as physicians check smartphones in the middle of patient encounters.

As a psychiatrist who has conducted psychotherapy for over 40 years, I also think about how people make crucial life decisions and how that process is impacted by electronics now. A good decision (Shall I move? Leave a relationship? Change jobs? Change careers?) requires acquisition of knowledge (due diligence, seeking opinions). And then the person needs to look within, to reflect, to mull the next step. This demands nondistracted quiet: a walk in the woods or a long bath, for example. Many young people in particular seem to spend all their waking moments multi-tasking, with constant stimulation via eyes and ears. Some experts think constant online access is “addicting,” with withdrawal anxiety when someone is forced to turn everything off. Finding time for quiet reflection may demand discipline, but I believe it’s worth the price.

-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


Winning: the only thing?

December 18th, 2011 by gelenberg No comments »

The holiday season is a good time for reflection. For me reflections this year are colored by the ongoing fallout from the child sex abuse allegations at my university, which is reverberating at institutions throughout our country.

I have worked in all the major sectors of our economy: for-profit, not-for-profit, and government. For most of my career, I’ve been in universities. Not-for-profit institutions are exempted from paying taxes because federal and state governments deem we are doing public good. Still, I have seen so many leaders and organizations in this arena act as if Vince Lombardi or Niccolo Machiavelli were their patron saints. It comes down to “winning,” outperforming the “other guy,” such as a “competing” institution, which is often charged with performing the same public good—like charity, health care, or education.

Of course, most decisions we make on a day-to-day basis are pragmatic and mundane. Few rise to ethical or moral issues. But I have seen many executives, leaders, and governing bodies, even when faced with moral dilemmas, calculate solely based on pragmatic projections—relying exclusively on legal, financial, and public-relations advice—forgetting the mission, moral, or ethical dimensions of important matters.

Sometimes those of us with administrative or governing authority must stand up, remember why we’re here, return to core values, and do the right thing. Is that a risk? Perhaps. But there are risks worth taking.

-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



Whither Healthcare Reform?

December 1st, 2011 by gelenberg No comments »

In multi-specialty groups and integrated academic health systems like mine, psychiatry struggles not to lose money. This economic anomaly stems from a system that biases economic rewards (i.e., gives more money) more for doing things (“procedures”) than for thinking and talking to patients. And it’s not just between specialties, but within: general medicine loses money; procedural subspecialties like cardiology and gastroenterology make money. And a cardiologist, gastroenterologist, or dermatologist, for example, who wants to earn more will devote more time and effort to procedures, shying away from low-reimbursement time with patients.

Care of patients with diabetes mellitus illustrates the dysfunction in America’s healthcare non-system today. Diabetes is a life-long disease. Patients age more rapidly than peers without the disease. Their organs degrade and blood vessels clog. But close monitoring, tight disease management, and behavioral factors like diet and exercise can combat many of these effects and prolong life and function. That’s good for people and saves money. But in our current system, doctors and hospitals aren’t rewarded for these low-tech, long-term, preventative interventions. It’s better for the bottom line to do the many late-stage extensive procedures these patients are likely to require: fixing retinas, bypassing coronary arteries, transplanting kidneys, amputating limbs. And most insurers seek to maximize profits not by cost-effective long-term care and prevention, but by finding ways to encourage people who become sick to leave their programs.

I can’t predict how or when we will see genuine healthcare reform in the United States. But the skyrocketing costs of health expenditures in our country, which buy only mediocre outcomes, dictate that things will need to be fixed and soon. And I have to believe that covering all our people with good health care will demand a cost-effective system, emphasizing prevention and effective long-term care. This, in turn, will require investment and uniformity in information technology, standardization of optimal practice, and—at long last—due attention to behavior. The behavior of our population—whether diet and exercise or compliance with prescribed treatments—is a huge driver of medical costs and an obvious target for attention in the New World Order. I believe that in the system to come, psychiatrists will play a role of great importance, as experts in behavior and specialists in conditions that commonly exacerbate other diseases. Stay tuned.

-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


To protect the most vulnerable

November 12th, 2011 by gelenberg No comments »

Rape is a terrible crime against anyone. Sexual abuse of children is among the worst. It is often perpetrated by adults whom the child trusts and respects. And it leaves scars on the brain and psyche that may never heal.

This is a time of soul searching at Penn State. Students, staff, and faculty are hurt, angry, confused, and shaken by the swirling story of sexually abused children. I am new to Penn State, but in my almost-two years here, I have been deeply impressed by the talent, energy, loyalty, decency, and commitment of the Penn State community. And our university has an amazingly dedicated alumni and donor base throughout the country.

I know no more than what I read and hear from the news media. Like everyone, I am left to conjecture about who did what and why. I cannot pass judgment on anyone, nor would I wish to. But right now it appears that children were sexually exploited, and some people who could have taken early steps to stop the abuse did not.

What lessons can we learn from this horrible experience?

I have participated in many discussions about the competence and professional behavior of certain medical students, residents, and physicians. Typically, colleagues express concern about the welfare and career of the student or doctor, which is reasonable and compassionate. But I always focus on the “end user”: future patients, whom we can’t know today. Our primary obligation, I contend, is to them, the most vulnerable, who will enter naïve into a doctor-patient relationship. Will this student, resident, or doctor be good and safe for these people, whose lives depend on our actions? I wonder if university administrators worried so much about the well-being and future of alleged perpetrators that they couldn’t “see” the kids who were injured and others who would be at risk? Did they fear potential damage to the reputation of our august institution so much that they missed the question of right and wrong, ultimately damaging this university far more?

In the denouement of the movie “A Few Good Men,” one of two marine defendants in a court martial explains to his subordinate that they were supposed to fight for those who could not fight for themselves. As healers and as administrators, we have a similar and sacred charge. I pray people will draw lessons from Penn State’s current travails. I hope that the next person to witness or hear of a child being brutalized will do the right thing—without hesitation or thought of politics. I hope the next doctor worried about the integrity or competence of a colleague will do the same.

Alan J. Gelenberg, M.D.
Shively/Tan Professor and Chair of Psychiatry
Penn State

And now, Lee

September 9th, 2011 by gelenberg No comments »

As I matured as a therapist, I started integrating elements of Buddhism into the psychodynamic approach in which I had been trained. (I believe Marsha Linehan did something similar in creating DBT, and I enjoyed Jack Kornfield’s book, A Path With Heart.) In particular, I have always been stirred by the simple wisdom in AA’s Serenity Prayer. As we stop banging our heads against the walls of things we cannot change, we have more energy to affect things we can change. I have tried to help patients find comfort and their own paths forward by accepting the many forces before which we stand helpless. I have shared that wisdom with my own children. And like Alice in Wonderland, sometimes I even try to follow my own advice.

Recently I posted a blog on my flight before the fury of Hurricane Irene on the Atlantic Coast. I didn’t know it when I wrote the blog, but soon after, the worst devastation from the storm hit not along the coast, but inland—particularly with flooding in Vermont. This week Tropical Storm Lee pounded my community in Central Pennsylvania with record floods.

When I first heard about global warming, I assumed the slow process of year-by-year temperature elevations would take many decades to affect real life. But climate scientists say the short-term effect is to increase weather volatility. When I moved from the desert southwest to Wisconsin in 2007, I expected a personal climate change—but not the record-breaking snowfall that began the day I arrived in Madison. Record-breaking snow followed me to Hershey, Pennsylvania, the week I moved here after Christmas in 2009. And this week my hospital was briefly isolated, I had to wade home through serious flooding, roads and buildings collapsed, our municipal sewage system has gone down, and I worry about weekend coverage for inpatients at our psychiatric hospital.

I can make small, personal efforts to conserve energy and reduce greenhouse gases. But I am helpless against nature’s fury when it appears. I can try to take reasonable steps to be prepared, and when disasters strike, I can work with colleagues and my community to help those in need. But truly we are small, and natural forces are immense. As doctors, we seldom cure, but usually we can attenuate symptoms and relieve suffering. I try to acknowledge what I can’t change and focus on what I can.

The pounding I saw from two back-to-back tropical storms taught me one other thing: the necessity of the social compact we call government. My state and community have good infrastructure, and today President Obama declared this a disaster area, allowing federal assistance. While some congressional representatives and presidential candidates rail against all government as evil and unnecessary, I realize that a well-functioning government is people helping people. It’s who we are, and it gives us more options and help in the face of powerful forces.

-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



August 28th, 2011 by gelenberg No comments »

After a two-decade absence from the East Coast, I decided to pay an overdue visit to an Atlantic beach. A few months back, my wife and I booked 3 nights in a B & B in Cape May, New Jersey, and I took 2 days’ vacation from my university duties. We arrived Thursday afternoon, unpacked quickly, and set out for a couple of hours to survey the lovely beach community. Coming back to the beautiful Victorian guesthouse to change for dinner, we learned of a mandatory evacuation courtesy of Hurricane Irene, bearing down on the heavily populated region from the Carolinas up to New England. Our brief holiday had been cut short. Bummer!

We dined, got to bed early, awoke at sunrise, downed a quick breakfast, and set out for an uncertain drive home. The coastal evacuation stretched from North Carolina through northern New Jersey. We knew there would be serious traffic.

My new car feeds real-time traffic updates into the GPS guidance system. As I drove, my wife sat with an iPad on her lap, receiving live route information and weather reports. We were fed and rested. And since our home in Central Pennsylvania is well inland, we had a safe, secure destination. In short, we were as fortunate as people could be in an unpredictable situation where nature shows its awesome destructive potential. And we live in a country with basically sound social and physical infrastructure. But it was unsettling, nonetheless, and we felt anxious and small in this mass movement of people before a huge storm. When we arrived home, we were drained and exhausted.

My experience, minor in the scope of our lives, and trivial in the eye of the universe, gave me renewed empathy for people dislocated, “turned upside down,” and traumatized by big events beyond their control: natural and human-caused. PTSD, a regular subject of my newsletter, BTP, is painful and disabling—affecting perhaps 20% to 25% of those with a vulnerability when they undergo severe trauma. People with PTSD have trouble restoring their equilibrium after civilian or military catastrophes. They are hurting and need help—from clinicians, social agencies, governments, and neuroscientists.

And when natural or man-made disasters strike—like wars, earthquakes, and hurricanes—the mentally ill are especially vulnerable. The assets I had—an intact marriage, access to information via expensive services, physical and mental health—are unavailable to most people with chronic psychiatric illnesses. Most often, they lack safe, secure, reliable resources. And their ability to make quick, rational decisions under stress is typically compromised. When major threats loom, let’s keep them in mind and look out for their needs.

-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