Archive for the ‘Uncategorized’ category

Dealing with Dementia

November 28th, 2015

As the population ages worldwide, society must bear a series of burdens. One set stems from the increasing rate of dementia: Alzheimer, vascular, frontotemporal, Lewy body, mixed, and others. Medical science has found preventions for a few diseases, cures for a few more, and symptomatic relief for many others. But so far, science has been stymied in attempts to understand and cure the ravages of dementia. An upcoming issue of BTP will review current medications for Alzheimer disease and other dementias, but alas, efficacy is very limited. Someday we can expect preventions and cures, but today’s interventions are modest.

Doctors should seek to diagnose and treat coincident conditions that can trouble dementia patients and lead to disruptive behavior. Common examples are urinary tract and other infections, arthritic and other sources of pain, bedsores, and various ailments of the frail and elderly. Specific treatments like antimicrobials and nonspecific approaches like analgesics sometimes quell aggressive behavior. Of course, identifying environmental and interpersonal factors that can aggravate patients may allow for constructive intervention. Music, activities, and aromatherapies can soothe and comfort even advanced cases. We do what we can and always remember primum non nocere.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Professor Emeritus, University of Arizona
Editor-in-Chief, Journal of Clinical Psychiatry


November 26th, 2015

I recently wrote about lithium as a “double-edged sword.” Clozapine is another—powerful, potentially life saving but, at the same time, life threatening. I am sad when I see young psychiatrists afraid of drugs like lithium, clozapine, and MAO inhibitors. They must be respected and prescribed with caution. But they have unsurpassed potential to help and to heal. Upcoming issues of BTP will feature new information about clozapine: including risks and possible benefits. Stay tuned.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Professor Emeritus, University of Arizona
Editor-in-Chief, Journal of Clinical Psychiatry


November 25th, 2015

Many people believe that natural products are safe and turn to compounds labeled “natural” (often erroneously) in the hope of symptom relief or cure. I often point to a host of medicines—old, highly efficacious, and potentially toxic—that come from plants or the earth. Examples are aspirin, digitalis, opium—and lithium. One of the oldest therapeutic agents in psychiatry, lithium is a salt of the earth and mined for a variety of uses, including batteries. In medicine, lithium is the proverbial double-edged sword: potentially life saving and, at the same time, potentially lethal. BTP will soon feature research highlighting some of this ion’s organ toxicity, as well as unexpected benefits for people who take it.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Professor Emeritus, University of Arizona
Editor-in-Chief, Journal of Clinical Psychiatry

Partnerships for Progress

February 27th, 2015

For the past two months my wife and I have lived in downtown Seattle, WA. I have lived in seven different cities, sometimes in urban neighborhoods. But this is the first time I have lived in a downtown district.

In the frequent walks that are now a daily feature of my city life, I encounter homeless people who appear to be mentally ill. Many talk to themselves (no Bluetooth devices) and are, I assume, psychotic. After forty-five years in Psychiatry, I find this very sad. These poor souls are at profound risk: of assaults, accidents, hypo- and hyperthermia, malnutrition, and overall poor health. They reflect the unintended consequence of the deinstitutionalization movement at the start of my career, a movement nobly intended but poorly thought out and implemented. I also believe that mentally ill people on city streets represent an imbalance in the tension between civil liberties and compassionate care for the vulnerable—a balance that is gradually being restored as more states adopt outpatient commitment statutes.

Seattle’s mayor recently described receiving letters from visitors to our city, who complain about the mentally ill wandering the streets. As the city grows rapidly and the downtown becomes more vibrant, he is appealing to business leaders to support improved funding for care of this population.

I have been in partnerships between advocacy groups and psychiatric organizations that have sought increased funding for mental health care. Even after horrific crimes committed by a few psychotic people, and despite front-page press coverage and statements by politicians, proposed legislation to improve public mental health systems typically languishes. The public attention and concern flags, and the mentally ill are forgotten—until the next public outrage.

What I find appealing and encouraging about our mayor’s call is the potential confluence of interests: an improved quality of life for visitors and residents, a better climate for business and commerce, and—as a moral dividend—a potential benefit for those who are often forgotten, disdained, and dismissed. Here’s hoping.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Editor-in-Chief, Journal of Clinical Psychiatry
Professor Emeritus, University of Arizona

Mood Disorders: Intervention works

July 29th, 2010

Bob Post just gave our weekly grand rounds at Penn State. Speaking from his long, productive (over 900 publications!), and illustrious career in studying mood disorders, Bob addressed the long-term course of unipolar and bipolar disorders. He speaks with the passion he feels for the topic and compassion for those who suffer from the ravages of these brain diseases.

Most probably people inherit a genetic vulnerability to mood disorders. It will be a long, long time before doctors can correct DNA anomalies. But stresses and abuse, especially in childhood but even long after, also contribute to the risk of episodes of depression. Current science suggests these environmental variables adversely affect brain structure and function, perhaps via epigenetic effects, which control how genes express coded proteins. More mood episodes are bad. They hurt, carry mortality and morbidity risks, and adversely affect function. Beyond that, they make future episodes even more likely, compromise long-term function and disease course, add medical and substance-abuse co-morbidity, and worsen treatment response.

The good news is that intervention works—decreasing the risk of future episodes, improving outcome, and saving lives. The broad array of treatments for bipolar disorder and recurrent depression—including medicines, stimulation techniques, psychotherapy, rehabilitation approaches, and perhaps even diet and exercise—protect the brain. Many increase levels of brain-derived neurotrophic factor (BDNF), which appears to attenuate the effects of bad life events.

Dr. Post emphasized the importance of early intervention in patients with mood disorders. (The typical lag from onset of bipolar disorder to first clinical attention is typically on the order of 10 to 15 years!) He also stressed the benefits of life-long treatment. In addition to warning patients about side effects, Bob suggests we tell patients about the positive benefits of psychiatric treatments for their brains.

Thoughts on science and complementary medicine

July 5th, 2010

I just wrote an editorial for the Journal of Clinical Psychiatry, “Complementary and Alternative Medicine in Psychiatry.”  It stresses the importance of rigorous science to support any clinical prescription or recommendation: a synthesized compound, natural product, diet, exercise, or psychotherapy. Please read it: J Clin Psychiatry 71:6, June, 2010.

Antipsychotics: 1st vs 2nd generation

July 2nd, 2010

Several long-term effectiveness studies over the past few years have come to the same conclusion about antipsychotic medications: that the first-generation is comparable to the second. Undoubtedly, efficacy appears comparable between generations (except for clozapine, which is superior to all). And the second generation is hardly free of side effects. They’re just different.

But let’s not forget movement disorders. A colleague and I were reminiscing about what it was like until the 1990s when we walked onto an in-patient ward or a clinic for chronically mentally ill people. A substantial number of patients showed tardive dyskinesia or dystonia—visible in many cases from across a room.

The newer agents cause far fewer of these disfiguring, disabling abnormal movements. That in itself is a blessing. If you are prescribing for someone I love, please try to avoid first-generation antipsychotics.

Summer heat: a big threat to the mentally ill

July 2nd, 2010

Having recently returned to my home state of Pennsylvania, I was saddened by a news report from Philadelphia. A number of frail people died in the east coast’s recent heat wave, most shut into sweltering apartments, with no air conditioning or even fans, and windows closed tight. The mentally ill are at particular risk. They are often unattended and live in conditions that are far from optimal. They may overdress and inadequately attend to physical cues, such as heat or dehydration. Their life styles can predispose them to the ill effects of prolonged heat. They may shut doors and windows out of suspiciousness—sometimes delusional, but often justified. And sometimes psychiatric medicines can increase the risk of heat stroke, as my newsletter, Biological Therapies in Psychiatry, has highlighted over many years.

Recent studies also indicate that heat and humidity may be particularly dangerous for people with diabetes, whose bodies do not adjust as easily to rises in temperature. Since many psychiatric drugs are now known to increase the incidence of diabetes, this is another important caution.

So, let’s remember the chronically mentally ill—especially in the heat of summer. Can they come to an air-conditioned shelter? Can someone check on them? Do they need reminding to drink water often—ideally with ice? Small attentions may save lives.

DSM and the 3rd Ear

June 25th, 2010

The controversy swirling around the creation of DSM-V reminds me of concerns that have troubled me since the advent of DSM-III. DSM-III represented a break with its 2 nosologic predecessors in its atheoretical stance and emphasis on defined observations. My mentor Gerald Klerman called it “Neokraepelinian.”

DSM-III could not create validity (something modern psychiatric nosology still waits for), but it did carry the promise of reliability. If applied as directed, DSM-III and its current successor, DSM-IV, should result in two clinicians making the same diagnosis in a patient. That brings me to my first concern: In real clinical life, DSM diagnoses often are applied casually—even sloppily. The required criteria are not met, and often a patient carries a slew of diagnoses that have been made by different psychiatrists—something that causes embarrassment for our field when it comes to public awareness.

My second concern is the loss of our field’s traditional “third ear.” Historically, psychiatrists listened not only to what a patient said, but to how the patient said it. Gaze, facial expression, tone of voice, body posture—all factored in to the clinician’s assessment and follow-up questions. I can’t count the number of psychiatric residents I’ve observed apply DSM-based questions in a clinical interview in a rote, checklist, fill-out-the-form manner, lacking warmth, empathy, and human intuition. Lyrics—but no music.

Let’s work to improve and enhance our diagnostic categories as we move forward to DSM-V. But let’s not lose the “baby” with the “bathwater.” After all, we are psychiatrists.

NCDEU: genes and the future

June 18th, 2010

I just listened to ASCP President Dr. John Kane give a perspective at NCDEU on the treatment of schizophrenia—past, present, and future. Chairman of Psychiatry at LIJ-Hillside in New York, John is an internationally renowned expert in this area. Among many perceptive points in his rich talk, two caught my attention.

Based on research from his group over many decades, Dr. Kane estimates the incidence of new tardive dyskinesia cases among patients taking first-generation antipsychotics as 5% per year.  This contrasts with an incidence in second-generation drugs of only 1% per year. As I wrote in a recent blog, this makes a huge difference in the lives of patients who take these medicines. Score this advantage for the second generation.

A second point concerns the health burden borne by the chronically mentally ill. These patients commonly eat unhealthy diets and lead sedentary lives. They take medicines that may add body weight and impair lipid and glucose metabolism. They often smoke. And they tend to get poor medical care. All of these issues are familiar to BTP readers. John Kane proposes that psychiatrists assume a greater role in the primary care of the chronically mentally ill. Even when a medical problem is outside of a psychiatrist’s expertise, we can act as advocates and help our patients navigate the health care system. It makes good sense and can prolong lives and enhance the quality of patients’ lives.