February 16th, 2011 by Dinah Miller, M.D. in Health Policy, Opinion
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Electroconvulsive therapy (ECT) is considered to be a highly effective treatment for depression. The story goes that roughly 90 percent of patients respond. The downside is that it requires general anesthesia with all its attendant risks, and patients may suffer from headaches and memory loss. The memory loss is often mild, but there are cases where it is profound and very troubling.
As with any psychiatric treatment — or so it seems — there are those who say it saved them and those who say it destroyed them. Because the risks aren’t minor, the procedure is expensive and often done on an inpatient unit, and people generally don’t like the idea of having an IV line placed, being put under, then shocked through their brain until they seize, only to wake up groggy and perhaps disoriented with an aching head, it’s often considered to be the treatment of last resort, when all else has failed. This makes the 90 percent response rate even more powerful.
I’m no expert on ECT. I haven’t administered it since I was a resident and I don’t work with inpatients where I see people before and after. I’ve rarely recommended it, and then I’ve been met with a resounding, “NO.” My memory of it was that it worked, and that most people didn’t complain of problems. One woman read a novel during her inpatient stay. I asked if she had trouble following the plot (ECT in the morning, novel reading in the afternoon), and she said no.
The Food and Drug Administration (FDA) has been looking at the safety and efficacy of the machines used to perform ECT. It’s a fairly complex story where the FDA advisory panel was considering whether to keep ECT machines categorized as “Class III” machines, which would now require machine manufacturers to prove their efficacy and safety. A reclassification as Class II (and therefore lower risk) would not require this stringent proof. Read more »
*This blog post was originally published at Shrink Rap*
February 6th, 2011 by Dinah Miller, M.D. in Health Tips, Humor
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So it’s Super Bowl Sunday and the fans are psychiatric patients waiting to happen — the beer and the beer and the beer, and maybe the fights will break out, and they’ll all end up in therapy. Oh, the angst and the panic, and the pre-game anxiety, and the post-game euphoria or depression.
New York Times reporter Benedict Carey talks about treatment options in his article, “A Home Treatment Kit for Super Bowl Suffering.” Mr. Carey suggests:
Breathing exercises are highly recommended and become increasingly important as the football contest nears the fourth quarter, when events on the field are likely to prompt strong physiological reactions, like a pounding heart, hyperventilation, even dizziness. These internal cues, as they’re called, can escalate the feeling of panic, a self-reinforcing cycle resulting in groans and cries that can be frightening to small children, pets and sometimes neighbors.
In the final minutes of the game, be forewarned: Many patients will move beyond the reach of therapy. Their faces may change, their breathing appear to stop. Researchers have not determined whether this state is closer to Buddhist meditation or to the experience of freefall from an airplane. All that is known is that, once in it, patients will fall back on primal coping methods, behaviors learned in childhood within the cultural context of their family.
Like emitting screams. Or leaping in an animated way, as if the floor were on fire. Or falling on their back and moving their arms and legs like an overturned beetle, in celebratory fashion.
This post is dedicated to my husband and son.
*This blog post was originally published at Shrink Rap*
January 31st, 2011 by Dinah Miller, M.D. in Health Tips, Research
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Meditation sounds like a great idea from the perspective of a psychiatrist: Anything that calms and focuses the mind is a good thing (and without pharmaceuticals, even better).
Personally, I tried transcendental meditation as a kid (more to do with my mother than with me) and found it to be boring. I have trouble keeping my thoughts still. They wander to what I want for dinner, and should I write about this on Shrink Rap, and will Clink and Victor ever eat crabcakes with me again, and did I remember to give my last patient informed consent, and a zillion other things. Holding my thoughts still is work.
The New York Times Well blog has an article on meditation and brain changes. In “How Meditation May Change the Brain,” Sindya N. Bhanoo writes:
The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.
M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.
Lower stress, lower blood pressure, higher empathy. I may have to give meditation another try.
*This blog post was originally published at Shrink Rap*
January 16th, 2011 by Dinah Miller, M.D. in Better Health Network, Opinion
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I’ve followed in bits and pieces — sometimes for Shrink Rap, sometimes because the issues fill my email inbox, sometimes because there’s no escape. Oh, and lots of the players have familiar names.
In the December 27th issue of Wired magazine, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association’s (APA) upcoming revision of the Diagnostic and Statistical Manual (DSM) entitled “Inside the Battle to Define Mental Illness.” Do read it. Here’s an excerpt:
I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.
“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.
“No.”
“So what would you say was the value of the diagnosis?”
“I got paid.” Read more »
*This blog post was originally published at Shrink Rap*
December 28th, 2010 by Dinah Miller, M.D. in Better Health Network, Opinion
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Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry. The author writes:
Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: My tendency to come to early closure.
Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule).
At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: What else could this be? Read more »
*This blog post was originally published at Shrink Rap*
