September 7th, 2007 by Dr. Val Jones in Expert Interviews
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Two new studies reported increasing suicide rates in teenagers. The first noted a trend between decreased use of anti-depressant medications (SSRIs) in teens and an increase in suicide, the second reported an increase in female teen suicide in particular.
What could be causing these tragic increases? I interviewed Revolution Health psychologist, Dr. Mark Smaller and child psychiatrist, Dr. Andrew Gerber, to get their take on this disturbing trend.
1. In previous research,
increased suicidality was associated with SSRI use in teens. Now this study
suggests that lower SSRI use is associated with increased suicidality. How do
you explain this?
Dr. Smaller: Following the previous research, parents and some physicians cut back on SSRI use for depressed teens. However, in doing so they may have neglected those teenagers who could have benefitted from an antidepressant. The problem with these medications is that they effect so many parts of the brain that it’s difficult to predict how different patients will respond to them. Also, these medications are often prescribed in too high a dosage. What needs to happen is that the patient, teen, child, or adult must have a full psychosocial evaluation that takes into account the whole person, and the environment in which he or she is living. A clear treatment plan combining talking therapy (individual or family) and perhaps medication must be implemented. This is not being done in enough instances. With a proper evaluation and a carefully designed treatment plan (as well as close monitoring of the teen) therapy may be further customized to the individual.
Dr. Gerber: The possibility of an association between suicidality and SSRI use in children
and adolescents is of clear concern to many people, including all psychiatrists
and parents of children on medication. Despite all the accumulated research to
date, it is still very unclear how this association works. However, we do know a
few important things.
First, in all the studies of SSRI use in children, there
is no report of a completed suicide attempt in a child who was taking an SSRI.
This goes to show that completed suicides in children, while tragedies whenever
they do happen, are rare events and therefore very hard to study methodically.
Second, in those studies that have shown a possible association of suicidal
thoughts (though not actual suicides) with SSRIs, there is a lot of disagreement
and controversy over how to best measure these thoughts in an accurate way. How
one does this influences the results considerably.
Third, it is important to
keep in mind all the ways in which an association between SSRIs and suicidal
thoughts may appear to exist because of how the data are collected, even if SSRIs
really don’t bring about suicidality at all. For example, it’s certainly true
that doctors are most likely to give medications to the kids who are the most
depressed and the kids who are the most depressed are most likely to be
suicidal. So it might look like SSRIs are related to suicidality, when they are
really being used to treat those kids who are most likely to develop it.
The
best way to really tease these apart is to randomly assign enough children
either to SSRIs or non-SSRI treatment and then observe what the differences are.
The problem, is that (1) the data are so good that SSRIs help many kids with
depression that it would be unethical to withhold treatment from half the
children in order to complete such a study, and (2) suicidality is rare enough
that this study would have to be enormous, and thus is impossible to
do.
With all this said, it is not surprising at all that an overall
decrease in the use of SSRIs, most likely due to the greater caution that
clinicians now have in using these medications in children, would lead to more
suicidality on a broader scale. We know that SSRIs help most children who take
them and this is undoubtedly a more powerful effect than any extent to which
SSRIs cause suicidality (if this is true at all).
2. Is there a role for
SSRIs in teens?
Dr. Smaller: I think so but only after a full diagnostic evaluation is made by a skilled mental health professional who works with teens, family and is familiar with the developmental phase of adolescence.
Dr. Gerber: There is unquestionably still a role for SSRIs in teens as long as they are
monitored carefully by a well trained clinician who, following agreed upon
guidelines, has decided that an SSRI is the right treatment for this teen. Of
course, as always, other treatments and their advantages and disadvantages
should be considered too. But for the best interests of kids and teens, SSRIs
need to remain a possibility.
3. What would you counsel
parents about these drugs?
Dr. Smaller: Get a full physchological evaluation and treatment plan so that you can make an informed decision about what might help. The mental health professional and the parent must have a working alliance to insure that the treatment is successful.
Dr. Gerber: I would advise parents that it is always good for them to be well informed and
vigilant about the risks and benefits of all treatment that they consider for
their children. There is much that we do not know about child psychiatric
illness and we are working furiously to learn more. In the meantime, though we
have to be careful to keep an open mind to both sides and to not make premature
judgments either in favor or against any one treatment. SSRIs have shown
themselves to be useful with many children and, in the hands of a well trained
professional, can continue to be very helpful to the right children and their
families.
4. What do you make of
the suicide rate increase in girls? What could be behind
this?
Dr. Smaller: This is alarming. The onset of adolescence for girls and boys is a hugely disruptive developmental phase, and maybe more so for girls with the onset of puberty. The teen years can be fraught with family issues that exacerbate moods and create symptoms. Our culture puts huge demands on all of our adolescents and this research might be showing that it is taking a high toll on girls. Social roles, peer pressure and issues, academic demands and family strife all contribute. The high incidence of eating disorders among teenage girls is a clear example of a symptom to which many teenage girls are vulnerable.
Dr. Gerber: The greater increase in suicide rates among teenage girls is surprising and
experts are unsure of how to interpret this. Since the overall number of
suicides is small – 94 in 2003 and 56 in 2004 – it is hard to interpret what was
different in this group of teenage girls. There are so many increasing pressures
on teenage girls today – from issues around body image and weight to balancing
complicated societal expectations, what some experts term pressure to live up to
a “superwoman ideal” – that one might speculate it is leading more and more
teenage girls to feel overwhelmed and hopeless. However, what we really need, as
with the SSRI controversy, is more carefully collected data and thoughtful
discussions between families, patients, and clinicians, to understand what is
happening and how we can prevent it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 4th, 2007 by Dr. Val Jones in News
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I subscribe to Eureka Alert Breaking News – and although a lot of their press releases are on small studies of questionable relevance, I do think that some of the basic science research is provocative. Let’s see if I can pique your interest with the best of this week’s Petri dish news:
1. Tylenol may inhibit bone growth? A small study conducted at the University of Granada suggested that bone forming cells (called osteoblasts) were inhibited by a Tylenol bath. As far as pain killers are concerned, we’ve known for a while that non steroidal anti-inflammatory medications (NSAIDs) may indeed inhibit bone growth. But since Tylenol is not an NSAID, we were hoping that it would not adversely affect bone healing. Could this mean that Tylenol is not so great for bone surgery pain after all? That’s a stretch… but an interesting question.
2. Can you clean blood with a laser? Boy it sure would be nice to be able to kill all the potential viruses in blood used for transfusions. Apparently there’s a new pulsed laser technique that shows some promise in fracturing viruses with laser vibrations. So far, the laser was successful in reducing bacterial viruses by 1000x. Next up? Let’s see what the technique can do to Hepatitis C and HIV viruses.
3. Skinny people might have a “skinny gene.” Scientists have been studying a gene called Adipose (Adp) for over 50 years now. It was first discovered in fat fruit flies (I kid you not). Apparently if the Adp gene doesn’t work well, the flies become fat and “have difficulty getting around.” Worms, mice, and humans seem to have the same gene. Further analysis might unlock the secret to the genetics of thinness. Or maybe we should just eat less and exercise more?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 30th, 2007 by Dr. Val Jones in Health Policy, Opinion
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Labor Day was founded in the late 1800’s as a way to thank
American workers (as Peter J. McGuire, a cofounder of the American Federation
of Labor put it): “who from rude nature have delved and carved all the grandeur
we behold.” There is some debate
about who originated the concept of the holiday, but one truth remains:
“All other
holidays are in a more or less degree connected with conflicts and battles of
man’s prowess over man, of strife and discord for greed and power, of glories
achieved by one nation over another. Labor Day…is devoted to no man, living
or dead, to no sect, race, or nation… It
constitutes a yearly national tribute to the contributions workers have made to
the strength, prosperity, and well-being of our country.”
Resident physicians are on my mind with Labor Day
approaching. I know that they are toiling away in hospitals across the nation,
and many of them do not get to take Labor Day off for vacation. Physicians work for 3-7 years after
graduating from medical school, and are paid (on average) about the equivalent
of a home health aide or a medical secretary but work about twice the hours
during residency. In fact, if you calculate
out the salary by the hours they work, resident physicians are paid about $9
-$10/hour which is roughly $1.50 more than minimum wage.
Not surprisingly, resident physicians have joined unions to
lobby for more reasonable wages and caps on the number of hours they must work
per week. The national cap is now at 80
hours per week – about 20 hours more than a truck driver is allowed to work
(for “safety reasons”). Research from Harvard
suggests that errors made by overworked residents increase by 700% when they
have worked more than 24 hours in a row.
Residents from the University of New Mexico, for example, received wages in the lowest 1% for resident physicians in their region, and
were denied a salary increase until they recently joined forces with CIR (the Committee of Interns and Residents) to
negotiate more reasonable salaries and working conditions. The New
Mexico contract adds one more CIR chapter to the more
than 70 hospitals — each with multiple residency programs — that are part of
CIR.
Founded in 1957 to improve patient care and resident working
conditions, CIR has remained true to those two goals throughout the decades. In
1975, CIR won an end to every other night on-call in New
York City, and created the first-ever Patient Care Fund in Los Angeles, where
residents could purchase equipment or create innovative programs to help
patients. Campaigns to prevent needle stick accidents by moving to safer needles,
or needle-less equipment, have also improved working conditions for residents.
CIR has been on the forefront of safe and humane work hours
for residents, helping to win the 80 hour regulations in New York State
in 1989, which became the foundation for the 2003 national guidelines. But
evidence shows that this is still too many hours, and so the advocacy around
hours continues unabated.
So please have safe travels on your Labor Day weekend – we
wouldn’t want you to wind up at a hospital where the residents work more than
24 hours in a row for ~$9/hour. Resident
physicians are one group of laborers who don’t have much to celebrate yet this
Labor Day. But with CIR’s help, next
year might be a little brighter.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 29th, 2007 by Dr. Val Jones in Expert Interviews, News
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We’ve known for quite a while that lowering your cholesterol can reduce your risk of heart disease, heart attack, and stroke. Low fat diets, weight loss, and exercise can help people to control their cholesterol levels – but for those who do not succeed with these methods, a class of medications have been developed (known as “statins”) to reduce cholesterol. These drugs have been so successful at reducing cholesterol that some doctors have joked about putting statins in the water supply. In fact, 36 million Americans take a statin every day, generating annual sales of
$15.5 billion for the manufacturers, and making two statins – Lipitor and
Zocor – the top two best-selling drugs in the USA.
Four new studies were published in the past week about these drugs. I thought I’d summarize the findings for you to keep you up to speed with the very latest statin information.
Statins May Reduce Mortality After Having A Stroke
Spanish researchers followed the progress of 89 stroke patients who were already taking statins. For the first three days after the stroke, 46 patients received no statins, and 43 got their normal dose. After three months, 27 people – 60 % of the “no statins”
group – had either died or were disabled to the point that they needed
help to live a normal life, compared with 16 people from the group
allowed to keep taking statins.
This small study suggests that stroke patients should not stop taking their statins. More research is needed to clarify the role of statins in stroke.
Statins May Reduce The Brain Plaques Associated With Alzheimer’s Disease
Researchers at the University of Washington examined the brain tissue of 110 people who had donated their brains to research upon their death. They found there were
significantly fewer plaques and tangles (the hallmarks of Alzheimer’s disease) in the brains of people who had taken statins compared with those who had not. This is good news, but will require further research to determine whether or not statins could be used (or should be used) specifically for the treatment or prevention of Alzheimer’s Disease.
Statins Don’t Seem To Reduce The Risk of Colon Cancer
A group of Greek researchers conducted a review of the scientific literature to see if there may be a reduction in colon cancer rates among people who take statins. They found no evidence that statins reduce the risk of colon cancer.
Statin Side Effects Appear To Be Ignored By Some Physicians
The journal Drug Safety surveyed 650 patients about their experience with statins. Eighty-seven percent of patients reportedly spoke to their physician
about the possible connection between statin use and a symptom.
Physicians were more
likely to deny than affirm the possibility of a connection. Rejection
of a possible connection was reported to occur even for symptoms with
strong literature support for a drug connection. This report is concerning since it seems to suggest that physicians don’t take patient complaints as seriously as they should.
I asked Dr. Frank Smart what he thought about the side effects of statins and whether or not physicians should be more aware of them.
“The statin side effects exist
but in my opinion are overplayed. In my practice about 5% of people on statins
have some muscle issues. Most improve with dose reduction or change to a more
hydrophyllic compound.
Physicians should be better educated about side effects and the one who
should do the educating is pharma, and websites like Revolution Health. Most docs are as
familiar with statin side effects as they are with other drug classes, so good
but not great. We would all love to raise the bar but it is tough as you
know.”
As many as 30% of patients reportedly experience a side effect from statins (including: headache, nausea,
vomiting, constipation, diarrhea, rash, weakness, and muscle pain) though severe muscle damage is very rare (for example, one article reported 24 cases in 252,460 patients.) Overall, statins have many health benefits and are well tolerated by the majority of patients.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 24th, 2007 by Dr. Val Jones in Opinion
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A new study in the American Journal of Public Health reports that teens can expect a 50% reduced risk of developing chlamydia and gonorrhea if they use condoms from their very first sexual experience. Starting to use condoms later on can certainly protect against disease – but it seems that there is something important about using them from the beginning. In other words, people who use condoms from day 1 are more likely to keep using them regularly, and are therefore less likely to contract sexually transmitted infections (STIs).
I could enter into some awkward speculation about why this is true (maybe it’s easier to get used to the sensation of wearing a condom if it’s all you’ve ever known? Maybe using condoms from the start is more likely to make it a habit?) but more importantly, a 50% reduction in sexually transmitted infections is an incredibly huge margin of success. Sadly, sex education programs for youth have had mixed success in increasing consistent condom use. This study seems to suggest that for those students who receive the message, and use condoms from their first experience, there is a much greater chance of avoiding STIs. Early sex education, therefore, may have more benefit than sex education offered after an adolescent is sexually active.
Of course, like Dr. Stryer, I feel a bit concerned about over-exposing elementary school kids to sexual messaging. But since kids are already exposed via TV, the Internet, and various other media, it behooves us to arm them with age-appropriate information at the earliest point possible. Abstinence is the only 100% guarantee of an STI-free adolescence – but since ~50% of teens are sexually active (regardless of beliefs, sex education, or parental controls) it might be best to teach them that condoms are an inextricable part of all sexual intercourse. Sexually transmitted diseases can mean the difference between fertility and infertility, long life, or earlier death for our kids. With stakes this high, consistent condom use should be our mantra.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
