Addiction & Substance Use

A pair of recent research articles has cast the public spotlight on treating schizophrenia in youths with antipsychotic medications.

There are 2 rooms a physician should never enter, or even go near: the executioner’s chamber and the interrogator’s cell. I’m speaking figuratively, but I have very concrete circumstances in mind. Indeed, in recent years, psychiatrists have been drawn into controversies related to both these “rooms”-one involving the physician’s role in capital punishment cases; the other, in cases related to the interrogation of suspected terrorists.

In the face of 200,000 or more dead and millions injured or homeless in Haiti following the January 12 earthquake, mental health and medical organizations, along with US government agencies, are offering aid both to those suffering and to those helping.

There are very few, if any, direct mental health provisions in the congressional health care legislation that has passed the House and is now awaiting Senate approval. The Senate bill-the Patient Protection and Affordable Care Act (HR 3590)-debated on the floor in December is similar in some respects to the Affordable Health Care for America Act (HR 3962), which the House passed by an extremely thin, Democrat-heavy vote of 220-215 on November 7, 2009. Both bills appear to extend mental health parity to individual and group policies sold within new health insurance Exchanges. They would also expand Medicaid, begin funding medical home demonstrations, and ban insurance companies from denying policies based on an applicant’s preexisting condition.

On October 19, 2009, the Office of the Deputy US Attorney General issued a memorandum, “Investigations and Prosecutions in States Authorizing the Medical Use of Marijuana.”1 The memo announced a federal policy to abstain from investigating or prosecuting “individuals whose actions are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana.” The memo made clear, however, that it did not “legalize marijuana or provide a legal defense to a violation of federal law.” Rather, it was “intended solely as a guide to the exercise of investigative and prosecutorial discretion.”

The empirical basis for the effectiveness of 12-step recovery and the psychotherapeutic benefits of opioid agonist maintenance were among the topics of several symposia with introspective views of time-tested treatments at the 40th Annual Medical-Scientific Conference of the American Society of Addiction Medicine (ASAM) in New Orleans.

Hired guns.” “Whores.” “Greedy, insensitive bastards.“ These are some of the more printable epithets used to describe psychiatric physicians who (allegedly) have “sold out to Big Pharma.”

Hy Bloom provided an expert psychiatric report in a multiple murder case in which the accused, who had schizophrenia and depression, had killed his wife and 2 children. Before the murders, the accused had been seeing a psychiatrist and family physician for treatment of the mental disorders.

I think I am going to talk about the neurobiology of happiness in my next column. The reason has to do with the nature of our 2-month journey into the biology of eating disorders-a subject that, considering the dearth of explanatory data, is tough to write about. It’s also a bit depressing, considering how difficult it can be to treat. This is the second installment in a 2-part series that focuses on the neurobiology of restricting-type anorexia nervosa (AN).

Obesity has emerged as a significant threat to public health throughout the developed world. The World Health Organization defines overweight as a body mass index of 25.0 to 29.9 kg/m2 and obesity as a BMI of 30.0 kg/m2 or greater.1 Nearly two-thirds of Americans are overweight or obese according to these criteria.2 Numerous health problems, including diabetes, cardiovascular disease, arthritis, and cancer, are associated with obesity. In addition, overweight and obese persons are more likely than their normal-weight peers to have a variety of psychiatric disorders.

New compounds and novel applications for established products were evaluated in many of the clinical trials reported at the recent 49th annual NIMH-sponsored New Clinical Drugs Evaluation Unit meeting.

Practical approaches to integrating 3 aspects of a suicide assessment have been well delineated for adults and adolescents.

Award ceremonies abound, from the Oscars for film to the Clio awards for advertising, but none are as important to mental health and psychiatry as the NARSAD annual awards. NARSAD is a unique organization that is dedicated to mental health research, and the NARSAD awards are considered to be the most prestigious prizes in psychiatric research. On October 30, NARSAD presented its 22nd annual awards for outstanding achievement in mental health research. This year the prizes went to 8 distinguished scientists whose work is making a huge impact on the way psychiatric disorders will be diagnosed and treated.

More than a thousand articles on mental disorders are published in medical journals each month! Also, clinicians have limited training, time, and inclination to keep up with reading research articles critically on a regular basis. Thus, a disturbing disconnect (for which there are no easy solutions) exists between clinical research and usual clinical practice.

Pediatric bipolar disorder (PBD) is a serious psychiatric illness that impairs children’s emotional, cognitive, and social development. PBD causes severe mood instability that manifests in chronic irritability, episodes of rage, tearfulness, distractibility, grandiosity or inflated self-esteem, hypersexual behavior, a decreased need for sleep, and behavioral activation coupled with poor judgment. While research in this area has accelerated during the past 15 years, there are still significant gaps in knowledge concerning the prevalence, etiology, phenomenology, assessment, and treatment for PBD.

The press reported it in various ways-either as a “brutal gang rape” or, more forensically, as a “21/2-hour assault” on the Richmond High School campus. Any way you look at it, the horrendous attack on a 15-year-old girl raises troubling questions for theologians, criminologists and, of course, psychiatrists. How do we understand an act as brutal as rape? What factors and forces in the rapist’s development can possibly account for such behavior? And how on earth do we explain the apparent indifference of the large crowd that watched the attack in Richmond, Calif, and allegedly did nothing to stop it-or even, to report it?

The debate within the medical profession over “conflicts of interest” (COIs) has often been shrill, and sometimes seems to be based on misunderstandings or myths about what COIs entail. In this psychiatrist’s view, it is helpful to step back from confident proclamations, acknowledge that the issues involved are complex, and aspire to some semblance of humility. Nobody has cornered the market on “the right way” to deal with COI in the realms of medical research, publication, and education.1 At the same time, as Alan Stone, MD, has noted (personal communication, August 27, 2009), ethical considerations lie at the heart of any debate on COI-in particular, the ancient dictum, “Do no harm.” Indeed, ethicist James M. DuBois has pointed out a direct connection between some types of COI and harm to the general public: “Mental health consumers are at risk when studies that involve questionable scientific and publication practices are translated into therapeutic practice.”1(p205)

The NIMH-sponsored New Clinical Drugs Evaluation Unit (NCDEU) meeting is a favored venue for reports and reviews of NIH-funded psychopharmacological studies, and this was true of the recent annual meeting in Hollywood, Fla. The meeting included a workshop on new investigations of antidepressant use in Alzheimer disease and a panel session on the safety of pharmacotherapy in older adults.

Many patients with HIV/AIDS experience numerous challenges beyond those posed by the physical effects of their disease-including poverty, mental illness, drug addiction, social alienation, racism, and homophobia. Counseling patients who face these issues can be difficult, but a careful risk assessment along with patient education can improve a patient’s ability to cope and lead to better outcomes, said Marshall Forstein, MD, associate professor of psychiatry, Harvard Medical School, Cambridge, Mass, in a presentation at the US Psychiatric Congress in Las Vegas. On the basis of his extensive experience in treating patients with HIV/AIDS, he said it is also important to provide hope and to encourage treatment adherence.

It is usually traumatic when parents learn that their child has an autism spectrum disorder (ASD). Be clear about the diagnosis and let families know that treatment will begin as soon as possible, said Doris Greenberg, MD, associate clinical professor of pediatrics at Mercer University School of Medicine, Savannah, Ga. In her presentation at the US Psychiatric and Mental Health Congress in Las Vegas, Dr Greenberg discussed strategies for talking to the families of children with ASDs. “Don’t talk around the diagnosis-identify the elephant in the room and get on with it,” she said.

Smoking cessation services should be integrated into substance use disorder treatment programs, according to David Kalman, MD, Department of Psychiatry, University of Massachusetts, and colleagues, in their recent review of tobacco dependency among patients who sought treatment for alcoholism.1

Victor Strasburger, MD, professor of pediatrics and chief of the division of adolescent medicine at the University of New Mexico School of Medicine, Albuquerque, discusses the impact of television and movies on the sexual behavior of teens.

A few simple steps can enhance your assessment of a patient’s suicide risk-and thereby reduce your own risk for liability if the patient does commit suicide. Phillip J. Resnick, MD, professor of psychiatry and director of forensic psychiatry at Case Western Reserve University in Cleveland, described those measures in a lecture today at the US Psychiatric Congress in Las Vegas.

Appetite regulation is made up of complex interlocking, incentive-driven motivational hormonal and neuronal circuitries . . . that can be pulled in many directions, especially where food is cheap and readily available.

The press reported it in various ways-either as a “brutal gang rape” or, more forensically, as a “2½-hour assault” on the Richmond High School campus. Anyway you look at it, the horrendous attack on a 15-year old girl raises troubling questions for theologians, criminologists, and, of course, psychiatrists.

You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically motivated language that seeks to conflate the words “medication” and “drug”-thereby tapping into the public’s understandable fears concerning “drug abuse” and its need to carry out a “War on Drugs.”

To Americans over 30, YouTube, Facebook, MySpace and Twitter are buzzwords that lack much meaning. But to those born between 1982 and 2001-often referred to as “millennials” or “Generation Y”-they are a part of everyday life. For the uninitiated, these Web sites are used for social networking and communication. They are also places where individuals can post pictures and news about themselves and express their opinions on everything from music to movies to politics. Some sites, such as YouTube, allow individuals to post videos of themselves, often creating enough “buzz” to drive hundreds and even thousands of viewers; in some instances, these videos create instant media stars-such as the Obama imitator, Iman Crosson.

In planning a media workshop to present Glenn Gers’ independent film disFigured for the May 2009 American Psychiatric Association meeting in San Francisco, my co-presenters and I devoted special attention to the diagnosis and treatment of anorexia nervosa. (The content was originally prepared by Katherine Halmi, MD, and was presented at the workshop by James Mitchell, MD, when Dr Halmi was unable to attend.) The film deals with the problems of body image represented by opposite ends of the spectrum of eating disorders-obesity and anorexia.

The prevalence of depression in children and adolescents ranges from 2% to 8% in the general population, which indicates that depression in this population is a major public health concern.1-3 This is especially apparent when rates of depression are compared with other serious medical conditions in childhood, such as diabetes, which has a prevalence of 0.18%.4 The burden of depressive illness-including significant functional impairment in interpersonal relationships, school, and work-on the developing child has been well documented. Affected youths are frequently involved in the juvenile justice system.5-8 Furthermore, adolescents with depression are at increased risk for substance abuse, recurrent depression in adulthood, and attempted or completed suicide.3,9-15

In August, the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation released a report based on its systematic review of research on the effectiveness of sexual orientation change efforts.1