The Paroxetine Study 329 Re-Write

I've not really written about GlaxoSmithKline's infamous paroxetine (Paxil) Study 329, except to briefly allude to it in a previous post. This is probably because I felt others had covered it so extensively already, especially over at the 1boringoldman blog. Another anonymous child psychiatrist has an entire website summarizing the study, and there's even a detailed wikipedia page. So go to those sites if you haven't heard of this study before. However, I wanted to write this post to share my thoughts about the re-analysis of the study's data by an independent, mostly-international team, which was accepted for publication in the BMJ.

First off, I want to be clear that I don't think the new publication's results will be news for anyone in the profession who has been paying attention. In my years of practice (which admittedly are not many), I've never seen a young patient prescribed paroxetine by a child psychiatrist. While studying for a board exam the other day, I saw this (source):

If it's been covered in a textbook published in 2010, you can be sure it's pretty common knowledge by now. In this regard, the profession has been self-correcting. However, it seems that despite acknowledging the risks of paroxetine, the profession has turned a blind eye toward the actions of the psychiatrists who had helped popularize its use in kids in the first place. None of the well-known academics whose names are attached to the study have offered to retract the paper, and as far as I know, none have suffered professionally. In fact, one of them, Karen Dineen Wagner, was just elected president of the American Academy of Child and Adolescent Psychiatry (AACAP).

There have been efforts to address this issue within AACAP, most notably by 2 regional child psychiatry organizations, including the Northern California Regional Organization of Child and Adolescent Psychiatry (NCROCAP). Dr. Mickey Nardo, the brains behind 1boringoldman.com and one of the authors of the Study 329 re-write, informed the AACAP Ethics Committee about the study's faults, and they initially seemed receptive.* However, those efforts went nowhere. At a recent AACAP annual meeting, I was chatting with an older child psychiatrist, who is a "Distinguished Fellow" of the organization and has been involved in AACAP affairs for decades. Somehow, the topic of NCROCAP came up. When I commented that they seemed to be an activist bunch, he replied, "Yes, probably too much so, which is not good for the group process."

Well, now we see the outcomes of this "group process." By prioritizing group harmony over doing the right thing, AACAP has invited outside intervention. This BMJ editorial accompanying the new publication, by Peter Doshi, is one of the most damning things I've ever read about institutional intransigence.* It'll be interesting to see how the organization reacts.

UPDATE: As I was finishing this blog post, I got the following email (New York Times article published around 6:30pm EST, email was sent around 6:34pm*):

Dear Members,

This week, The BMJ published a study, “Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence,” which reanalyzes data from a clinical trial performed in the late 1990s and published in JAACAP in 2001. The conclusions of this article contradict those of the original study. Please know that the Academy has been fully aware of the pending publication of this article by The BMJ.

Research provides the foundation for child and adolescent psychiatry’s knowledge base. The Academy encourages rigorous scientific design and methodology and supports the highest ethical and professional standards. We also believe it is essential that research be conducted within a strong framework of transparency and disclosure. As an organization, AACAP has been a leader in advocating for the positive changes that have taken place in the last decade in the relationship between the pharmaceutical industry and academic and professional associations.

As the leading national professional medical association dedicated to promoting the healthy development of children, adolescents, and families, through advocacy, education, and research, our response to The BMJ publication is as follows:

• AACAP has the utmost respect for the The BMJ and we thank them for their continued efforts to further scientific knowledge and understanding.
• AACAP supports transparency in clinical trial reporting and welcomes the RIAT initiative, which enables publicly available primary data to be reanalyzed and published as new, potentially revised reports.
• JAACAP is a forum for scientific reporting and scholarly discussion. The scientific process builds on itself over time through a cycle of new research, analysis, and ongoing dialog. This process stimulates debate and moves the field forward toward a better understanding of critical issues.
• As with most medical journals, JAACAP operates with full editorial independence. AACAP does not influence or direct decisions regarding specific publications. Furthermore, the statements and opinions expressed in JAACAP articles are those of the authors, and not necessarily those of AACAP, the editors, or the publisher. Inquiries about the articles and study in question should be addressed to their respective authors.

Moving forward, we will continue to monitor any developments and keep the membership informed of relevant information as it becomes available. Please direct any questions to the Communications Department via email at communications@aacap.org.

Thank you for your continued support!

Paramjit T. Joshi, MD
President, AACAP

Like I said, this is gonna be interesting.

* These sentences were added/edited after original publication for completeness.

Who Controls the Future of Medical Knowledge? Part I

The recent discontent amongst physicians regarding the process of maintaining board certification in various specialties got me thinking about a broader question: how do doctors acquire new medical knowledge, especially after medical school? Which brings me to an even more critical question: who controls said knowledge?

I would argue that next to our ability to listen to and empathize with patients, the other most valuable aspect of the medical profession is our knowledge. Ever since the days of Hippocrates, medical knowledge has been transmitted from one doctor to another in essentially the same way. In medical school and residency, we attend lectures, read textbooks, study cases, answer Socratic questions posed by more experienced clinicians, and most importantly, learn by seeing numerous patients and accumulating experience. After graduating medical school, it seems that most doctors learn by conferring with one another, reading journals, and attending conferences.

But the more information there is, the more time it takes to access and acquire new knowledge, and the harder it becomes for individual physicians to keep up.

You can be sure that corporations are well aware of this. On the patient side, of course, Dr. Google already provides incredible ease of access to knowledge and profits handsomely from selling ads to consumers. Pharmaceutical companies know more about my prescribing practices than I do, which fuels their targeted marketing efforts. More ambitiously, IBM's Watson Health Cloud promises to "bring together clinical, research and social data from a diverse range of health sources, creating a secure, cloud-based data sharing hub, powered by the most advanced cognitive and analytic technologies." And as much as I panned athenahealth's advertising in an earlier post, the electronic medical record companies will certainly find clever ways of profiting from the vast troves of health care data that they accumulate. And doctors are paying for the privilege of providing that information to them!

At least SERMO ("the most trusted and preferred social network for doctors") pays doctors for completing surveys, but you can be sure that they're in the same game. They keep their service free by monetizing the attention and knowledge of doctors: "Organizations seeking physician expertise, such as pharmaceutical companies, medical device firms, and biotechs, underwrite the market research and sponsorship opportunities within our site."

So what options are available for doctors who want to share their knowledge with each other free from the confines of a data mining operation? Of course, we can still consult with colleagues the old fashioned way, either in person or by phone. But after having these conversations, the knowledge still resides in the brains of people, not easily accessible to future doctors who may run into similar situations. Our professional associations post practice guidelines that hardly anyone reads, and at annual meetings, there are opportunities to meet with expert clinicians to discuss cases, which seems terribly inefficient. What about higher-tech options? There are numerous subscription services that provide summaries of research studies, but I believe that the patients doctors see do not necessarily resemble those who sign up for clinical trials. There are electronic mailing lists in which doctors can discuss cases, and which allow members to search through previous conversations. And there's wikidoc, a free wikipedia for doctors. However, these options are used by very few doctors and are paltry efforts next to the commercial ambitions of Big Data.

With all these business interests aiming to aggregate and profit from the knowledge of doctors, is there anything that the medical profession can do to avoid having our knowledge become some company's proprietary intellectual property?

I don't claim to have the answers, but I will explore some ideas in Part II. Stay tuned…

The Old Man: A Story

Part I

The first time I met the old man was during my residency interviews. He was spry and looked younger than his age, and why not? He was at the top of his game: head of a department, boatloads of research funding, one of the most well-known psychiatrists around. Another psychiatry department chair who had interviewed me previously hinted that the old man was quite a businessman and enjoyed cozy relations with industry.

As he asked me his first question, the old man practically winked: "So, are you single, in a relationship, or married, or what?" That was my first hint that he might not be the most ethically-inclined individual. I had been told by my medical school before interview season that such personal questions were definitely off limits. Yet he made his greeting seem like the most natural and friendly thing in the world.

Part II

The old man was fuming. He was supposed to be giving a talk on depression treatment, but what seemed to preoccupy his mind was a just-published study from Irving Kirsch suggesting that antidepressants were not better than placebo for mild to moderate depression. Our speaker seemed deeply and personally offended. After many words assailing Kirsch's motives, he concluded: "Even if it's no better than placebo, it doesn't mean we shouldn't treat the patient!" Almost sounded like advice from Allen Frances, but twisted.

Part III

By random chance, I saw the old man again recently, when I was going out to dinner in the city where he lives. There he was, walking down the sidewalk with his wife, right past where I had just parked my car. He was wearing a sweatshirt with the name of his university employer on it. I'd never seen him out of a suit before. I thought he seemed older, frumpier, humbled. Or perhaps that was just my wishful thinking?

A lot has happened since the last time I saw him. He was no longer the department chair, replaced by someone known for work related to ethics. I briefly considered going up to him and saying something, but what? "Thank you for being an example of what not to aspire to?" Or, "That's a very plain-looking sweatshirt; did all your industry funding dry up?" Poor sportsmanship and too passive-aggressive. I briefly imagined following him down the sidewalk, yelling: "Shame, shame, shame!"  But he probably would've mistaken me for a Scientologist or something.

A Child Psychiatrist's Review of Pixar's Inside Out

I finally watched Disney/Pixar's Inside Out, and I agree with the consensus opinion that Pixar has done it again, making a movie that's both fun and poignant, with a narrative that young children can understand while containing deeper messages for adults. Read on for more of my thoughts, but be aware that MAJOR SPOILERS FOLLOW, since it is hard to discuss my thoughts as a child psychiatrist on the movie's depiction of emotions without going into the details.

The main characters: Fear, Disgust, Joy, Anger, and (sigh) Sadness.

The plot of Inside Out is fairly straightforward: a preteen girl named Riley moves with her parents from Minnesota to San Francisco, and she experiences a crisis in her emotional state, in her relationship with her parents, and in her concept of herself. Most of the action takes place inside Riley's head, where 5 different emotions (Joy, Sadness, Anger, Disgust, and Fear) take turns at the control center of the brain's headquarters, directing Riley's actions depending on which emotion is at the controls. Joy is the energetic (cheer)leader who attempts to remain in control as much as possible, especially over Sadness. The crux of the movie is about Joy going on a journey in which she (and everyone else) learns to value Sadness.

How the Pixar filmmakers takes us on the journey, though, is where they show off their delightful imagination and remarkably decent grasp of psychology. Here are my thoughts on the aspects of Inside Out that delighted me the most:

• The movie demonstrates the inner workings of memory in a visually coherent and fairly accurate way. I especially like how Riley's incoming memories, which look like softball-sized glowing orbs, are temporarily kept at headquarters until Riley sleeps, at which point they are sent into long term memory. They also find a way to neatly show core aspects of Riley's identity/personality as floating islands that serve as repositories of concepts such as Family, Honesty, and Goofiness.
• The depiction of the weight of parental expectations is very well-done. When Riley becomes upset after the move, her parents say to her: "Where's my happy girl?", clearly indicating their preference for how she should feel. This is one way that parents insidiously and inadvertently tell their children it's not OK to be sad, and the fact that (if I recall correctly) each parent says this to Riley on separate occasions shows that Pixar is emphasizing the harm that this sort of communication can do.
• A critical scene that works incredibly well both as a turning point in the plot and a learning opportunity is when Sadness convinces a character to do something that Joy could not, simply by listening and showing empathy for that character's feelings. This teaches Joy (and us) the importance of validating another person's emotions.
• Some of my favorite moments in the movie are when it delves into the minds of characters other than Riley. I really enjoyed how each character has a different predominant emotion, and the emotions work together in different ways depending on the individual. For example, inside the head of Riley's mother, the different emotions sit around like a committee with Sadness presiding, while a teen boy's mind is dominated by fear, with all his emotions running amok.
• When Riley and her father get into an argument during dinner, the camera dives into each person's mind and clearly shows how Anger in one person leads to escalating Anger in the other, in a mutually assured destruction kind of way. This is a good example of an amygdala hijack, which comes up frequently when I discuss family conflict with patients.
• Despite being a primary emotion, each of the emotion characters are capable of expressing other emotions. This helps make them more interesting and less one-dimensional; it also helps subtly reinforce the point that having one emotion dominate all the time may not be desirable.
• Initially, each of Riley's memories passing through the control center is a distinct color, corresponding to the emotion associated with the memory. By the end of the movie, memories have become multi-hued, nicely illustrating Riley reaching a developmental stage where she is capable of more emotional nuance.

However, I do have one major criticism, and that is the portrayal of Sadness as short, rotund, and bespectacled. How…sad that Pixar uses such obvious stereotypes to depict her appearance! Sure, this may get more laughs from the audience and fit the look of the actress supplying the voice, and the movie does try to redeem itself by turning Sadness into a heroine. But how would kids fitting that description feel inside early on, even if they're laughing along with everyone else on the outside? I wish Pixar had simply portrayed Sadness on the basis of her facial expressions and body language without adhering to our cultural norms regarding the physical characteristics of a sad person; they're good enough animators to be capable of that. A few of other nitpicks:

• A scary clown is locked away in Riley's subconscious, visually depicted as a vault in a deep cavern. I'm not sure if even the psychoanalysts still use the term "subconscious," yet it persists in the popular culture, perhaps because it's so easy to conjure up that visual image of something deeply buried.
• Memories, of course, are not accurate recordings preserved in amber, but are malleable and often unreliable. While it would have been nice for the movie to show this, I understand that it would probably overcomplicate things. Similarly, expanding beyond just the 5 emotions featured would have been nice but too complicated.
• Though dramatic, I do not feel that the scene of Riley taking a credit card from her mother's wallet and getting on a bus back to Minnesota is very believable. Given her generally good relationship with her parents in the past, it would take much more than a couple of arguments to make a kid who did not have previous conduct problems steal and run away from home.

Despite my criticisms, Inside Out is easily one of my three favorite Pixar movies of all time, along with Wall-E and Ratatouille. I can even envision it being useful in therapy. Asking a child to think about a situation and consider what Joy would say versus what Sadness or Fear would say about it might help make cognitive-behavior therapy more engaging and fun. If you're a child therapist/psychologist/psychiatrist and haven't seen it yet, what are you waiting for? It's the only Pixar movie where I'm eagerly anticipating a sequel, given the portents at the end about Riley turning 12. I'd love to see what Pixar does with the even more tangled emotions and relationships of adolescence.

Free Branding Advice For The American Psychiatric Association

On Sunday, while going about my weekend business (which means possibly wasting some time on Twitter), I was greeted with this unsolicited gift from the American Psychiatric Association:

Say hello to the APA's new brand! #APAAM15 pic.twitter.com/wV062FoLbK

— American Psychiatric (@APAPsychiatric) May 17, 2015

There's also an announcement on the APA website and an accompanying Youtube video. Here's an alternative version of the new logo:

Now, I'm not an APA member, but as a psychiatrist, this is just embarrassing. Poor Benjamin Rush must be rolling over in his grave! I'm also not a "branding expert," but it seems that the APA could use all the help it can get these days. Thus, I'm offering some pro bono advice as a public service.

Typeface

First off, the text becomes very fashion-forward with the use of a skinny font (resembles Avenir, but I'm not sure exactly what it is) for "American" and "Association." The semi-bold and colored emphasis on the word "Psychiatric" just seems a bit…desperate. Look at us, we're psychiatrists! I'm not saying that the typeface doesn't look nice, but it smacks of trying too hard to match the latest trends in visual marketing:

Now, Apple can do with this because they actually are producing new high-tech products. But the APA? Sorry, I don't think Understanding Mental Disorders: Your Guide to DSM-5 qualifies. Why not make something that looks timeless and classy, rather than trendy and fashionable? Here's my suggestion:

This has the added benefit of allowing the letters "APA" to line up, emphasizing to the world that the fight over what "APA" stands for is not over, even though the American Psychological Association owns apa.org and the Google search results. We psychiatrists don't give up!

Logo

Though I discussed the choice of typeface first, the new logo emphasizing the brain is the most jarring aspect of the APA brand refresh. Here were my initial thoughts:

New @APAPsychiatric logo looks like a fuzzy egg from the distance. Hope they didn't pay too much for it! #APAAM15 https://t.co/hJVNDWpGJ4

— Psycritic (@psycrit) May 17, 2015

A couple of days later, I still feel the same way. If you're trying so hard to signal that the organization is modern and future-looking, then why in the world use such a literal outline of a brain? The whole point of logos is to make a simplified visual representation of something so it becomes an instantly recognizable icon. That's why Apple's logo doesn't look like an actual silhouette of an apple, and the Microsoft Windows logo doesn't look like a photorealistic window. It's also why the serpent on the Rod of Asclepius winding its way through the brain (wisely) does not show snake scales. Also, note what happens to the APA's brain when it's shrunk:

Look how fuzzy the brain becomes, while the Rod of Asclepius retains its shape nicely. So, APA, if you're going to use a brain with folds, then at least make them look somewhat rounded:

Even though it's a bit cartoony and not anatomically accurate, it's at least visually cogent, especially at smaller sizes. Alternatively, you can get even more minimalistic:

These changes took me all of 20 minutes in Photoshop, and I'm no graphic artist. I wonder how much the APA paid their consultants for all this?

Tagline

Finally, that tagline: "Medical leadership for mind, brain and body." While I won't argue too much over the missing Oxford comma, I do think: wouldn't it be nice if the tagline matched the typeface and the logo? The typeface signals future-think, while the logo features a traditional symbol of medicine within the brain. I don't see anything conveying "mind" or "body." Since I believe honesty is the best policy when it comes to branding, why not this:

Or even better, if the focus in going to be on medical brain disorders, why not a complete rebrand of the APA into something even awesomer?

There, that's more like it!

One Pringle

Like many psychiatrists, I see a fair number of patients whose relationship with food has been fraught with difficulty. Some of the patients that we worry about the most are those with anorexia, who are at a high risk of dying from their illness. However, it seems that those who have problems with binge or over-eating are much more common.

One memorable patient that I saw during residency was a man in his 50s, who reported feeling severely depressed ever since he had gastric bypass surgery 2 years prior. The man had been obese his whole adult life; he ate whenever he felt lonely, bored, or stressed, and eventually he weighed close to 400 pounds. I was surprised when he told me this, because he was trim and fit when I first met him, and he was fortunate enough to not have noticeably loose skin from losing over half his body weight. Of course, his doctors initially wondered whether a nutritional deficiency caused his depression, but all their tests came back normal. The patient himself attributed his mood change to no longer being able to eat the foods that he used to enjoy, and no amount or combination of medication made a difference. It seemed that his main coping skill was taken away without him gaining anything to replace it. Seeing this patient led me to think a lot about how one develops or fails to develop self-control with food.

Growing up, I sometimes travelled with my family to visit my grandparents, who lived in another country. During one week-long visit to their home, one of the things that drew my interest was a can of Pringles® sitting high on a book shelf in the living room. Day after day, it remained there, out of my reach. I'm sure I would have eaten most of the can during that time if it were more easily accessible. Then one day, I saw my grandfather open the can, take one chip out, and then he put the can back on the shelf. He bit off half the chip, closed his eyes, and chewed slowly and deliberately, savoring every last bit of that salty, crunchy goodness. Then, he did the same thing with the other half. One Pringle, and he was done. I can't even type the word "Pringle" without the spellchecker highlighting it and suggesting that I change it to "Pringles", but there was my grandfather, eating just one at a time, less than once per day.

While writing this, I checked out what Pringles® is using as their latest marketing slogan. Here it is:

Well, my grandfather did in fact "just eat 'em," and he would have easily won a bet with anyone repeating the Lay's® phrase "betcha can't eat just one." How was he able to do that? I never thought to ask him directly, but I've often wondered how his journey through life shaped him. His father died when he was still an infant, and he was raised by his mother and grandfather. His was a scholarly family, and despite growing up in a place under foreign occupation during World War II, he was able to do well academically, eventually attending medical school. After the war, instead of enjoying the consumer exuberance that swept the U.S., my grandfather had to contend with decades of ongoing deprivation and strive while working long hours and raising a family.

Since I grew up in America, I had abundant access to food and never had to worry about getting enough to eat. I was also exposed to all the mass media messages that we Americans are inundated with. I craved Happy Meals® and Kellogg's® Froot Loops® and Nabisco Chips Ahoy!® and anything from those cute Keebler® elves. Not surprisingly, I often did not stop eating when I was full; there have been times when I ate so much at buffets that I felt sick. Yet as I got older and was faced with the temptations of overeating, I would often think back to that image of my grandfather and his one Pringle, and then I would ask myself, "Do you really want that extra serving?” And over time, my self-control gradually improved. How much of that was influenced by the fact that I randomly witnessed my grandfather's way of snacking? I'll probably never know, but I'm still grateful for the memory.

Of course, my grandfather was not perfect; he had his bad habits just like anyone else. He was a pulmonologist, but he also smoked cigarettes for many years. However, when he smoked, guess how many cigarettes he had on each occasion?

The Most Popular Psychiatrists in America (According to Twitter)

All the recent hubbub over Dr. Memhet Oz got me thinking more about fame when it comes to medical doctors: how they gained their popularity, to what end they employ their platforms, and how they keep (or don't keep) their professional integrity. One of the easiest ways to estimate popularity is to look at how many people follow an individual on Twitter. There, Dr. Oz is clearly way ahead of the practicing physician pack with 3.75 million followers. Dr. Drew Pinsky is second at 3.16M, while CNN's Dr. Sanjay Gupta is a distant third with 1.98M. In comparison, well-known blogger Dr. Kevin Pho "only" has 122K followers.

Curious about who the most popular psychiatrists are, I searched Twitter for individuals (not organizations) with profiles matching "psychiatrist" on 4/26/15. I examined the first 100 or so profiles written in English, looking at the follower count and selecting the 4 psychiatrists with the most followers for further scrutiny (and speculation), focusing on the nature of their popularity and just how much B.S. they espouse. Here's what I found:

#4: Judith Orloff (40.0K followers | following 10.3K)

Claim to fame: According to her Twitter profile, Dr. Orloff is a "psychiatrist, intuitive healer, and author of THE ECSTASY OF SURRENDER about how to let go of stress, trust intuition, and embrace joy." She has also written other books with titles such as [her CAPS]: EMOTIONAL FREEDOM, POSITIVE ENERGY, INTUITIVE HEALING, and SECOND SIGHT. I have never heard of her or any of her books; judging by their descriptions, they are very much targeted toward a non-scientifically-minded audience (which is to say, just about everyone).
B.S. meter: 7 . Dr. Orloff's about page emphasizes the power of intuition to help us "heal—and prevent—illness" and is full of quotations describing her as "a prominent energy-based healer" and a "positive energy guru." I have no doubt that she is a great psychiatrist who helps her patients and readers feel better, and I happen to agree with the message in her latest book about the importance of letting go as opposed to "pushing, forcing, and over controlling people and situations." Yet my intuition tells me that anyone who promotes herself with a sentence like "Dr. Orloff is accomplishing for psychiatry what physicians like Dean Ornish and Mehmet Oz have done for mainstream medicine" needs to be approached with a healthy dose of skepticism.

#3: Daniel Amen (78.7K followers | following 29.3K)

Claim to fame: Frankly, I was surprised that he was not #1. He's the only psychiatrist that I immediately recognized out of the 4 I found doing this search and the only one with a verified Twitter account, which Twitter only bestows upon "key individual and brands." Dr. Amen is the founder of Amen Clinics, which uses SPECT brain scans to purportedly diagnose mental disorders. He has been featured in programs running on PBS, and he even has influence amongst Christian audiences. In 2012, a Washington Post article called him "the most popular psychiatrist in America."
B.S. meter: 8 . There have been numerous well-articulated criticisms of Dr. Amen and his ridiculous claims regarding SPECT scans that I won't rehash here, save for one especially galling fact: his clinic charges $3500 for an initial evaluation and SPECT scan, which is generally not covered by insurance. While the clinic's website does not reveal this cost up front, it does say they've done over 100,000 scans, so you do the math. PBS's own ombudsman has disavowed any association with Dr. Amen's infomercials that were aired by local PBS affiliates without adequate disclaimers. Dr. Jeffrey Lieberman, former president of the American Psychiatric Association, was quoted in the Washington Post article as saying this about Amen: "In my opinion, what he’s doing is the modern equivalent of phrenology." On that point, Dr. Lieberman and I can agree.

#2: Brian Weiss (80.7K followers | following 25)

Claim to fame: Dr. Weiss's website tells us he "was astonished and skeptical when one of his patients began recalling past-life traumas that seemed to hold the key to her recurring nightmares and anxiety attacks. His skepticism was eroded, however, when she began to channel messages from 'the space between lives,' which contained remarkable revelations about Dr. Weiss's family and his dead son. Using past-life therapy, he was able to cure the patient and embark on a new, more meaningful phase of his own career." He is the author of books such as Miracles Happen: The Transformational Healing Power of Past Life Memories, and Many Lives, Many Masters: The True Story of a Prominent Psychiatrist, His Young Patient, and the Past-Life Therapy That Changed Both Their Lives. Not surprisingly, his homepage prominently features a photo of him and Oprah. He runs 5-day workshops costing $1000/person for "anyone interested in exploring these profound psychospiritual techniques."
B.S. meter: 10+ . Someone in a past life once told me, "If you ain't got nothin' nice to say, then it's better to say nothin' at all." I will stick with that for my current life and any of my future lives…

Thus far, the trend seems to be greater popularity correlating with ever escalating levels of B.S. I was losing what little faith I had entering this exercise. So I was shocked by who ranked first:

For a moment, I thought I was looking at Dr. Tobias Fünke from Arrested Development. But no, it's actually this guy:

#1: Norman Rosenthal (101K followers | following 28.3K)

Claim to fame: I have never heard of Dr. Rosenthal before, but he is the only psychiatrist I can find with over 100K followers. According to his website, he "has written over 200 scholarly articles, and authored or co-authored eight popular books. These include Winter Blues, the New York Times bestseller Transcendence, and the Los Angeles Times bestseller The Gift of Adversity. Rosenthal has conducted numerous clinical trials of medications and alternative treatments, such as Transcendental Meditation for psychiatric disorders, and the treatment of depression with Botox." Watching him on Youtube, it seemed that his South African accent instantly gave him added authority and gravitas (I call this the Salvador Minuchin effect).
B.S. meter: 1 . I was ready to be skeptical of Dr. Rosenthal, and this promotional page for his newest book is chock full of celebrity endorsements, including one from Dr. Oz himself. But the book actually seems to offer very sensible advice (based on Dr. Rosenthal's own life) on how to cope with adversity, and reading a passage from it on Google books, I even learned some interesting things about how the NIMH worked during the transition to the Steve Hyman/Tom Insel era. Dr. Rosenthal's research publications also left me impressed. He worked at the NIMH for 2 decades, and he did impactful studies on seasonal affective disorder, sleep disturbance in mania, and the use of light therapy for delayed sleep phase syndrome. He still sees patients in his clinical practice, where he seems to emphasize integrating different treatment modalities instead of pretending there's some magic bullet. And this is my own personal bias, but I find it touching that his son Joshua has followed in his footsteps, becoming a child and adolescent psychiatrist.

So what did I learn about psychiatrists and fame, at least when it comes to Twitter? Obviously, it helps to write multiple best-selling books and to regularly appear on television. Presenting oneself as an "alternative" practitioner with special knowledge or healing techniques helps as well. I won't delve into the content of their tweets in this post, but it seems relentlessly positive messages and pithy tips on how to improve one's life are a must in order to reach as broad an audience as possible.

Also, 3 of the 4 psychiatrists employ the method of following tens of thousands of people in hopes of trying to get as many people to follow them back as possible. In contrast, the truly famous doctors tend have much more sane follow counts: Dr. Oz follows 85, Dr. Pinsky follows 422, and Dr. Gupta follows 198. Thus, Dr. Weiss may well have the most impressive follower count amongst psychiatrists, given that he only follows 25 people for a follower:following ratio of 3228!

Before doing this search, I did not follow any of these top 4 psychiatrists on Twitter. Of the accounts that I follow, 8 of them follow Dr. Amen, 4 follow Dr. Orloff, 4 follow Dr. Rosenthal, and only 1 follows Dr. Weiss (really, @AACAP?). While writing this post, I've decided to follow Norman Rosenthal. He's the one out of the 4 who seems to have most preserved his professional integrity without wading deeply into the realm of pseudoscience, pop spirituality, or utter nonsense. I think every psychiatrist (or doctor, for that matter) aspiring to semi-celebrity status can learn something from him ;-)

Success, but at What Cost?

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

The patient, who was in his late 20's, was clearly very driven. He was a straight-A student from K-12, graduated from an Ivy League school with a 3.9 GPA, and proudly tells me that he works at a startup. He wakes up early every morning for his hour-long commute and works 12-hour days. Admirably, he makes sure to exercise for an hour each night after he gets home. Then, after he eats dinner, he even tries to spend a couple of hours with his girlfriend. When he finally gets to bed, he sleeps from about midnight to 5:30am. Ever since starting college, he has not gotten more than 6 hours of sleep a night.

He tells me he's been feeling more tired and less focused over the past year, a period coinciding with him gaining greater responsibilities at work. This lack of focus is not constant, and he tends to have the hardest time concentrating around 2-3pm, when he would often feel tired and sleepy. Not surprisingly, he wonders if he has ADHD and if a stimulant medication can help.

I tell him: "I can't really diagnose you with ADHD because there is no evidence of impairment when you were younger. Plus, most people really do need close to 8 hours of sleep, and almost everyone who gets less than 6 will eventually have trouble staying alert and focused during the day. I recommend that you try to sleep between 7 and 8 hours a night for a few months and see if things improve." He was both dismayed and somewhat defiant: "Look, I'm really busy, and I'm not about to compromise any aspects of my life. There's no way I'm going to work less or give up my workouts or not spend time with my girlfriend."

This was the patient that came to my mind when I was reading the New York Times article over the weekend about adult prescription stimulant abuse:

Elizabeth, a Long Island native in her late 20s, said that to not take Adderall while competitors did would be like playing tennis with a wood racket.

"It is necessary — necessary for survival of the best and the smartest and highest-achieving people," Elizabeth said. She spoke on the condition that she be identified only by her middle name. […]

Elizabeth’s sleep tracker was confused. Her nightly rests were so brief, the iPhone software thought they were just naps. It recorded her average sleep over nine months: from 4:17 a.m. until 7:42.

After founding her own health technology company, Elizabeth soon decided that working hard was not enough; she had to work harder, longer. Sleep went from an indulgence to an obstacle.

So she went to a psychiatrist and complained that she could not concentrate on work. She received a diagnosis of A.D.H.D. and a prescription for Adderall in about 10 minutes, she said.

"Friends of mine in finance, on Wall Street, were traders and had to start at 5 in the morning on top of their games — most of them were taking Adderall," Elizabeth said. "You can’t be the one who is the sluggish one."

I'm saddened that we live in a world where the founder of a health technology company doesn't seem to care about how sleeping 3.5 hours a night affects her own health. It seems very Kafkaesque and short-sighted to me. How did things get this way, to the point where "success" is defined by individual achievement and productivity above all else?

I found David Brooks's column from last week to be quite pertinent. He traced the changes in American society stemming from the late 1940s, when the generation who had suffered through the Great Depression and World War II let loose and embraced consumerism, transforming the culture from one of self-effacement and sacrifice to one of self-expression and indulgence:

But I would say that we have overshot the mark. We now live in a world in which commencement speakers tell students to trust themselves, listen to themselves, follow their passions, to glorify the Golden Figure inside. We now live in a culture of the Big Me, a culture of meritocracy where we promote ourselves and a social media culture where we broadcast highlight reels of our lives. What’s lost is the more balanced view, that we are splendidly endowed but also broken. And without that view, the whole logic of character-building falls apart. You build your career by building on your strengths, but you improve your character by trying to address your weaknesses.

Instead of "broken," I would've chosen "incomplete," but otherwise I agree with Brooks's main points. And speaking of a glorified Golden Figure, I thought I was reading a late April's Fool joke when CNN/Money ran an article last week titled: "Mark Zuckerberg only works 50 to 60 hours a week." Unfortunately, it was not a joke, and of course the author qualified Zuck's work hours with: "But he conceded that if the definition of 'work' were expanded, he'd be working his 'whole life.'" Is this the sort of role model that we want for our kids? Do we want a society where people are admired for driving themselves to extremes, and a lucky few will become fabulously wealthy, while many more get stressed out and sleep-deprived, and a certain regrettable percentage end up with depression, anxiety, or suicide?

Disruptive Mood Dysregulation Disorder Revisited

In the brief history of this blog, the post where I shared my thoughts on DSM-5's disruptive mood dysregulation disorder (DMDD) has gotten by far the most pageviews. It's been almost two years since I wrote that post, and I would like to revisit DMDD with some updated thoughts on this diagnosis.

As you may recall, DMDD sprang out of a desire to have a diagnosis other than "bipolar disorder" to describe children who are chronically irritable and have explosive tantrums. Almost all of the children with DMDD also meet the criteria for oppositional defiant disorder (ODD) and are at higher risk of developing depression but not mania. The NIMH researcher Ellen Leibenluft, whose work on severe mood dysregulation (SMD) strongly influenced DMDD's creation, had commented in the past that she was not 100% sure that DMDD was a good idea.

In the last few years, I have only seen a handful of children who met the criteria for DMDD. Here is what I noticed in my own practice:

• One boy was being raised by a single mother who worked full time, so his grandparents were very involved in childrearing. The mother tried to set rules, but the grandparents were much more permissive, and whenever the mother tired to enforce her rules, explosive tantrums resulted.
• Another boy was very violent toward his mother on an almost daily basis. His father was home but did not intervene, while the mother had anxiety and literally appeared fearful of her son during their visits with me. When he hit her, she would tell him verbally that it was wrong, but did not do anything else (like using a time-out) to try to change his behaviors.
• There was a girl (who I'd written about previously) whose mother was very emotionally distant and pulled away further every time the girl acted out because the mother was reminded of her own emotionally intense mother. This distancing seemed to lead to the daughter becoming even more irritable.
• And then there was a boy who was extremely aggressive at home, constantly fighting with his 3 siblings. The household was very chaotic, with parents still married but frequently arguing with each other. Both parents often resorted to spankings, which did not seem to decrease the boy's aggression or irritability.

Certainly, correlation between the parental characteristics and the children's behaviors does not tell us about causation. It is very stressful raising irritable, explosive children, and the children described above definitely had intense, strong-willed temperaments. My intuition is that it's an interactive process where both parental and child characteristics trigger maladaptive behaviors in each other that escalate over time. But are these families typical of cases of DMDD? I searched Pubmed for "disruptive mood dysregulation disorder" and found 20 papers published in the last 2 years (out of 29 total).

Of the 20, most were reviews/commentary, and only 6 papers were original research. One was a brain imaging study looking at "neural mechanisms of frustration in chronically irritable children." Another examined the prevalence of SMD 2 and 4 years out from initial diagnosis, and found that 40% still met full criteria at 4 years, but a significant number not meeting the criteria were still moderately impaired. Another study from Duke's developmental epidemiology program used a large database to examine the adult outcomes of those who would have met DMDD criteria as children and found higher adult rates of depression, anxiety, adverse health outcomes, impoverishment, police contact, and lower educational attainment.

To my pleasant surprise, there were actually several papers that included data on family characteristics of children with DMDD. The first was a cross-sectional study of a community sample of 6 year-old children, which found that 8.2% of them met DMDD criteria based on a structured interview of parents. Impressively, the study examined 6 domains ("demographics; child psychopathology, functioning, and temperament; parental psychopathology; and the psychosocial environment") for correlates of DMDD. The parents were also interviewed about what things had been like when their children were 3 years old, and here's what the researchers found:

The age 3 years predictors of DMDD at age 6 years included child attention deficit hyperactivity disorder, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, poorer peer functioning, child temperament (higher child surgency and negative emotional intensity and lower effortful control), parental lifetime substance use disorder and higher parental hostility.

The second study was a prospective one that "followed 317 high-risk children with early externalizing problems from school entry (ages 5-7) to late adolescence (ages 17-19)." The children sorted into 3 groups by the time they were adolescents: one group with conduct/criminal problems and anger, one group with mood dysregulation, and one group with a low level of symptoms. The authors found that generally, those who were more overtly aggressive as children tended to have conduct problems as adolescents, while more emotionally dysregulated children had more mood dysregulation in adolescence. The key finding:

For children with early emotion dysregulation, however, increased risk for mood dysregulation characterized by anger, dysphoric mood, and suicidality - possibly indicative of disruptive mood dysregulation disorder - emerges only in the presence of low parental warmth and/or peer rejection during middle childhood.

Another study (with 13! authors) was published in a much more prestigious journal than the previous 2 papers, and to me it was the least enlightening. The study examined the risk of DMDD in offspring of parents with bipolar disorder and found a much higher risk of DMDD (odds ratio = 5.4 "when controlling for demographic variables and comorbid parental diagnoses") compared to offspring of control parents. Given what those two other studies found, I'm not surprised that parents with bipolar disorder, one of the most severe psychiatric illnesses, would have children at risk of DMDD.

One last noteworthy paper that turned up in my Pubmed search is a recent article on whether DMDD should be included in ICD-11. The International Classification of Diseases is the World Health Organization's standard system for classifying every health problem imaginable, and the 11th revision is due in 2017. Even in the U.S., the ICD diagnostic codes are the standard for coding and billing purposes, and each DSM diagnosis is mapped to a corresponding ICD code. In this paper, the authors, who were members of a task group convened by the WHO to provide recommendations on the classification of disruptive behavior disorders, wrote:

The task group has recommended that WHO not accept DMDD as a diagnostic category in ICD-11, but rather approach the issue in an alternative, more conservative and more scientifically justifiable way. Specifically, the group has proposed that ICD-11 include a specifier to indicate whether or not the presentation of ODD includes chronic irritability and anger. We believe this option provides the most parsimonious basis for identifying and appropriately treating children with this maladaptive form of emotional dysregulation.

In my previous post on DMDD, I thought that it was overall a positive step away from the rampant over-diagnosis of pediatric bipolar disorder. But I did not end up using it; I was not about to diagnose those children with bipolar disorder in the first place. Thus, I find myself agreeing with the WHO task group. With ODD, the standard first line treatments are interventions that help parents better manage their children's behaviors and/or improve the parent-child relationship. I still worry about drug companies trying to market a medication for DMDD that supposedly targets a problem in the brain of the child. Thankfully, at least Abilify hasn't been approved yet for treating DMDD and hopefully never will, having gone off-patent this year.

Psychiatry as a Clinical Neuroscience, Why Not?

I first heard the term "clinical neuroscience" used in relation to psychiatry as a resident in 2009, when my associate program director handed out a paper to us trainees titled: "The Future of Psychiatry as Clinical Neuroscience." She presented this as a ground-breaking document that would greatly influence the rest of our careers. Shockingly, the authors of that paper did not cite NIMH Director Thomas Insel, who had an earlier article in 2005 titled: "Psychiatry as a Clinical Neuroscience Discipline." Since then, Dr. Insel has posted an updated version of the article on his blog (publication date: unknown) and wrote other blog posts championing the notion that in order for psychiatry to advance, we must focus on basic neuroscience research. And now, a recent article asks, "The Future of Psychiatry as Clinical Neuroscience: Why Not Now?"

The authors, who are program (or associate program) directors of residency training at Yale, Pitt, and Columbia, bemoan the fact that advances in understanding mental illness based on neuroscience research have not made their way into clinical practice. As barriers, they cite "the pervasive belief that neuroscience is not relevant to patient care," as well as the complexity of the research. They argue that the best place to start enacting this paradigm shift is in psychiatry residency programs right now. They also write:

The diseases that we treat are diseases of the brain. The question that we need to address is not whether we integrate neuroscience alongside our other rich traditions but how we work as a field to overcome the barriers that currently limit us. Ultimately, the most powerful force will be the improved translation of research into more refined explanatory models of psychiatric pathology and into novel therapeutics. To ensure that our field is ready to embrace new findings as they emerge, we need to begin the process of culture change today by enhancing communication and collaboration between researchers and practitioners.

I think 1BOM hit the nail on the head when he wrote: "Rather than being 'ready to embrace new findings as they emerge', tomorrow’s psychiatrist needs to know how to critically evaluate new findings as they emerge [italics in original]." I remember being taught as a resident about Broadmann Area 25 being critical in the pathogenesis of depression, based on exciting initial deep brain stimulation results from Dr. Helen Mayberg. This was almost treated as an established fact, despite the very preliminary nature of the research. Well, what happened when they tried to do a larger clinical trial? Neurocritic reported that the trial was halted before its planned endpoint in December 2013, and last month it was revealed that the medical device company conducting the trial (St. Jude) stopped it due to perceived study futility.

Do the clinical neuroscience curriculums for psychiatry residents teach the importance of humility and emphasize just how much we don't know? One of my favorite articles in the past year has been Tom Stafford's BBC Neurohacks column from December 2014 in which he discussed the importance of redundancy in the brain. He described the case of a woman who, despite missing her entire cerebellum, was able to live a fairly normal life:

This case points to a sad fact about brain science. We don't often shout about it, but there are large gaps in even our basic understanding of the brain. We can't agree on the function of even some of the most important brain regions, such as the cerebellum. Rare cases such as this show up that ignorance. Every so often someone walks into a hospital and their brain scan reveals the startling differences we can have inside our heads. Startling differences which may have only small observable effects on our behaviour.

Part of the problem may be our way of thinking. It is natural to see the brain as a piece of naturally selected technology, and in human technology there is often a one-to-one mapping between structure and function. If I have a toaster, the heat is provided by the heating element, the time is controlled by the timer and the popping up is driven by a spring. The case of the missing cerebellum reveals there is no such simple scheme for the brain. Although we love to talk about the brain region for vision, for hunger or for love, there are no such brain regions, because the brain isn't technology where any function is governed by just one part.

 As Neuroskeptic recently tweeted:

Neuroscientist: someone who knows how little we know about the brain.
— Neuroskeptic (@Neuro_Skeptic) March 28, 2015

This is a point that needs to be made and repeatedly emphasized to those who write things like "the diseases we treat are diseases of the brain." The irony for me is that I do appreciate the importance of neuroscience in psychiatry and agree with the authors when they wrote: "The more sophisticated and nuanced our science becomes, the more critical it is to have individuals who can translate this work to make it accessible to students at all levels." It reminded me of one of my favorite college classes, Principles of Neuroscience. The professor, who studied ion channels in different animals, was an amazingly good teacher, and the first lecture started something like this:

"Ernest Hemmingway once boasted that he had a six-word story—complete with beginning, middle, and end—that would bring tears to anyone who heard it. Here it is [he lowered the lights in the room and said the following words softly and slowly]: 'For sale…baby shoes…never used.' [dramatic pause] While not all of you are tearing up, very few people could have heard those words without thinking of or feeling something. Any images in your mind (did you see the shoes, what color were they?), any thoughts or emotions you may have experienced after hearing those six words, formed as signals in your nervous system. Without the nervous system, we cannot see, hear, feel, taste, or smell—in short, our five senses would produce no corresponding thoughts, and life as we experience it does not exist."

The tour de force lecture progressed to descriptions of single neurons and how our nervous system is comprised of approximately 100 billion of them, each of which can have tens of thousands of synaptic connections to other neurons. The quote I remember most clearly: "All of the neurons together in one brain form more connections with each other than there are stars and planets in the galaxy." The professor ended his lecture by giving us some practical tips based on his knowledge of neuroscience. Time and repetition, he told us, is what will help us succeed in the class, because that is how neuronal circuits are programmed and how processes in the brain ranging from retrieving facts from memory to riding a bicycle become automatic. I use the same advice almost daily with my patients when I emphasize to them the importance of practicing new behaviors or ways of dealing with difficult thoughts and emotions. Similarly, based on my reading of research on the effects of sleep, exercise, and social interactions on the brain, I share with my patients the importance of getting enough of each.

I learned more neuroscience of clinical relevance in one semester from this PhD Biology professor than I have from years of attending lectures and reading papers from psychiatry researchers who are considered world experts in areas like the neurobiology of OCD, pediatric bipolar disorder neuroimaging, or how transcranial magnetic stimulation affects neural circuits in depression. For me, the most important distinction when we talk about clinical neuroscience is whether we take a broad view of neuroscience or a narrow view. The broad view would emphasize the huge effect of all of the different inputs on the brain (e.g. that six words can bring a person to tears), whereas the narrow view tends to emphasize things like genetics, neurotransmitters, biomarkers, and circuits.

The Tragedy of Palo Alto

Sorry for the long absence. I'm going to try to shake off the winter doldrums and resume blogging semi-regularly.

Palo Alto, CA (est. 2013 population: 66,642) is one of the wealthiest cities in America, with nationally-ranked public high schools, quiet tree-lined streets, and exceedingly low crime rates. Since 2000, the city has averaged about 1 murder per year. Sadly, that number has been dwarfed by the number of Palo Alto teens committing suicide every year.

In 2009, Palo Alto gained national notoriety when a cluster of suicides occurred amongst students at Henry Gunn High School. The attention-grabbing nature of the suicides (most occurred by jumping in front of an oncoming train) and the relative ease of access to the suicide method likely contributed to subsequent suicides. The national youth suicide rate is about 10 per 100,000 per year, so any suicide in a district that has several thousand high school students is a cause for concern. Multiple suicides in such a short span of time understandably led to alarm.

At the 2011 AACAP meeting in Toronto, I attended the session Teaching the Community in Times of Crisis: Responding to Teen Suicide. The main speaker (Madeline Gould, MPH, PhD) was very informative and presented a wealth of research-based data emphasizing how suicides can cluster and spread, while media reports on the suicides can either help or hurt the situation. Dr. Shashank Joshi, a psychiatrist at Stanford, discussed the school-based suicide prevention program that Stanford helped the Palo Alto school district put in place after the suicides. The program has similarities to public health approaches designed to combat disease outbreaks: There are efforts to decrease stigma, provide education about depression how it can lead to suicide with emphasis on the effectiveness of available treatments, train teachers and parents to recognize signs of depression, teach coping skills, and identify vulnerable teens through screening and then making appropriate referrals. From what I gather, this program is still in place, and Dr. Joshi just published an article titled School-Based Suicide Prevention: Content, Process, and the Role of Trusted Adults and Peers, with one of the key points being: "Prevention efforts must focus on school-based mental health education and promotion."

What was not addressed at the AACAP session was what may have been happening at the community level that was triggering the suicides in the first place. Given the relative rarity of suicides, it is hard to prove what causes each suicide or how effective current school-based prevention methods are. Unfortunately, what we do know is that suicides amongst Palo Alto students are still occurring, with another one earlier this month, bringing the total to 3 for the year.

In this past week, Palo Alto Weekly has published two opinion pieces, one by Palo Alto psychiatrist and parent Dr. Adam Strassberg, the other by pediatricians from the Palo Alto Medical Foundation. Both are worth reading in full, because in my opinion they make a valiant attempt to get to the root of the problem. Neither one mentioned anything about screening for depression or increasing access to mental health care. Dr. Strassberg emphasized the pressure that parents place upon their children to succeed:

We are so many of us wealthy and secure beyond imagining, and yet we have such enormous anxiety. We fear the future harm that we will lose our wealth and privilege and be unable to pass it on to our future generations. Maintaining and advancing insidiously high educational standards in our children is a way to soothe this anxiety.

But it harms our children.

The pediatricians make a similar point:

While we are not education specialists, as pediatricians we do recognize dangerously unhealthy lifestyle patterns and habits that are known to exacerbate stress, anxiety, depression and physical illness. These include chronic sleep deprivation, lack of unscheduled time for thought and relaxation, unhealthy eating habits, lack of exercise and unrealistic pressures (real or perceived) to achieve. Those unrealistic pressures include excessive homework, overly ambitious course loads and a seeming demand for perfection in grades, sports and extracurricular activities.

We see these problems day after day in our teen patients. We believe there are specific factors that could be targeted for change.

Sleep: Surveys have shown that Palo Alto teens sleep an average of 6.5 hours per night. Studies have shown that teens need 9 hours of sleep to function at their best. […]

Six-and-a-half hours of sleep, average. So for every teen sleeping 8 hours a night, there's one who's only getting 5. I know that I feel grumpy and foggy even with 7 hours, so it's hard for me to imagine what these teens are going through. I'm not saying that the school-based mental health programs are useless, but it's clear as day to me that they do not go far enough up the chain of causality to address the most important factors leading to all of these adolescent suicides. And it's not just Palo Alto, but achievement-driven communities everywhere, that have this problem. Hopefully, more professionals will start engaging families in a discussion of these root causes, rather than only trying to treat surface symptoms.