September 2006 Monthly Archive

September 27, 2006

How to Write A Suicide Note

I'll write this for the ER psychiatrist seeing acute cases, but the strategy applies to all types of psychiatry.  Always keep in mind what is the purpose of the note, and who will actually be reading it.

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September 25, 2006

How To Get Rich In Psychiatry Steps 1-5

No one ever tells you this stuff in residency.  So I'm going to give you ten steps towards wealth.  This isn't about being a better doctor, okay?  That's what all the other posts are for.  This is simply about making money. 

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September 17, 2006

Breast Implants and Suicide

I'll give you the punch line first:   In each of the Danish, Swedish, Finnish, American,  and Canadian  studies,  appx. 0.4% of breast implant patients killed themselves, representing a two to threefold higher risk than the general population.  In some studies, the risk of suicide was increased to 1.5 times for any type of plastic surgery. Getting implants over 40 may also be a risk for suicide.


2761 Danish women who got breast implants from 1973-1995 were compared to 7071 women who got breast reduction, and 11736 who were considered controls.  Median age was about 31.

14 (0.5%) breast implants committed suicide, 3 times more than expected (i.e. standardized mortality ratio=3).   7 of them  had been previously psychiatrically hospitalized.  220 (8%) of all implants were psychiatrically hospitalized.  

22 (0.3%) breast reduction committed suicide, 1.6 times more than expected. 6 of them had been previously psychiatriically hospitalized.  329 (4.7%) of all reductions were previously psych  hospitalized.

0 controls committed suicide. 96 (5.5%) were previously psychiatrically hospitalized.

A U.S. study  followed 12144 implant patients (mean age 31) and 3614 other plastics patients (mean age 40) from 1970-2002.  29 (0.24%) implant patients suicided vs. 4 (0.1%) other plastics patients.  Thus, the 29 suicides were 1.6 times more than expected (SMR=1.6).

Interestingly, the risk of suicide was increased only after ten years;  22/29 died after 10 years.  And while the majority killed themselves before 35 (16/29, SMR=1.4), the biggest risk was for >40 year olds. (SMR=3.4)

Really interestingly, the authors found that for breast implants there was no excess risk for any kinds of accidents-- why should there be, they were accidents-- except car accidents.  Hmmm. 10 MVA deaths (occurring 15 years post implant) vs. 0 for other plastic surgery.  The authors speculate these may not have been accidents.

Swedish study, prospective but no comparator group, of 3521 women (mean age 31) found 15 (0.4%) suicides, SMR 2.9.  

Finnish study of 2166 breast implant women from 1970-2000 were studied (retrospectively) until 2001; there were 10 (0.4%) suicides, SMR 3.  6/10 happened in the first five years (in contrast to the U.S. study.)  (Accidents here were 14, SMR 2.1.  No explanation given for this.)

Canadian study:  24558 women with breast implants vs.  15893 women with other plastic surgery from 1974-1989, studied through 1997.  Mean age 32.  Once again, overall all-cause mortality was lower for breast implant women, except in suicide: 58 (0.24% SMR 1.73) ) suicides vs. 33 (.20%, SMR 1.55)  for other plastic surgery.  Like the U.S. study, women over 40 with implants carried the greatest risk of suicide (SMR 2.3), but no relationship to how far after surgery suicides occurred.

So in these studies, appx. 0.4% of breast implant patients killed themselves, representing a threefold higher risk than the general population. In some studies, the risk of suicide was increased to 1.5 times for any type of plastic surgery.  At least in North America, getting implants over 40 is a risk for suicide.   It goes without saying that the number of actual suicides was very small, and this could all be bunk.

All studies excluded implants for breast cancer surgery. 

You may be interested in knowing that suicide is the only serious risk that has been regularly  associated with breast implants-- silicone included-- and supported by real evidence, so far.  Everything else is either no greater risk, or less risk.  For example, there is a higher risk of lung cancer, but it most likely is related to  smoking, not the implant.

The obvious next step is to see if there is a causative link between implants and suicide (likely impossible) or the implant is a clue to something else (poor self image, depression, drinking, etc.)


Something else: the stereotypical breast implant recipient (e.g. 20 year old coed in Playboy) is not really the typical recipient.  The average recipient is older (mean age 34,); is more affluent; is married (75%) and has two kids; had kids at younger ages; has had abortions; and smokes.  I mention this so that you have the right person in mind when you go looking for risks.

Other fun facts:

80% are cosmetic, 20% are breast cancer surgery reconstructions.

290,000+ breast implant surgeries done last year (compared to 130,000 in 1998).  25% are replacement surgeries for ruptures, pain, etc.  Compare to 324k liposuction and 300k nose jobs.

10% of US women have implants. (This seems wrong.)  95% are white.

10% did it in California. 


Since we're on the subject of implants and suicide, it seems to me an easy maneuver to fill breast implants with liquid explosives, puncture and mix. I am not sure why no one has tried this, actually-- or, more specifically, why no one at the TSA is looking for this as they stop to search my stupid tube of toothpaste.   Not that there's any good way of checking, of course.


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September 15, 2006

What is Off Label Usage?

Some guys in Georgia do a massive study and discover that doctors use medications off label.  They also determine that that's bad.

The real question is not why we use them off label, but why we persist in thinking that means anything.   

First, the core problem with the paper, and the entire thesis of the validity of indications, is that the definition is recursive.  A drug has an indication because it was found effective for a cluster of symptoms that we have defined as a disorder.  This does not necessarily make the disorder valid, and it does not preclude the drug’s efficacy elsewhere. 

In other words, it tells you what it is good for, but not what it isn’t good for.

So what is the value of an indication?

Can someone clarify the basis for the arbitrary distinction between “dementia related psychosis” and any other kind of psychosis?  Is there new PET data that I missed that distinguishes the two?

Similarly, to say a drug “is” an antidepressant doesn’t mean it isn’t actually an antipsychotic.  For example, what is it, exactly, about Prozac that makes it not an antipsychotic?  The only legitimate answer is that when tested, Prozac didn’t work in psychosis—not that an antidepressant can’t be an antipsychotic.  It is an artificial hierarchy that puts “antidepressant” below/weaker than “antipsychotic.”  Try the reverse: can an antipsychotic be an antidepressant?  Why is that easier to believe?


Thus, categorizing a medication based on an arbitrary selection of invented indications to pursue—and then restricting its use elsewhere—may not only be bad practice, it may be outright immoral.


I do not make the accusation lightly.  Consider the problem of antipsychotics for children.  It is an indisputable fact that some kids respond to antipsychotics.  They are not indicated in kids.  But don’t think for a minute there will be any new antipsychotics indicated for kids.  Who, exactly, will pursue the two  double blind, placebo controlled studies necessary to get the indication? No drug company would ever assume the massive risk of such a study-- let alone two-- in kids. 

And which parents will permit their child in an experimental protocol of a “toxic” antipsychotic?  Rich parents?  No way. The burden of testing will be undoubtedly born by the poor—and thus will come the social and racial implications of testing on poor minorities. Pharma is loathed by the public and doctors alike, and the market  for the drugs in kids is (let’s face it) is effectively already penetrated.   There will not be any new pediatric indications for psych meds.  Not in this climate.  Think this hurts Pharma?  It's the kids that suffer.

Lastly, the likely most common laments to this paper will be that it will be used by insurance companies to further restrict the practice of psychiatrists.  Too bad.  If psychiatrists cannot be bothered to learn how medications work and their appropriate usage, then unfortunately the State must intervene.  It is, after all, their money, and it is not infinite.  But restricting formularies based on "approved indications" (read: nothing) is not the solution.  If the problem is economic (and it is) then you need an economic solution.  And you're not going to like it.



Off-Label Use of Antidepressant, Anticonvulsant, and Antipsychotic Medications Among Georgia Medicaid Enrollees in 2001.Hua Chen, Jaxk H. Reeves, Jack E. Fincham, William K. Kennedy, Jeffrey H. Dorfman, and Bradley C. Martin 67:6 2006.



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September 7, 2006

Stopping Meds Does Not Cause Relapse

Glick and friends did a  small study finding-- big surprise-- stopping some of the medications when a schizophrenic is stable does not drive them into a horrible suicidal relapse.  Some even got better.


Naturalistic study: 53 stable schizophrenics on antipsychotics were tapered off of antidepressants or mood stabilizers and followed for up to two years, using CGI as the measure (sigh.)

20/21 patients tapered off antidepressants were unchanged or (n=3) better; the one who did worse was an 18 yo WM on 300mg Wellbutrin.

9/12 tapered off mood stabilizers were unchanged; the three who did worse were all WM (actually, they were all white) on Lithium 600, Tegretol 1200, or Neurontin 1200. 


So while that is very encouraging though only preliminary, what got me about the paper was this sentence:


"There are definitivew data in general medicine showing that combintations are much more effective than monotherapy, supported by many randomized blinded studies with a good understanding of mechanism--" 

 Seriously?  Does he have access to some other internet than I have?  What are the references?


"-- in chronic pain, for example.16"


Oh, chronic pain.  I see.


FYI: Glick also did a study on suicidality, finding that the study that showed Clozaril's anti-suicide property (InterSePT) had nothing to do with the concomitant medications (mood stabilziers, antidepressants or benzos). 



(16) references a morphine  +/- neurontin for pain paper. 

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September 5, 2006

Ritalin Doesn't Cause Cancer(?)

Supplement to this earlier post:  Ritalin Causes Cancer?

Follow-up study from a different group finds no clastogenic effect of Ritalin:

In summary, MPH was found to be non-genotoxic in all bacterial assays reported [5] and [8], in all in vitro mammalian assays conducted in compliance with current guidelines (5, present study) and in two in vivo bone-marrow micronucleus studies (5, present study).

It sounds like the El Zein study was a fluke (and thank God, too.)

But it doesn't resolve my main point: how is the average psychiatrist going to know about these findings? Is there a mechanism for new information?  Is there somewhere, hell, even a blog or listserv, where psychiatrists can at least get the headlines of important articles?  But that requires someone to write this all up, and I don't know anyone who has that amount of funding or time to spend on such an endeavor.


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