From Psychiatry Vol 4. No. 2, Feb 2007 p.42:

 

"Second, paternal postpartum depression might be related to lower levels of estrogen."

 

I didn't read any further because both my eyeballs exploded. 

 

Many interesting and varied reactions to my post, "What Goes Wrong In A Psychiatrist's Family?"  It struck a nerve with a lot of people, and others couldn't relate to it at all.  But I would like to clear up one element:

It's not that even handed, calm, unemotional criticisms directed only to the child's behavior is wrong; it is that no one does it well.  And that's where it all falls apart.

 

Is a glass or two of wine a day good for you?  You would think this would be an easy question to answer, but it's not, and that's because of this:

How many glasses of wine are in a bottle?

If you answered 4-5, continue reading.  Because guess what?  Apparently the answer is eight. No, I'm not kidding. Yes, they are serious.  Unplug your monitor and ram it into your skull as hard as you can. 

Rebecca Riley is the 4 year old who died of psychiatric drug overdose-- she was on 3 of them-- supposedly with a diagnosis of bipolar disorder.  If you want the scoop from a psychiatric perspective, you should read this post from the resident blogger (no pun intended) at intueri.

But I'll add two things.  Let me be very clear: it is not unlikely a 4 year old has bipolar-- it is absolutely impossible.  This is because bipolar disorder is not a specific disease with specific pathology that one can have or not have; it is a description of symptoms that fall together.  We decide to call a group of behaviors bipolar disorder-- and meds can help them, for sure-- but this decision is completely dependent on the context of the symptoms.  Being four necessarily removes you from the appropriate context, in the same way as having bipolar symptoms during, say, a war, also excludes you from the context.  You might still have bipolar, but you can't use those symptoms during the battle as indicative of it.   If I transplant you to Brazil, and you can't read Portugese, does that make you an idiot? 

I don't mean that 4 year olds can't have psychiatric symptoms.  I'm saying  you must be more thorough, more attentive to the environment.  As soon as a person-- a kid-- is given a diagnosis, it automatically opens the flood gates for bad practice that is thought to be evidence based.  That's what makes the diagnosis so dangerous.  Instead of, "should I use Depakote in this kid?" it becomes "It's bipolar, so therefore I can use Depakote."

Secondly, we must all stop saying these drugs are not indicated for kids.  That's meaningless.  We can debate whether they should be used or not in kids, but you can't say they shouldn't be used because they're not indicated.  To quote myself (lo, the narcissism):

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.

It's funny how psychiatry always tries to appeal to a higher authority (FDA, "studies", clinical guidelines, thought leaders, etc) except when it gets in trouble.  And then it's always the same refrain: "no one can tell me how to practice medicine." 

 

 

I'm no Lost expert, and I doubt the writers were thinking along these lines.  But yesterday's episode got me thinking about how we become who we are.

A short digression on my fourth favorite subject.

Does coffee raise blood pressure?  Does coffee elevate cholesterol?  Does coffee hurt your liver?  Does coffee taste delicious?

At the outset, you need to know that not all coffee preparations are the same.   The diterpenes cafestol and kahweol are the alleged cuplrits in the negative effects of coffee, especially raising cholesterol and increasing risk of coronoary artery disease.  However, these are lipid soluble and are almost entirely filtered out by paper filters. Mix coffee grounds and water in a pot, and boil.  Pour off the cofffee into a glass.  Drink.  Now look at the glass.  That oily residue is-- well, oily residue.  You don't get that with a filter.

For example, here is the breakdown of lipids in coffee: filtered coffee: 7mg/cup.  Boiled and  unfiltered (Turkish): 60-160mg/cup.  Metal screener (french press): 50mg/cup.  The types of lipids in each were the same (no selectivity in lipid filtration.)   So how you make your coffee matters.

Blood pressure: as long as you're a regular drinker, don't worry.

Reports of coffee elevating blood pressure are misleading, because they aren't done they way we drink coffee: daily.  Going from nothing to a triple espresso raises blood pressure; but chronic coffee drinking eventually allows for normalized blood pressure.

For example, the much repeated finding "unfiltered boiled coffee causes a significant elevation in blood pressure, especially in women" is misleading:  the study actually found that if you switch exclusively to boiled unfltered coffee from filtered coffe, your systolic blood pressure rises about 4mm Hg.  However, switching from filtered coffee to abstinence did not have any effect on blood pressure or heart rate.  Another study found a trivial change in blood pressure (-3.4mm Hg) after two months of abstinence (afgter 5 cups/d.)

Interestingly, a metaanalysis of 16 studies found that chronic caffeine (400mg/d) raised systolic blood pressure by 4 mm Hg. while 5 cups coffee/d (>500mg caffeine ) only raised it 1.2mm Hg.)  This was corroborated by another study finding >5 cups lead to 1.35mm Hg increase.

 

Cholesterol: raised slightly by unfiltered coffee, and possibly with filtered. 

Initial reports had found that drinking unfiltered coffee was associated with higher triglycerides and cholesterol levels than filtered coffee, because the filter removed almost all (80%) of the causative substance.  Another study found unfiltered caused higher cholesterol (but not TG) than filtered; filtered coffee had no effect on lipids over no coffee at all.

These findings were slightly contradicted in a recent study: Abstaining after 4 cups/d reduced cholesterol by about 12mg/dl.  Drinking filtered coffee raised cholesterol by about 11 mg/dL.  For perspective, 4 cups/d of whole milk would raise cholesterol by about 14mg/dL.

The question t ask here would be, how good was the paper filter? 

Coronary/heart disease: no. 

Retrospective analyses find that >4 cups/d, but not <2/d, had almost double the risk of coronary disease;  however, prospective studies found no increased risk.

A review identified possible explanations for an increased risk of heart disease in coffee drinkers  including a genetic predisposition to slower caffeine metabolism in some people, and the presence of diterpenes (which raise cholesterol) in unfiltered coffee .  However, the same review found several studies indicating a protective effect of moderate coffee drinking, which they conclude is related to the  antioxidants.

One study found heart attacks more frequent in coffee drinking women than abstainers: but was only usefully relevant at <7 cups/d, which doubled the heart attack risk.   However, a gigantic 85000 middle aged women prospective 10 year study found no effect of 6 or more cups coffee/d on coronary heart disease. 

For what it's worth, unfiltered coffee seems to be associated with higher rates of heart attacks than filtered. 

But it pays to wait: a week after I initially posted this, an 8 year  prospective study in the elderly found a dose dependent (i.e. greatest >4 servings) protective effect of caffeine in cardivascular mortality (reduced by 50%) (but, oddly, no effect on cerebrovascular mortality).  Importantly, these were normotensive individuals.

 

Suicide: Opposite of smoking: drink up.

Gigantic 10 year prospective study of 86626 female middle aged nurses:  suicide rate was reduced by 60-70% in those who drank more than 3 coffees/d, all other factors controlled.

A Finnish study of 43000 people over 14 years-- 216 suicides-- found that 2-5 cups/d moderately (30%) reduces suicide risk, while >8cups increases risk 1.5 times.  (For reference: "heavy drinking" (weirdly: 2 drinks/d) or smoking had about the same risk.)

A 1993 study looking at death from any cause found a reduction in suicide risk (RR 0.87 per cup) with increasing coffee. 

Liver cancer and cirrhosis: can't hurt, may help, especially if you're an alcoholic. 

The same 1993 study above also found a lower risk of cirrhosis (RR 0.77/cup).  The same authors, in a more recent study, again find such a reduction in risk, and find lower levels of liver enzymes ALT and AST. An Italian study found coffee reduced the risk of hepatocellular carcinoma from any cause (Hep B, C, alcohol, etc); same in the Japanese, and in the Japanese in a prosepctive trial.  And in Americans chronic liver disease rates were half in 2 cups/d drinkers.

Recent evidence suggests that this may be partly due to caffeine, but also to phenolic acid antioxidants which are not present in tea.  The authors cite reports of such ingredients' protective effect sagainst various forms of liver damage (including Tylenol.)  

So if you're going to drink coffee, there are two prudent things to do.  1) drink filtered coffee, made with a good filter.  2) drink medium roast, not dark roast.  The roasting process burns off volatile chemicals such as caffeine and the antioxidants. 

For this reason, my vote for best, healthiest, and most delicious coffee to drink is Dunkin' Donuts.

 

If one more person tells me Geodon "doesn't do anything," I'm going to choke them with the capsules.  If it's never worked in your practice, how do you explain the numerous efficacy studies?  All flukes?  All of them?  It couldn't be you?

Probably everyone has heard Geodon must be taken with food.  But that's not to prevent nausea or protect the stomach lining, it's to get the drug to be absorbed.

You'll have to take my word for it right now that 120mg is the a base dose. (120mg Geodon=10mg Zyprexa=3mg Risperdal.)  This is amazingly hard for psychiatrists to appreciate ("there are equivalences?  And those are the doses??")  But it's even harder to get them to understand the relationship to food: Geodon needs fat to be absorbed.

 

 

 

80mg on an empty stomach (blue line) gets you the equivalent of 40mg if taken with food.  That's half the dose.  In other words, if you dose your Geodon "all at night" (no food) then you're getting about half of what you thought you were.  (In chronic dosing this will be less of a problem, but 30-50% increased absorption with food is a good guideline.)

Hospitals: they dose BID, which means morning and night, which means no food either time.  Guess what happens (or doesn't). 

BTW, crackers won't do it.  The graph above is with 800 calories, 400 calories of fat.  That's a meal, not juice.

If your doctor gives you less than 120mg and then gives up, he doesn't understand the proper dosing of Geodon. If he doesn't know about the importance of food, then you're in big trouble.  Forget about reading journals, he's not even listening to the reps. (I know: because they're biased.)

I bring this up partly as a public service message, but also to explore the curious observation that even though many doctors know this already, they still don't dose with food.  I can't imagine laziness is the answer.  There is some weird thinking that this isn't relevant in the "real world" because food is weaker than medication.  Drug-drug interactions matter; drug-food couldn't be important.    And if it was really important, someone e would have mentioned it.

Everyone complains about diabetes and weight gain; here's a drug that likely doesn't have these problems.  But because it doesn't have those toxicities, it therefore can't be "strong," or effective.  

I'm not trying to advocate for Geodon.  I'm pointing out that much of our perception of a treatment's efficacy can come simply from our mishandling of it; and to alert humanity to the inherent bias in ourselves.  If we've never gotten Geodon to work, then not only do we think it doesn't work, but we think everyone who says it does work is a Pfizer schill.

Seroquel had this problem, too.  Six years ago, no one used Seroquel.  Now everyone uses it.  Did they improve it?  No.  It's marketing, but in reverse: Astra Zeneca didn't delude everyone into thinking it works when it doesn't; we deluded ourselves into thinking it didn't, when it did.  So whose fault is that?  Depakote: six years ago Depakote was untouchable, it was the king of bipolar treatment.  Now?   Did we get new data saying don't bother?  Did they make the drug weaker?   This is the key: the data that brings us today's conclusions is the exact same data that gave us the past's, opposite, conclusions.  In other words, no one actually read the data; they based their conclusions on something else.  Clinical experience?  No.

The bias goes well beyond "Pfizer paid that doctor off"-- it comes from a belief system ("meds are life savers" vs. "meds are band-aids"; nature vs. nurture; your own race/gender; your family history of mental illness/drug abuse (or lack of it); your desire to be a "real doctor" etc, etc) that is much deeper and exerts a much stronger control over your thinking.  To the exclusion of any new information.

And, of course, it's so much a part of you that you don't see it as a bias.   And other people (patients) don't know it's there, so they're at the mercy of your unexamined assumptions. 

The solution is exhausting, and no one will like it: constant critical re-evaluation of your beliefs.  Both the science (as much of it as there is) and countertransference.  And, most importantly, long looks at your own identity.  How did you come up with it?  Because, in fact, you did.

 

So maybe I am generalizing a bit, but I'm trying to get at something that isn't easily explained by science: why do so many psychiatrist families go bad in the same way?

In my experience (see, there's my disclaimer) psychiatrist-parents go wrong in a very specific way. They judge behavior, not the person.  It sounds like a good thing, I know.  For kids, it's a disaster.

Psychiatrists identify the behavior, but then focus on changing not the behavior directly, but the underlying cause of the behavior-- which is still not something intrinsic to the person.  If a guy with bipolar spends $10,000 in a week, psychiatrists link the behavior to the bipolar, and then try to medicate the bipolar.  (NB: "the patient has bipolar," not "the patient is bipolar.")

The obvious problem here is that maybe the guy spent $10,000 in a week because he doesn't give a damn? Or he wanted to impress some girl? i.e. just because someone has bipolar, doesn't mean every breath he takes is related to bipolar.  Psychiatrists are going to deny that they make it so simple, but in actuality they do: the moment you raise the dose of Depakote, you are sending the message that the behavior was related to bipolar. 

The psychiatrists with children-patients handle their kids in the same way.  They teach them what they are allowed to do and what they are not, what is acceptable and what is not-- but make no judgment on the kids themselves. Doing this denies the kid's identity, which is the whole purpose of childhood to begin with.  Rules then exist in an invented framework, or worse, in a vacuum.  There's no internalization of the rules; there's no superego.  Just some arbitrary limits on id.

If you tell a kid that a behavior is unacceptable, the kid has learned nothing about himself; he's only learned that this one thing is something he can't do. But if you make the kid own it-- make the behavior part of his identity, then he has a chance to change his identity.  Instead of learning it is unacceptable to take his brother's potato chips away, he can learn that he has a choice: to be the kind of person who takes chips, or the kind of person who doesn't. 

I understand the trickiness of this; you don't want to make the kid feel like he is a bad person.  But you do have to find a way to teach him that if he does that thing again and again, then he is a bad person.  Is that what he wants?  Who are you, kid?  Who do you want to be?  This also allows his to take personal credit for doing something good:

And you can see the creation of a future borderline here.  For God's sake, will someone please tell me who I am?  Give this storm of emotions some context?  Right now, I get angry/sad/thrilled/terrified over nothing, it just comes over me-- I wish I could be angry/sad/thrilled/terrified over something.  But all people ever do is tell me what I can and can't do.  If I do something bad, people freak. If I do something good, no one even notices.  No one likes me for me, they just over/underreact to what I do.

There's a second lurking trouble: parents' control of their affect. 

The psychiatrist isn't supposed to get mad at his patient; but then he comes home, and tries very hard not to get mad at his kid-- just tells him the behavior is unacceptable, gives him a time out, whatever.  But guess what?  The psychiatrist is exhausted, eventually his patience runs out, and BAM! a tsunami of anger.

calm&firm...calm&firm...calm&firm...EXPLOSION.

The explosion part can come at any time, depending on how much patience the parent has that day.  And that's exactly the problem.  What does the kid learn? That this ethereal rulebook for what is acceptable and unacceptable only has two, binary results: no affect, or all affect-- and you never know what you're going to get.

In the biz, this is called inconsistent parenting.

What the kid needs to know are the rules of the game; they need the parent to be consistent, predictable, so that they can be safely chaotic, experimental, exploratory off of your foundation.   You want her to know exactly how you'll react if she tries pot, you want a superego so well constructed you're superfluous.   And you want levels of emotion, different things get you more or less angry.  We know you went berserk because your boss is a big jerk whose been riding you all day, but your two year old thinks you went berserk because she spilled the milk.  Geez, sorry.  May as well try heroin, what's the difference?

It doesn't necessarily mean you have to be an angry parent-- your predicted reaction could be anxious acceptance or loving disappointment-- but it has to be predictable.  And it has to be about the kid, not the behavior.  The kid needs to know you're connecting with them, not what they do, or else they'll think that the only way to connect is by behaviors.

You can see the further development of a borderline here: what the hell do I have to do to get some emotional response from you?  Kill myself?  Keep pushing until you finally blow up?  I don't even feel like I'm alive, but I'm not sure that you are either-- or is it just me, that I matter so little that I can't even get a little affect? You're insanely jealous if I talk to another guy, but you totally ignore me when I'm with you. At least with jealousy you're being real with me. Etc.

Trust me on this: at age 2, a kid feels your rage and your love the same.  It's exciting, and they haven't yet learned to fully differentiate the two feelings.  What counts is the amount of emotion, not which emotion.  (Horror movies and porn are the same to a 14 yo for this reason.)  Fast forward 20 years-- that all-out screaming match with your boyfriend felt weirdly relaxing.

And so you have a scenario: busy psychiatrist, often tired, can't generate much emotion past anger-- and it can come at any time.  No deep connection with the child as a person-- as their kid, yes; as the sum total of their behaviors, yes-- but not as a developing individual.  The kid learns that as long as some things are done correctly-- e.g. school-- they can get away with other things that the parent won't notice, e.g. pot.

Oh, and this is the best part: if the kid (adult or child) becomes a psychiatric patient, they now have a bond with their parent-- and the parent's over-involvement in their kid's psychiatric care is the framework for a relationship.  It's analogous to helping them build a go cart. 

And that's all the kid ever wanted anyway.