Markham's Behavioral Health

Antidepressants Can Cause Withdrawal in Newborns

Reuters reports on an article in Lancet on February 5, 2005 that found withdrawal symptoms in newborns when their mothers were taking SSRIs like Paxil, etc.

"The prenatal use of a widely prescribed class of antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) can cause withdrawal reactions and convulsions in newborns, analysis of an international database suggests. The data indicate that paroxetine, marketed in the US as Paxil, is the SSRI mostly often linked to these problems.

There have been other reports tying antidepressant use in pregnancy to postnatal symptoms including convulsions, irritability, abnormal crying and tremor."

I find in my practice that SSRIs are widely overprescribed in my opinion without good reason. As I have said repeatedly on this blog, there are many studies which show that psychotherapy is more effective in the long run in treating depression and other psychiatric disorders. The idea that people can fix their dysphoric moods generated by external stressors and poor coping skills with a pill is misguided nonsense perpetrated by pharmaceutical companies to make money and by HMOs to cut costs.

I have to laugh about all the discussion about evidence based medicine and research based practice when scientific findings are so easily disregarded when it doesn't fit with economic interest or professional ideology.

The Reuters report notes:

"In a related editorial, Drs. Vladislav Ruchkin and Andres Martin, at Yale University School of Medicine in New Haven, Connecticut, recommend that clinicians not shift away precipitously from using SSRIs.

However, a necessary first step is for individual practitioners to use well-defined clinical guidelines before an antidepressant is prescribed.

They also advise doctors to make better use of non-pharmacological interventions that have been proven to be effective in treating depression."

That's good advice for anyone, not just pregnant women.

Link: MedlinePlus: Antidepressants Can Cause Withdrawal in Newborns.

Texas Teens Increased Sex After Abstinence Program

The teen pregnancy rate is down across the country at the lowest levels since World War II. This is a good thing and it is not clear to me what the explanation is. Abstinence based sex education programs have been proliferating and I wondered if they were contributing to this finding, but Reuters reports on a study in Texas which found that abstinence based programs had no effect on the teens in Texas and may have actually increased sexually activity.

I favor abstinence based education but I am against programs which advocate for abstinence only. Kids also need information about contraception and other sexual practices. For example, there is evidence that kids now days engage in more oral sex to avoid genital intercourse because they believe this protects their virginity and is not "real" sex.

Governmental policies shaped by religious agendas rather than public health science is bad practice. It bothers me, and I believe it should bother every intelligent American, that increasingly public health and human service programs are being run by "faith based" organizations which have religious agendas with governmental tax dollars rather than by health care and human service professionals who base their practice, as best they are able, on science rather than religious ideology and dogma.

While we castigaged and drove the Taliban from power in Afghanistan, it appears that we, increasingly, have our own home grown version here in the United States.

Link: MedlinePlus: Texas Teens Increased Sex After Abstinence Program.

Kids' Passive Smoking Tied to Later Lung Cancer

There is a report on the online edition of the British Medical Journal on January 28, 2005 which found that risk to kids subjected to second hand smoke of getting lung cancer was increased 34% and other respiratory diseases by 30%.

"As reported online by the British Medical Journal, Dr. P. Vineis, from Imperial College London, and colleagues analyzed data from 303,000 subjects who participated in the European Prospective Investigation into Cancer (EPIC) study.

The analysis focused on 123,479 subjects who provided information about exposure to secondhand smoke. During more than 7 years of follow-up, 97 people were diagnosed with lung cancer, 20 were diagnosed with upper respiratory malignancies, and 14 died from chronic obstructive pulmonary disease, which includes emphysema and chronic bronchitis.

In the overall analysis, exposure to environmental tobacco smoke raised the risk of all respiratory diseases by 30% and lung cancer by 34%, the researchers report."

A practice I find especially troubling and which should be outlawed is smoking in automobiles with children present. In New York State we have the Expanded Clean Indoor Air Act implemented in July of 2003 which makes it illegal for any smoking to be indoors where employees working for pay are located. The next big expansion would be to outlaw the smoking in private automobiles when children are present.

Link: MedlinePlus: Kids' Passive Smoking Tied to Later Lung Cancer.

Rejoice! We have built the best health care system in the world.

Continuing my reading and discussion of Gregg Easterbrook's book, The Progress Paradox, I run across his comments on page 25 that while currently 14% of Americans have no medical insurance, two generations ago nobody did and only the very wealthy knew any protection against ruinous medical expense because of their wealth.

Physicians, nurses and hospital staff lived humbly often bartering services with locals who traded the goods and services that they had for the health care they received. Of course, the locals often went without and died.

As health care has become more technological it has become more effective, getting better outcomes, but also more expensive, and the practice of medicine has shifted from a vocation, a calling, and a profession, to a business, a way for individuals and organizations to make money. What has been gained in effectiveness and efficiency has also been lost in humanity and caring.

I think many health care providers struggle with the conflicts between being a good business person who needs to generate revenue to stay in business, and being of service to people which is often time consuming, energy depleting, and not as efficient. People want to be attended to, not simply treated as objects, pieces of meat. There, unfortunately, is no billing code to be used with insurance companies for caring about patients.

As much as we may regret the conflicts between ministering, and fixing for money, the health care system has improved tremendously in two generations in terms of its effectiveness, its efficiency, and its coverage for the vast majority of Americans rich and poor alike.

A co-worker told me two days ago that her infant son who required cardiac surgery within a week of his birth or he would die, has been successfully treated now and is doing well at 2 1/2 months. She said the bill has come to over one million dollars. 30 years ago this infant son would have died.Without health insurance this young family would be bankrupted for the rest of their lives.

It's a grand world we are living in. Rejoice and be happy!

Gambling Among Older, Primary-Care Patients: An Important Public Health Concern

Laughing about the grandmotherly bingo queens might be funny until we find out that grandma just gambled away the rent, or didn't have enough money left after her loses for groceries or the light bill.

With the increase in gambling outlets whether they are lottery outlets, VLTs, casinos, or internet gambling, we will see an increase in problem gambling in our society in the coming years. This addiction hits especially hard on senior citizens with fixed incomes, time on their hands, who enjoy an "outing" on the bus to the casino as a way to cope with lonliness, and isolation.

Co-moribity with other substance abuse and psychiatric disorders is high.

The study published in the January, 2005 issue of the American Journal of Geriatric Psychiatry found that 2/3s of the study participants had gambled in the previous year, and for 10% it posed a problem with participants saying that they gambled $100.00 or more on a single bet, or bet more than they thought they could afford to loose.

"Of 843 screened patients completing the gambling questionnaire, 69.6% reported that they had participated in at least one gambling activity in the last year. At-risk gamblers were defined as those who reported having bet more than $100 on a single bet and/or having bet more than they could afford to lose in the last year. Of those responding, 10.9% were identified as at-risk gamblers. The strongest predictors of at-risk gambling behavior were being a binge drinker, presence of current posttraumatic stress disorder symptoms, minority race/ethnicity, and being a VA clinic patient. Subjects with mild-to-moderate cognitive impairment were just as likely as those without impairment to gamble and to report at-risk gambling behavior. At-risk gambling behavior was not significantly associated with gender, current or past depressive symptoms, or cigarette smoking."

Link: Gambling Among Older, Primary-Care Patients: An Important Public Health Concern -- Levens et al. 13 (1): 69 -- American Journal of Geriatric Psychiatry.

Average high school student has sexual contact with 288 people with just one episode of intercourse

Ever wonder why STD (Sexually Transmitted Disease) rates are so high? A team of researches at Ohio State University actually mapped out the chain of contact for an average high school student in a mid sized public high school in an average US town and found that one student who has sex with one partner who may have had sex with somebody else before them is actually one link in a chain of 288 sexual encounters.

The old saying that a person doesn't just have sex with one person but with all the people that person has had sex with takes on a new context when you consider the "map" of these sexual chains.

No wonder STDs are so prolific.

The answer? Education, condoms, monogamy, waiting til marriage..............

"The first "map" of teen sexual behavior gives new meaning to the old warning that you don't just have sex with a person, but with everyone that person ever had sex with, researchers said on Monday.

They found a chain of 288 one-to-one sexual relationships at a high school in the U.S. Midwest, meaning the teenager at the end of the chain may have had direct sexual contact with only one person, but indirect contact with 286 others.

The sociologists who conducted the study said they were surprised by the findings, which also showed that despite reputations and popularity, most teens in their study did not engage in promiscuous behavior with many others.

"From a student's perspective, a large chain like this would boggle the mind," said sociologist James Moody, who led the study. "They might know that their partner had a previous partner. But they don't think about the fact that this partner had a previous partner, who had a partner, and so on."

Link: MedlinePlus: Sex Map Shows Chain of Almost 300 High School Lovers.

Moral values not what you say but what you do

When you get right down to it, moral values is about behavior not belief, they are about practice not ideology. People can say all kinds of things, but behavior has consequences and talk is cheap. It's the law of karma, of cause and effect.

Anna Quindlen's essay in the January 24, 2005 issue of Newsweek magazine entitled "Connecting Up The Dots" points out that Mississippi has only one abortion clinic, down from seven, with 3 million people living in the state. Mississippi also tried to restrict abortion to the first trimester which the US Supreme Court struck down.

Quindlen goes on to look a number of public health indicators for women's health and child welfare, and finds Mississippi dead last on most measures such as infant mortality rate, teen birth rate, income, women in prison, women's earning power in relation to men, second trimester abortion rates, etc.

It made me start to think of Mississippi as a third world country run by the American version of the Taliban.

Let, me be clear, I am pro-life. I believe in a consistent life ethic meaning that I am against abortion, euthanasia, capital punishment, and militaristic approaches to world conquest. However, I have serious concerns with people who are anti-abortion and do very little or nothing to support life which appears to be the case in Mississippi if you look at the relevant public health indicators.

Social policies which are nonsupportive of people, and down right abusive, in the name of "moral values" are confusing and ineffective in promoting the health of the population. I think promoting abortion is bad social policy, but allowing a woman to choose, and providing support and other options to support life is good social policy.

When the anti-abortion folks influence pulbic health policy they should be challenged to profess not only what they are against, but what they are for, and to put their money where their mouths are. Taking a look at the public health indicators in Mississippi leaves the observer with the clear conclusion that they leave alot to be desired and have a long way to go to create a healthier society.

Patient-Safety Concerns Don't Delay Implementation of Prescribing Law

As psychiatry has moved increasingly away from psychosocial education and training, and focused more heavily on biochemistry, the prescription of psychotropic medication has become the primary treatment tool of psychiatrists rather than psychotherapy.

As psychotropic medications have come under increasing criticism for a whole variety of reasons, it seems odd that psychologists would want the permission of state legislatures to prescribe medications.

Two states so far have passed legislation to allow psychologists to prescribe medications: New Mexico, and Louisiana. Understandably, psychiatrists are upset because their monopoly has been broken. As much as they complain and fear monger, I know of no studies which show that they do a better job and get better outcomes prescribing psychotropic medication than anyone else.

If I were a psychiatrist, I would be complaining much more vociferously about primary care physicians prescribing psychotropics than psychologists. Psychologists, afterall, are mental health professionals and understand psychiatric problems much better than primary care physicians.

As a psychiatric social worker I am often asked by primary care physicians to recommend psychotropic medications for patients that we share. I am happy and knowledgable to do so, although I am first to admit I don't know anything about the patient's concomitant physical health and treatment.

What effect will all this have? I would guess that the pharmaceutical companies love it, and have probably lobbied for it, because they now have a whole new group of health care providers to push their products. This will increase the use of psychotropic medications to treat emotional disorders which I think is probably a bad thing overall. Study after study clearly shows that psychotherapy works better than medications in treating depression, anxiety, and other non-psychotic psychiatric disorders.

So, in the long run, it is my judgment that this is not a good thing for patients, not because I don't think that psychologists are competent to prescribe medications, but because I think that psychotropics are a poor choice when it comes to treating many psychiatric disorders.

Link: Patient-Safety Concerns Don't Delay Implementation of Prescribing Law -- Levin 40 (2): 2 -- Psychiatric News.

Many U.S. alcoholics recover

Having worked in the Behavioral Health field for over 35 years, I get a little annoyed, even though I am pleased, to read reports like this one that says that 1/3 of Alcoholics recover.

First, there are not good ways to diagnose alcoholism and my clinical experience teaches me that there are many kinds of alcoholics for whom recovery rates are quite different. For example, there is some public health data which suggests that 80% of people for whom alcohol has caused problems quit on their own without ever getting any kind of treatment or going to any AA meetings, etc. Our President, President Bush puts himself in this category.

Secondly, we know that alcoholism can be a chronic disease and therefore many attempts are often made to quit before the person successfully gets into recovery so these studies don't always tease out which quit attempt is being measured. At my agency, GCASA, about 40% of our clients are with us for the first time. 60% are back for a second, third, fourth episode of care. Consequently, our successful completion rates of outpatient treatment are higher than the 30% described in this article.

Thirdly, persistence in managing a chronic disease is what pays off for patients, and I believe that 80% of patients with alcoholism eventially will be in recovery or they will die.

100,000 Americans die every year from alcoholism and alcohol problems. I have known 100s of them.

The primary message that needs to be communicated is that alcoholism is a treatable disease, and it does work, and there is hope. Committment to treatment and recovery almost always pays off in terms of improved health and quality of life.

So, while this article is positive, it takes things out of context a little bit, because things are even better than a lay person might gather from reading this data.

Link: MedlinePlus: Many U.S. alcoholics recover.

Best Fitness Routine May Depend on Personality

Reuters reports on Monday, January 17, 2005 on an article in the December, 2004 journal, Physician and Sportsmedicine, which recommends that before physicians encourage patients to get involved in a fitness program that they take a personality profile first to understand better what their preferences are in regard to activity and daily routine so they create a fitness program that fits their personality.

I think this is a great idea. Not everyone likes team sports just as not everyone likes the solitary activity of working with weights. Some people are morning people and some people are night people. Some people are swimmers and some people are walkers. Knowing what the individual's preferences and inclinations are makes it more likely they will continue with whatever program they design for themselves.

There is evidence that exercise is also related to mental health. People who exercise regularly have better moods, more energy, greater sense of well being, less depression, etc.

Only 1 in 5 Americans gets enough exercise. I am one of the four that don't. My idea of exercise is a bowl of popcorn sitting in front of a good movie. Of course, I am 295 lbs., 6'1", with high blood pressure. What would be a good exercise program for me? I don't particularly like it, but I have been known to walk 30 minutes three or four times per week, and I feel better for it.

My current excuse? There is 6 inches of snow and last night it got down to -10F. Of course, if it was sunny and 72F, I can't promise it would have got me out there waling either.

What kind of personality do I have? Slug............................

Link: MedlinePlus: Best Fitness Routine May Depend on Personality.