Tom Hale -Psikoterapia zentroa

Post-Prozac Nation

     A wide-ranging group of new books and articles have recently been published challenging the efficacy of the enormously popular new generation of anti-depressant medicines, the SSRI's (Selective Serotonine Reuptake Inhibitors), which include Prozac.  One of the most popular medications in the country, Prozac is currently the third-most-common prescription drug taken in America.

    Siddhartha Mukherjee, assistant professon of medicine at Columbia University, in a recent New York Times artictle, called it "the new villain of modern psychopharmacology - overhyped, overprescribed, chemical sympotmatic of a pill-happy culture searching for quick fixs for complex mental problems". 

    Two books that are raising these issues are, "The Emperor's New Drugs"  by pyschologist Irving Kirsch, "Let Them Eat Prozac", by David Healy, to name just a few.   The use of these drugs and for so many people is being challenged on many levels, not the least being (1)"the very theory (the serotonin hypothesis) for how these drugs work" and (2) the "slippery, seemingly-contradictory studies"  that suggested that 75 - 82% of an antidepressant' effect could have been obtained merely by taking a placebo.   Many researchers concluded that "pharmaceutical companies were exaggerating the benefits of antidepressants by selectively publishing positive studies while suppressing negative ones".

    Mukherjee goes on to cite research done in 2010 when the placebo effect data was reevaluated using six of the most rigorously conducted on antidepressants.   The findings vindicated the early research conclusions for the most part.  First, patients with severe depression tend to respond most meaningfully to antidepressants while those with moderate to mild depression do not.  Second, serotonine probably plays an important role, but not fully understood fully, in cases of severe depression.   Third, the "brain-as-a chemical-soup" theory was "far too naive".

    The author describes much of the new research that is being done.   Many are wondering whether depression might have multiple subtypes - with some responding to treatment with serotinin-enhancing drugs and some not.   Also, could depression be another kind of neurological disorder in which the illness is precipitated by the death of neurons in certain parts of the brain?   A sort of degenerative disease - like Alzheimers or Parkinson's - sort of a "dementia of the mood?"  Depression may be  "emotional pain with context", some believe.   The role of the hippocampus may be to help put the situation with an emotional component into context.   If the hippocampus is working properly, it may act as a conduit to tell our conscious brain, for expample, that the loss of love should be experienced as sorrow or the loss of a job as anxiety.

    All in all,  the author says, "depression is a complex, diverse illness, with different antecedent causes and manifestations."    None of the new theories explain why "talk therapies" work (and the research shows they indeed do) and in some patients and not in others.   Or "why the combination of talk and antidepressants seems to work consistently better than either alone".

Full Circle

 

 

                                                        Full Circle

                                                 by Alden Nowlan

In my youth, no one spoke of love

where I lived, except I spoke of it, and then only in the dark. The word was known

like the name of a city on another continent.

No one called anyone his friend,

although they had friends. Perhaps they were afraid

to commit so much of themselves,to demand so much of others;

for if they'd said,

"We're friends," as they never did,

it would have been a contract.

As it was, they could quarrel,

even hit one another if they were drunk,

and remain friends, never having said it.

Where nothing was sworn there could be no betrayal.

Nor did they touch

casually; their persons seemed to occupy

more space than their bodies did.

Seeing an adult run we'd have looked first for the reason

in the direction from which he came. We never met trains;

my people were like that.                                              It was not enough for me.

                      "I love you," I said.

Whispered it, painfully, and was laughed at;

hid until the wounds healed and said it again, 

            muttered it.

Wanting to be loved, "I love you," was what I said.

And I learned to touch, as a legless manlearns to walk again. 

 

                                  Came to live among people

who called anyone a friend

who was not an enemy, to whom there were no strangers:

because there were so many, they were invisible.

Now, like everyone else, I send

postcards to acquaintances, With Love—

Love meaning, I suppose, that I remember the recipients

kindly and wish them well. But I say it

less often and will not be surprised

at myself if the time comes when I do not say it,

when I do not touch, except desperately, when I ask

nothing more of others, but greet them with a wink,

as my grandfather might have done, looking up

for an instant from his carpenter's bench.

 

"Full Circle" by Alden Nowlan, from What Happened When He Went to the Store for Bread. © The Thousands Press, 2000.

The State of White America

    I've been watching with some interest the reaction of critics to a new book by social scientist Charles Murray, Coming Apart: the State of White America, 1960-2010.    I haven't read the book yet since it was just published about ten days but I will probably read it in the next month.   This is a huge compliment, which means it has been bumped up through a tall pile of very good books I am slowing plowing through.

    What is the big deal  about this book?

    First, Murray (born 1943), is an American libertarian political scientist, author,columnist, and pundit currently working as a fellow at the American Enterprise Institute, a conservative think tank in Washington, DC.   He is best known for his controversial book The Bell Curve, co-authored with the late Richard Herrnstein in 1994, which argued that intelligence plays a central role in American society.    They proposed in the book that intelligence is a better predictor of many factors including financial income, job performance, unwed pregnancy, and crime than one's parents' socio-economic status or education level.    Also, the book argued that those with high intelligence (the "cognitive elite") are becoming separated from the general population of those with average and below-average intelligence, and that this was a dangerous social trend.  Murray's ideas were roundly criticized by liberals, in particular, as racist and simplistic.

    Second, the new book addresses the issue of class in America at a time when many people, especially Republicans, have been claiming that raising the issue of "class" is a liberal divisive political strategy.   And now we have a conservative Republican, devoting 400 pages to the subject.   

    As you might expect, writers have been all across the political contimuum in their responses.   Charles Brooks, columnist for the NYT said, "I'll be surprised if there is another book this year that so compellingly describes the most important trends in American society''.  While Brooks is not a commentator I am particular fond of, I suspect he may be right on this.  

    It seams that Murray's basic  premise is that the "white working class is no longer a part of a virtuour silent majority; it has become increasingly alienated from the "founding virtues" of American civic life."   He goes on to say, "our nation is coming apart at the seams, not ethnic seams, but the seams of class."   

    My first response is that finally we can begin to talk about the state of the American family again without being politically incorrect. 

     This seems to be primarily a book of scholarship, not politics.  Murray has approached the topic as a work of scholarship, full of charts, footnotes and regression analyses.  He uses the data to create an imaginary white world of two classes, the new upper class, "Belmont" and a new lower class, "Fishtown".     And what he sees for America in the new, emerging social construct should make us all shiver.   The two worlds are so vastly different in so many ways, includeing income, illegitimacy rates, crime, and joblessness,  with Fishtown slowly sinking.    What are we going to do about it?

    The controversy seems essentially to be found in the response to Murray's description of this sad, new American world, and along the classic political lines.  Murray makes suggestions for change in the last chapter of the book and these are being roundly challenged.   Good.   It sounds like a conversation is breaking out.   I hope that this book stimulate a huge, non-political conversation.

    As a psychotherapist whose early training was in family systems, I have for years been concerned about many of these same issues, and the slow decline of the quality of life in working class communities has troubled me.   As health care availability has eroded for the working poor, fewer and fewer services have been utilized by them and the help necessary for them to challenge the trends being reported here were/are missing.   If we are looking at real solutions to some of these issues, adequate, affordable health care is imperative.

 

 

Returning Home

    I had mentioned several posts ago that I was a mental health provider for the U.S. Military, primarily through TriCare, and now through OneSource.   Tricare is the "insurance company" for military personnel and retirees and OneSource is a new, additional mental health care program for N.G. and Reservists returning from the Middle East.

    I recently received a notice from Karen Remley, MD, MBA, FAAP, Virginia Health Commissioner, and Paul Galanti, Virginia Commissioner of Veterans Services, advising mh providers of important information about returning vets and resources that can be used.  I've printed parts of the letter here for all of you to read, even if you're not in Virginia, because of its relevence.  The resources are excellent to know about.   I'll say more about it very soon in another post.

 

    Virginia is home to hundreds of thousands of veterans, many of whom served multiple deployments in the wars in Afghanistan and Iraq, and may become patients of yours. According to the U.S. Department of Veterans Affairs (VA), there are more than 800,000 veterans in the state. That means 1 in 8 Virginians is a veteran. 

    Over the next six months, 1,200 – 2,000 servicemen and women in the Virginia National Guard will be returning home, many from the front lines of combat. While some will make their way through the VA for their health care, many will not; they will come to you. Each of us would like to provide the very best care to every patient and knowing their specific medical and social history can significantly change our diagnosis and treatment plan. Below are resources available to assist you in the coordination of care and support and to provide straightforward language to begin a discussion with a patient who may be a veteran. And lastly, there’s information on where to turn for additional services for these brave men and women. 

    First and foremost, there is the Virginia Department of Veterans Services Virginia Wounded Warrior Program (VWWP). Mandated by law, VWWP provides behavioral health, rehabilitation services and support to veterans, National Guard members, reservists and their family members. These services are coordinated through local/regional VWWP consortia consisting of community providers, including community services boards, brain injury services providers, VA Medical facilities and other public and private providers. To learn more about VWWP and to locate the Regional Coordinator who serves your locality, go to www.wearevirginiaveterans.org. The Regional Program Offices can be accessed under “contact.”  

Here are three other great resources for clinicians:        

VWWP Web page specifically for clinicians http://wearevirginiaveterans.org/Resources/For-Clinicians.aspx·        

The Citizen Soldier Support Program, which provides training courses for health care providers such as “A Primary Care Approach,” at www.aheconnect.com/citizensoldier·        

If you are caring for a veteran, the US Department of Veterans Affairs maintains a toll-free Caregiver Support line at 1-855-260-3274. 

Finally, I have also placed on the VDH website (www.vdh.virginia.gov/clinicians/ ) several informative presentations that offer an in-depth look at the changing face of our veterans, the challenges they and their families face when they return home, potential long-term care and what we as health care providers need to know.

    

"The Mental Health Parity Act May Save The Day"

 

    Finally something new on the Mental Health/Addictions Parity Act. 

    Former CIGNA executive-turned-whistleblower Wendell Potter is still writing about the health care industry and the ongoing battle for health reform. Potter is the author of Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans.  I've written about him before and his book and feel he is an important voice in the mix of information we get about health care.  

    Potter also has a web-site, NationofChange, in which he regularly writes about his work and the industry.   It's a good site and one of sections on it is "Ask Wendall", in which people write in and ask questions about difficulties they are having with accessing health care.    Many of the inquiries “Ask Wendell” has received pertain to mental health and behavioral issues.

    Here is something he wrote about recently:

 

 

    "Until recent years, insurers in general provided little or no coverage for treatment of mental illnesses. It took an act of Congress—literally—to change that. The Mental Health Parity Act (MHPA), which became law exactly 15 years ago today, requires that annual or lifetime dollar limits on mental health benefits be no lower than the dollar limits for medical and surgical benefits offered by a group health plan.

    Because insurers were finding ways to get around the law’s requirements—they were, for example, limiting the number of provider visits and the number of days they would cover for inpatient psychiatric hospitalizations—Congress amended MHPA three years ago by closing some loopholes. Nevertheless, many Americans with mental health problems still face more coverage limitations than those with physical illnesses, as the letter below illustrates. If that is happening to you, fight back.

 

    Dear Wendell,

    My son was diagnosed with severe psychotic depression. He is slowly recovering, but he still has a way to go and does best when he can see his psychiatrist four times a week. Anthem Blue Cross will only pay for two sessions a week. We've tried to fight this, but they won't budge, saying their psychiatrist has decided my son's condition only warrants twice weekly sessions. Their psychiatrist has never met my son, so how can they justify this judgment call? Is this legal? How can they justify this when there is no longer a cap on the amount of treatment? Is there any way we can fight this?

Lisa

Dear Lisa,

    What your son is experiencing is a practice in the insurance industry known as "partial denial," and it very possibly could be illegal.  As a first step, you should initiate an appeal right away. But don’t stop there or even wait for the results. Become a “squeaky wheel.” Insurers hate squeaky wheels. Anthem executives very possibly will agree to the number of sessions your son’s psychiatrist believes is necessary when they realize you will squeak long and loud if they don’t.

    You should have two or three levels of appeal available to you: one with your health plan and at least one with an outside review company.

    If you lose the first round and have to request an outside review, do so promptly and notify Anthem executives in writing that you are giving them seven days to respond or you will contact your state’s insurance department.

    Be prepared to do just that. If you file a complaint with your insurance department, send a copy of it to the benefits manager where you work (if your policy is through an employer) and to Anthem bigwigs. 

    Doing all of this will send the message that you are not going away.

 

    Actually, the MHPA is being integrated, albeit slowly, into the coverage of most health care insurance company, including Anthem; in fact, Anthem has seemed to me to be one of the companies that has been more proactive then most in implementing it.   Value Options has also been a leader.  As Potter says, "it may save the day".    The law's full implementation will change many of the concerns raised above but until it works better, taking his suggestions may be necessary.  But, as always, get informed.   Go on-line and see what you can learn.   Then ask your insurance company and your therapsit about how it works.   They should have some answers for you.   Then you might ask Wendall.