Earlier this week, the Boston Globe’s health blog dived into the issue of conflicts of interest for the latest mental disorder diagnostic manual being formulated. The diagnostic manual is known as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and a fifth version of it is currently in development.

How a disorder makes it into the DSM — which is used by mental health professionals and insurance companies to legitimize and pay for a mental health concern — has been the subject of numerous research papers and essays. It is a messy process, like sausage-making, and involves a combination of expert testimony (often given by the same experts who lead a subcommittee on the specific disorder), research on the disorder, and, of course, a healthy dollop of politics. Disorders do not make it into the DSM based solely upon the empirical evidence.

As the Globe’s health blog reported, 16 of the 28 members of a task force overseeing revision of the DSM have disclosed financial ties to drug or medical device companies, according to the Center for Science in the Public Interest. This naturally raises some concern about possible conflicts of interest.

The American Psychiatric Association, publisher of the DSM, responded to the Globe by saying,

“We have made every effort to ensure that [the manual] will be based on the best and latest scientific research, and to eliminate conflicts of interest in its development,” Carolyn B. Robinowitz, president of the psychiatric association, said in a statement.

The number of professionals with pharmaceutical industry ties has risen 14% from the last revision:

Lisa Cosgrove, a clinical psychologist at University of Massachusetts-Boston, who helped write a 2006 paper exposing conflicts of interest in the last edition of the manual, said the new task force has 14 percent more members with industry ties than the one working on the 1994 version.

“When I did that study, it was not an attempt to ban people with financial ties,” she said in an interview. “I think a more balanced and realistic approach would be to actively recruit critics of industry-funded research as opposed to an outright ban.”

I think the Globe’s reporting missed the mark about this issue on two counts — conflicts of interest and relevance of such conflicts to the task at hand.

What the article didn’t really underline was that (a) the DSM committees have always had members with conflicts of interest and (b) that these conflicts of interest go well beyond ties to pharmaceutical companies. Remember, many of the experts chosen to sit on these committees are the same professionals who have made their livelihood studying these disorders.

An expert on depression, therefore, has her entire professional career (a pretty big conflict of interest) invested in ensuring that the depression diagnostic category is not only represented, but expanded. After all, experts regularly believe their area of expertise is under-appreciated and under-represented. The same thing is true with experts representing new disorders under consideration for inclusion in the new revision. You won’t …

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Therapists have a secret that they would rather most people not know.

Up to 40% of new psychotherapy clients never come back for a second session.

While many therapists would consider such single session clients “failures,” but the fact is that given how often it happens, they must provide people with some benefit or relief in some percentage of those cases. (Others likely just find the therapy experience not helpful to their needs, not what they expected, or disliked the particular therapist they saw.)

The APA’s Monitor on Psychology this month has an article on phenomenon, with helpful tips to therapists on how to make the most of a single session, including the finding that such single sessions can be helpful to people:

Indeed, as-yet-unpublished research by a team of psychologists from the Department of Veterans Affairs, found a single, 60-minute session can even help people with serious mental illness. After just one “motivational interview,” participants were significantly more likely to enter a vocational rehabilitation program, and they stayed in the program for three months longer than a control group, says Lisa Mueller, PhD, a research associate on the study, led by psychologist Charles Drebing, PhD.

Most people feel very relieved after their first session of psychotherapy. And for many, that’s sufficient. It’s a cathartic experience for them and they take something away from the chance to bare their souls to another person. Even if they never return.

The four tips offered in the article include:

• Zero in on a single problem. By focusing on a single issue of most concern to the person and the reason that brought them into therapy, a therapist may be able to help provide the person with some guidance on how to best approach the issue.
• Unearth hidden resources. The article notes that most people might have the tools and resources necessary to fix the big issue in their life. They may just need a little help finding them.
• Don’t cajole. It’s important for a therapist to show a person they are on their side, and help them explore the pros and cons of a situation. You can’t force change to happen quickly, so a therapist shouldn’t bother to try.
• Plan for the future. A therapist can be helpful if they provide the person with additional resources and direction on where to learn more about their problems on their own. One simple exercise taught in a single session can be helpful to a person to practice on their own, such as a relaxation tip or reframing of irrational thoughts.

I’d add a fifth tip — Never assume your new patient is coming back. If you treat every new patient as a possible single session intervention, you may be surprised to find how powerful and helpful that one session can be for people.

Read the full article at the American Psychological Association: Make the most of one session

Forgo genetic testing for mental disorders such as bipolar disorder for now. The commercial tests which are coming on the market now offer little in the way of useful, actionable information, and can only tell you whether you may be at increased risk for a tiny subset of genes which may have a slightly higher incidence connected to a diagnosis of bipolar disorder.

Worse yet, the vast majority of people who are diagnosed with a disorder that may have a genetic component do not carry the genes these tests look for. That means that the test could come back negative, and you could still have the disorder. So what’s the point then?

Someday, genetic testing may prove useful in mental disorder diagnosis and prevention. But that day is still many years — and perhaps even decades — away. Don’t get suckered in by these companies looking to prey on people’s misunderstanding of these tests and the stigma associated with these disorders.

Read the full article at the Philadelphia Inquirer: A $400 test to evaluate your chances of bipolar disorder?

Some people wrap themselves in marketing phrases and feel-good privacy statements which mean little in the real world. So just a reminder to our regular readers about what online anonymity entails.

You can’t be anonymous online if you…

1. Join virtually any social network (since, by their very nature, they encourage you to share as much information as possible with their services and others through their website).

2. Post a photo of yourself anywhere online (or on any social network). Photos are readily identifiable and anyone who’s ever thought, “No one will ever see this,” are usually disappointed at how incredibly wrong they are when their boss/boyfriend/girlfriend/spouse/parent gets an emailed copy of it.

3. Share key identifying information about yourself, including (but not limited to): where you work or go to school; your hometown; where you live now; your neighborhood; your age; your favorite band; your favorite hobbies; the people you know; etc. While any one single piece of information is unlikely to identify you (outside of your name, phone number, email address or social security number), a combination of pieces of information (which most people share haphazardly, over time) can often paint a picture of your identity.

4. Use the same pseudonym or email address as your identity on multiple communities or social networks. People are amazed at how easy it is to track down their online history through this simple piece of data (which is very often unique).

5. Sign a guestbook or add a Facebook application to your profile. As the BBC so easily demonstrated last week (link to BBC video which auto-plays), once you give away access to your profile information to a Facebook application, it can be gone for good (as well as all of your friends’ profiles too!). While Facebook pays lip service to being able to spot such malicious applications, the truth is that there are far more people incentivized to create these kinds of applications than there are people who can stop them from proliferating.

As the head of Sun, Scott McNealy said nearly a decade ago, “You have zero privacy anyway. Get over it.”

While that may be true, you’re better off if you don’t delude yourself that you have any inkling of privacy when you join a social network (especially those that claim they offer “anonymous” social groups).

Your privacy online is fleeting and fragile. Take it from there…

One of the biggest problems facing the mental health system today is slipshod diagnoses — diagnoses made too quickly, without obtaining enough information, and checking for reasonable alternative diagnoses. Professionals sometimes complain that they are overworked and need to make a diagnosis quickly in order to be reimbursed for the interview. I say that’s rubbish and puts people’s lives in jeopardy, in pursuit of quick treatment, quick payment, and quickly moving onto the next patient.

Don’t get me wrong — most mental health professionals take their time, explore rule-out diagnoses, and always seek to ensure the person in front of them really fits the diagnostic picture for a given disorder. But as we reported today, bipolar disorder may be overdiagnosed in real life practice, where nearly half those initially diagnosed with bipolar disorder didn’t actually meet the criteria for that diagnosis.

Imagine any other scientific field where you can be wrong half the time and still be considered “scientific” in any sense of the world.

Via Philip over at Furious Seasons today, I learned of one college student’s mental health journey, published in the college newspaper as, To hell and back. While long, it’s an interesting story of a college student’s experience with various psychiatrists and grappling with mental health issues while in college. And it shows just how badly professionals can work to misdiagnose an individual, over and over again. (Keeping in mind, of course, that this is just one side of the story; the story the professionals mentioned in the article may tell of this person might paint a very different picture.)

Diagnosis is part art, part science. While there are structured clinical interviews that can take much of the “art” and guess-work out of diagnosis, such structured interviews are rarely used in everyday clinical practice because they take too much time (and one might argue, too much effort on both the clinician’s and patient’s parts). So most clinicians rely on their experience and training to diagnose. After seeing dozens or hundreds of people with depression, a professional can start to feel they can spot “depression” a mile away.

But an initial interview with a person who is seeking mental health services should take time and patience. In an outpatient setting, it is typically about 75 to 90 minutes in length, and this is on purpose. It is an information-gathering session and one that, if rushed, much can be lost in obtaining a balanced picture of the person’s life. By the end of that first session, most experienced clinicians have a pretty good sense of what might be going on with the client and can reliably formulate an initial diagnosis.

Sometimes, a professional will defer a diagnosis because the picture is still not clear. It may take another session or two before they feel like they have enough information to provide an accurate diagnostic label. Other professionals don’t care as much how …

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Earlier today we reported on new research that shows a link between a parent’s mental health and an increase in the likelihood of having a child develop autism. The research examined Swedish hospital records of children born between 1977 and 2003 who were diagnosed with autism and compared them with children who were not diagnosed with autism.

Then the researchers looked at the rates of psychiatric hospitalizations of either parents between the two groups.

The researchers found that mothers and fathers diagnosed with schizophrenia were about twice as likely to have a child diagnosed with autism. They also found higher rates of depression and personality disorders among mothers, but not fathers.

Knowing whether autism might be more prevalent in families with a history of psychiatric problems could better inform future prevention efforts. Whether the link is passed via the environment (e.g., through the family child-rearing environment) or through genetics, or a combination of the two.

Richard Florida is a researcher and author whose column, Where Do All the Neurotics Live?, appears in today’s Boston Globe. The article offers some interesting insights into the potential “psychogeography” of the United States.

Psychologists have shown that human personalities can be classified along five key dimensions: agreeableness, conscientiousness, extroversion, neuroticism, and openness to experience. And each of these dimensions has been found to affect key life outcomes from life expectancy and divorce to political ideology, job choices and performance, and innovation and creativity.

These are referred to as the “Big Five” personality factors by psychologists and can generally be measured by a test called the NEO-FFI, NEO PI-R, or something along those lines (here’s an online version, but it takes forever to complete). Wikipedia’s description of each of these traits is succinct:

The Big Five factors and their constituent traits can be summarized as follows:

Openness - appreciation for art, emotion, adventure, unusual ideas, imagination, curiosity, and variety of experience.

Conscientiousness - a tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous behaviour.

Extraversion - energy, positive emotions, surgency, and the tendency to seek stimulation and the company of others.

Agreeableness - a tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others.

Neuroticism - a tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability; sometimes called emotional instability.

Florida’s findings?

Interestingly, America’s psychogeography lines up reasonably well with its economic geography. Greater Chicago is a center for extroverts and also a leading center for sales professionals. The Midwest, long a center for the manufacturing industry, has a prevalence of conscientious types who work well in a structured, rule-driven environment. The South, and particularly the I-75 corridor, where so much Japanese and German car manufacturing is located, is dominated by agreeable and conscientious types who are both dutiful and work well in teams.

Is this a self-fulfilling prophecy? Do people move to a specific area because it’s full of people like themselves, or are these areas simply full of these kinds of people due to age-old immigration patterns? The research can’t really say, but Florida does make some educated guesses.

The Northeast corridor, including Greater Boston, as well as San Francisco, Los Angeles, Seattle, and Austin, are home to concentrations of open-to-experience types who are drawn to creative endeavor, innovation, and entrepreneurial start-up companies. While it is hard to identify which came first — was it an initial concentration of personality types that drew industry, or the industry which attracted the personalities? — the overlay is clear.

One of the things interesting to me, and not mentioned in the article, is that the entire West coast is completely absent from representation on the maps. This must be due to lack of data or something, because it’s hard to imagine that California doesn’t have a specific concentration of a certain type of person.

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If it’s May, it must be Mental Health Month, that special, warm, cozy time of the year that we all gather around our medication bottles and sing a little mental health happiness song.

Yes, I’m starting a new tradition. Please join in if you’d like.

But for most Americans, Mental Health Month is meant to highlight mental health issues in a positive light to help people better understand them. Understanding something means not being so afraid of it, and if you’re not so afraid of something, maybe you won’t seek to avoid that thing in your life (e.g., stigmatize it). Virtually every big health condition or concern has such an “awareness month.”

Mental Health America, formerly the National Association for Mental Health, brings us a timely survey this month to let us know something that I think most people already knew — most people have friends. They also found these surprising results:

• Most people have an emotional bond with at least one other person
• Most people talk to other people about important decisions in their lives
• Most people have someone in their lives that appreciates them for who they are

Heady stuff, no?

The survey is meant to support MHA’s theme for Mental Health Month this year — “Get Connected.” But with response rates well over 90%, it shows that most people already have strong social connections in their lives. And while we may believe a larger social network benefits all, the research is decidedly mixed on whether social relationships help buffer stress. But don’t let the data mess up a good PR opportunity:

Research shows that social connectedness can reduce stress and promote overall health by providing a sense of belonging, self-worth and security.

“Individuals who feel valued and cared for are better equipped to deal with stress and adversity and even experience less severe illnesses than those with little social support,” said David Shern, Ph.D., president & CEO of Mental Health America. “The results of this survey are overwhelmingly positive because they show that most Americans do, in fact, have supportive relationships and that they recognize the vital role these relationships play in protecting them from depression and other illnesses.”

This sounds like the stress-buffering model (as described in Burton et. al., 2004):

This interactive model posits that, when faced with troubling life events, individuals with greater support from family and friends are less likely to become depressed than individuals with lower levels of support. This social support presumably enhances efficacy, esteem, and confidence, thereby increasing an individual’s perception that he or she can cope effectively with negative life events. In addition, the tangible support provided by network members may directly facilitate the resolution of negative life events (e.g., financial assistance).

But unfortunately, despite the fact that this theory is widely accepted, there’s actual little positive research support for it. I’ll let Burton et. al. (2004) tell you:

In sum, results from our study provided support for the assertions that negative life events and deficits in social

…

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One of the long-standing concerns amongst professionals and parents alike is the possibility that early treatment of attention deficit disorder (ADHD) with stimulant medication (such as Ritalin or Adderall) could possibly lead to later problems. New research suggests these concerns are largely unfounded, with one possible exception.

The studies were published in the latest issue of the American Journal of Psychiatry and both studies largely showed no positive association between the use of stimulant medication in children and an increased risk of substance abuse later on in life. The first study, Biederman et. al. (2008) reported on the 10-year followup of 112 children who were between 6 and 17 years-old when first entered into the study:

In a longitudinal sample of male subjects diagnosed with ADHD in childhood and followed up for 10 years into their young adult years, we found no evidence that prior treatment with stimulants was associated with subsequent increased or decreased risk for alcohol, drug, or nicotine use disorders. Further, we did not detect any significant association between age at stimulant treatment onset and subsequent substance use disorders or any associations between the duration of stimulant treatment and subsequent substance use disorders. These findings support the hypothesis that stimulant treatment does not increase the risk for subsequent substance use disorders.

The second study, Mannuzza et. al. (2008) showed more mixed results. While they did find an association between stimulant use for the treatment of ADHD and later substance use disorders, it was accounted for by a third, unexpected factor — antisocial personality disorder. Subjects who didn’t start stimulant medication until they were between ages 8 and 12 had greater substance abuse that was mediated by an increase in antisocial personality disorder in adulthood. Subjects with early stimulant treatment — before the age of 8 — did not differ from comparison subjects in lifetime rates of non-alcohol substance use.

So kids who are diagnosed and begin medication treatment later in childhood may be at more risk for later substance abuse because of the development of an antisocial personality disorder. There really is no adequate explanation for the greater prevalence of antisocial personality disorder in the later treatment group compared to the earlier treatment group, which the journal’s accompanying editorial notes:

The authors discuss the possibility that early stimulant treatment of ADHD may have a protective effect toward the emergence of conduct disorder, which usually precedes antisocial personality disorder and increases the risk for drug abuse. However, this hypothesis is not supported by early findings from the Multimodal Treatment Study of ADHD, in which treatment with stimulants in this prospective follow-up study did not selectively reduce conduct disorder, or by national trends over the past decade, when there has been a dramatic fivefold increase in the treatment of ADHD children in the United States with stimulants but no change in the prevalence of conduct disorder.

The upshot is that these studies confirm …

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The National Alliance on Mental Illness (NAMI) got some grant money from Wyeth Pharmaceuticals to produce an updated brochure on Women and Depression. The result?

A publication that is largely information that’s been regurgitated time and time again (you can see many of the same topics in NIMH’s Women and Depression brochure), culled from a myriad of sources (sadly, not a single one of them attributed in the brochure, meant for consumers), reproducing little tidbits of facts long known, such as:

• An estimated one in eight women will experience depression in their lifetimes; twice the rate as men, regardless of race or ethnic background
• Middle-aged Hispanic women have the highest rate of depressive symptoms, followed by middle-aged African American women.
• Young Asian American women have the highest rate of younger groups and the 2nd highest rate of suicide among 15 to 24 year olds.
• American Indians and Alaska Native adolescents are the most likely to attempt suicide and die from it.

Interesting, if any of this were new data, but none of it is.

What the brochure really needed was a decent editor, because it’s full of nonsensical statements. Excuse me for shooting a few fish in a barrel, but we expect a higher standard from an organization like NAMI.

I picked a few of our favorites from the brochure, although there are many more to choose from. Let’s start with one of my favorites, What causes depression?

Researchers suspect that, rather than a single cause, many factors unique to women’s lives play a role in developing depression.

The section on “Causes” then goes on to talk about genetics, biology, psychosocial, victimization and poverty. Few of these factors are unique to women. Obviously women have similar genetic makeup as men and no research has implicated a female-specific gene as being the cause of depression in women. Same with the psychosocial — men have pessimistic thinking, low self-esteem and can worry a lot too. There’s been no research to show these kinds of factors are more significantly prevalent in women (except, perhaps, low self-esteem).

Victimization and poverty are really sub-topics under psychosocial, since they indeed deal with social aspects of living within a shared society. While poverty bias is prevalent in non-industrialized countries, it is on more equal footing in the U.S. and other industrialized countries. It’s likely that depression doesn’t discriminate when it comes to the incidence of depression amongst poor men and women.

Men have biology, too, of course, but women’s biology can indeed be more of a contributing factor to depression. Postpartum depression, for instance, is a very real and serious concern for many women after childbirth. Oddly, however, it is mentioned briefly only once in the entire brochure. This would’ve been an ideal opportunity to dispel many of the common misconceptions about this type of depression unique to women, but the brochure largely fails to do so.

Let’s see if the brochure presents a balanced picture about antidepressant medications (FYI, …

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The latest research results on deep brain stimulation (DBS) suggests it is helpful for severe, chronic depression. DBS is a simple surgical procedure that implants electrodes in parts of your brain. Once implanted, they emit tiny electrical pulses that help block the dysfunctional activity in your brain. The key to success in the procedure is for the neurosurgeon to carefully identify the right places to implant the electrodes, because if they end up in the wrong area of the brain, little benefit will be realized from the procedure (although there also appears to be minimal opportunity for harm as well).

Deep brain stimulation is not a new procedure, but its use in the treatment of depression (as well as severe OCD) is. It’s been used successfully for about 20 years in the treatment of Parkinson’s disease.

New research was presented on Tuesday at the American Association of Neurological Surgeons annual meeting in Chicago. In the study, 15 people received the DBS electrode implants. These people had been suffering from severe depression for at least five years and had tried other forms of treatment with no success.

Six months later, 7 of the 15 subjects had at least a 50 percent reduction in their depressive symptoms, based on a commonly used depression scale. But even subjects who didn’t enjoy a 50 percent reduction in their symptoms still experienced some symptom reduction. All subjects said they would undergo the DBS procedure again (even if it didn’t significantly help them).

Keep in mind, people with severe depression and who’ve tried other forms of treatment with no success are often at the end of their ropes in terms of hope and finding a treatment that works for them. These are often the “worst of the worst,” and turn to these types of procedures in hope of finding relief from their depression. Even if only half of the patients studied enjoyed significant relief from the treatment, DBS appears to be a better treatment option than many others with far more severe side effects (ECT comes to mind, with its unpredictable memory loss).

I’m all for new treatments of severe depression, especially those that appear to be well-tolerated with few negative side effects. I hope future research into DBS for depression bears out these preliminary kinds of findings.

Read the full article: Brain Stimulation for Treatment Resistant Depression

The Second Annual Summit on Behavioral Telehealth: Technology for Behavior Change & Disease Management is June 2-3, 2008 at Harvard Medical School in Boston, Mass. Psych Central is proud to be a supporting publication for this event, and we encourage our readership that’s interested in getting an update on what’s going on in “behavioral telehealth” (e.g., mental health and technology) to register today. Here’s the full conference brochure and registration form (PDF).

This Summit is designed so that participants will be able to:

• describe how to use telemedicine and other emerging information technologies to support the integration of
  behavioral health into primary care and chronic disease management
• learn how to e-empower health consumers through the design, use, and evaluation of technology-assisted
  self-care
• identify and describe barriers to the spread of telehealth and telemedicine as well as strategies to overcome
  these barriers
• describe the impact of depression on productivity in the workplace and discuss approaches to address this
  problem

I will also be hosting a panel discussion during the conference, details below:

SESSION 4.3: PANEL DISCUSSION: SOCIAL NETWORKING AND HEALTH

With the popularity of social networking sites like MySpace and Facebook, companies have turned their eyes toward healthcare and patients. How can patients fully participate on these sites and still protect their privacy? Who owns their shared data and experiences, and can they ever be removed? How do such sites enable patients to find others like themselves, to share experiences and knowledge about their disorders? And how can such social networking sites point us to the future by becoming early warning systems for adverse drug events or identifying the downsides to the newest fad or experimental treatments? This panel will examine these questions and demonstrate some of the emerging social networking sites for health and behavioral health concerns.

Moderator:
John M. Grohol, PsyD, CEO & Publisher, PsychCentral.com

Panelists:
Enoch Choi, MD, Product Manager, MedHelp.org & Family Medicine Physician, Urgent Care Department, Palo Alto Foundation Medical Group
Nathan Cobb, MD, Research Fellow, Tobacco Treatment and Research Center, Massachusetts General Hospital & Harvard Medical School
Jeana Frost, PhD, Research Scientist, PatientsLikeMe
Benjamin C. Williams, CEO, Firefly Health (CarePlace)

I think it’s going to be a great panel discussion and am looking forward to it!

If you plan on attending the summit and would like to meet for lunch one day, I’ll be happy to do so… Leave a note in the comments, or email me.