Category Archives: Psychiatry

Counties Pursue Safer Drug Disposal

New programs to make it easier and safer for San Francisco Bay Area residents to get rid of unused medications are some of the first to try this on a large scale, and may serve as models for other cities and counties.

Since May 2012, a pilot program in San Francisco has allowed residents to drop off old medications at 13 pharmacies and 10 police stations (where controlled substances must be brought). San Francisco supervisors initially considered forcing drug companies to fund the program, and instead agreed to accept $110,000 from Genentech and the Pharmaceutical Research and Manufacturers of America to fund the program.

(Photo by J. Troha, courtesy of National Cancer Institute)

On July 24, supervisors in Alameda County (which includes East Bay cities such as Oakland and Berkeley) are likely to approve a Safe Drug Disposal Ordinance that would require drug companies to pay for disposal of their products or face fines of up to $1,000 per day, The Bay Citizen reports. Public agencies currently fund 25 drug disposal sites there, and the cash-strapped county wants the comparatively wealthy pharmaceutical industry to take more financial responsibility for the lifecycle of its products in order to reduce overdoses, accidental poisonings, and water pollution.

As we reported earlier this year, making prescription-drug “recycling” a cultural norm is one of five emerging public policies that could help the medical system keep opioids available while reducing the risk of addiction, abuse and accidental overdose, according to Keith N. Humphreys, Ph.D. Smaller versions have met with success, such as a drug take-back day organized by sheriffs in a small town in Arkansas (population 20,000) that brought in 25,000 pills, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He reports having no financial conflicts of interest on this issue.

Not everyone is happy with the idea. Trade associations for the pharmaceutical industry and biomedical companies argue that there’s no evidence that these programs will reduce poisonings, and they haven’t ruled out the possibility of suing to block the Alameda County ordinance, The Bay Citizen reports. The compromise that San Francisco reached for voluntary instead of mandatory funding from the pharmaceutical industry may be a middle ground.

In an era when government agencies have less and less money for public programs, it’s probably inevitable that they’ll pursue alternative financing for programs like this.

If your community has a drug disposal program, let us know how it’s working. Will these programs succeed, and will they reduce abuse, addiction, and accidental overdoses? We’ll keep an eye on this topic, and keep you posted.

–Sherry Boschert (@sherryboschert on Twitter)

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“Turning the Tide” on HIV/AIDS

In advance of the upcoming XIX International AIDS Conference, the International AIDS Society and the University of California, San Francisco, have issued the “Washington D.C. Declaration,” a nine-point action plan aimed at broadening global support for “Turning the Tide” of the AIDS epidemic.

Everyone is urged to sign the Declaration.

It calls for:

1) An increase in targeted new investments;
2) Evidence-based HIV prevention, treatment, and care in accord with the human rights of those at greatest risk and in greatest need;
3) An end to stigma, discrimination, legal sanctions, and human rights abuses against those living with and at risk for HIV;
4) Marked increases in HIV testing, counseling, and linkages to services;
5) Treatment for all pregnant and nursing women living with HIV and an end to perinatal transmission;
6) Expanded access to antiretroviral treatment for all in need;
7) Identification, diagnosis, and treatment of tuberculosis;
8) Accelerated research on new tools for HIV prevention, treatment, vaccines, and a cure;
9) Mobilization and meaningful involvement of affected communities.

Turning the Tide is the theme of this year’s biennial conference, which will take place July 22-27 in Washington.  It is expected to draw 25,000 attendees, including HIV professionals, activists, politicians, and celebrities. Sir Elton John will open the conference and Bill Clinton will close it. A large delegation of U.S. members of Congress will participate, and Bill Gates will moderate a session. An enormous “Global Village” outside the D.C. Convention Center will be open to the public. “If you haven’t been, it’s a conference like no other,” conference cochair Dr. Diane V. Havlir said at a press briefing.

The recent optimism regarding HIV/AIDS stems from major advances in knowledge regarding prevention of partner transmission with early patient treatment, pre-exposure prophylaxis, and male circumcision as HIV infection prevention (new data will be released at the meeting), all of which are viewed as breakthroughs  in the fight against HIV/AIDS. “So we have now in our hands the tools. The question is how do we combine those tools together, and how do we roll them out,” said Dr. Havlir, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS division at San Francisco General Hospital.

Dr. Diane V. Havlir / Photo by Miriam E. Tucker

Monday’s plenary session will include an address from Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, on “Ending the HIV Epidemic: From Scientific Advances to Public Health Implementation.” Other plenary topics during the week will include viral eradication, vaccines, TB and HIV, and HIV/AIDS in specific populations including minorities, women, youth, and men who have sex with men. On Friday, there will be a plenary talk that may be of particular interest to the primary care community, “The Intersection of Noncommunicable Diseases and Aging in HIV.”

Plenaries and other conference sessions will be webcast at http://globalhealth.kff.org/aids2012.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Focus Shifts from Children’s Self-Esteem To Self-Control

The child-rearing meme of self-esteem is being replaced by self-control. Well-intentioned efforts to promote children’s self-esteem in recent decades too often produced empty praise and, some argue, an epidemic of over-indulgence.

(Courtesy Wikimedia Commons/Dave Hogg/Creative Commons License)

Among physicians and therapists who counsel parents on effective child-rearing, “These days, self-esteem is out, self-control is in. In terms of concepts, we don’t talk about self-esteem any more,” says Laura Kastner, Ph.D.

Self-control is “a very powerful concept right now and, of course, is an important part of executive functioning,” she said at the annual meeting of the North Pacific Pediatric Society. “It’s not that self-esteem is not important, it’s just very imprecise as a measure.”

Measuring children’s self-control (ability to delay gratification, control impulses, and modulate expression of emotion) not only is easier and more precise, but it is producing important findings in longitudinal studies, added Dr. Kastner of the University of Washington, Seattle. She’s also co-author of the book “Getting To Calm: Cool-Headed Strategies for Parenting Tweens and Teens” (Parent Map 2009).

Children with “undercontrolled temperament” at age 3 were more than twice as likely to show evidence of a gambling disorder as adults at ages 21 and 32 compared with those who were well-adjusted at age 3, according to an analysis of data from a large, 30-year prospective cohort study in New Zealand (Psychological Science 2012;23:510-516).

The degree of childhood self-control predicted the likelihood of physical health, substance dependence, sound personal finances, and criminal records, another analysis of the cohort found (Proc. Natl. Acad. Sci. U.S.A. 2011;108:2693-2698).

Dr. Laura Kastner (Sherry Boschert/IMNG Medical Media)

Dr. Kastner said studies of this longitudinal data have shown that among the 20% of people with the lowest self-control as children, more than 40% had criminal records as adults, compared with criminal records for less than 15% of the 20% of people with the highest childhood self-control. Approximately 10% of the lowest self-control group was dependent on several drugs as adults, compared with less than 5% of the highest self-control group. Multiple health problems were reported by nearly 30% in the lowest self-control group compared with just over 10% of the highest self-control group. An annual income under $20,000 NZ (the equivalent of roughly $15,400 in U.S. dollars) was reported by more than 30% in the lowest self-control group and 10% of the highest self-control group.

The self-control meme is spreading rapidly, with books and articles exploring what it means and cultural differences in child-rearing. For one good example, see The New York Times article “Building Self-Control, the American Way.”

It remains to be seen whether interventions to help parents help their children to develop self-control will improve their lives later on.

–Sherry Boschert (on Twitter @sherryboschert)

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Teens with Eating Disorders Try Yoga

If the thought of yoga doesn’t bring to mind long-haired, half-naked gurus in India, it probably makes you think of thin young people in pretzel poses. True that, but it’s also become popular among populations that you might not expect. Yoga increasingly is being incorporated into treatment programs for young people who may be too thin or too fat – adolescents with eating disorders.

Yoginis relax and stretch. (Courtesy Wikimedia Commons/zivpu/Creative Commons License)

Dr. Cora C. Breuner helped conduct a study of 50 girls and 4 boys with diagnosed eating disorders. Participants were randomized to treatment with standard care (every-other-week appointments with physicians or dieticians) or standard care plus individualized yoga for 12 weeks. The yoga group showed significantly reduced food preoccupation immediately after each yoga session and significantly decreased Eating Disorder Examination scores at 12 weeks (J. Adolesc. Health;2010;46:346-51).

Speaking at the annual meeting of the North Pacific Pediatric Society, she gave a brief update: the teens in the yoga group showed greater improvements in weight a year after the study ended compared with the control group.

Dr. Cora C. Breuner (Sherry Boschert/IMNG Medical Media)

“Pretty much every eating disorders unit in the country now has yoga,” said Dr. Breuner, professor of pediatrics at the University of Washington, Seattle.

I don’t know about every eating disorders program, but a quick look on the Web found plenty that include yoga and lots of independent yoga classes geared toward people with eating disorders. On this list of eating disorder treatment programs from EDreferral.com, for example, yoga is mentioned by nine facilities in California and one each in Arizona, Hawaii, Mississippi, New Jersey, Pennsylvania, Tennessee, and Virginia. I found others online in Michigan and Washington, too, with just a few clicks.

Dr. Breuner’s 2010 study isn’t the only one endorsing yoga for eating disorders. Here’s another (Psychology of Women Quarterly 2005;29:207-19). Columbia University reported on this trend in 2007. And the Wall Street Journal reported in 2011 on increasing use of yoga not only for kids with disorders but for healthy students, under the clever headline, “Namaste. Now Nap Time.”

Some of the key goals of yoga are to strengthen the mind and body and the connection between the two. It’s not a solo treatment for eating disorders, but it supplements the standard strategies of weight stabilization, nutrition therapy, cognitive behavioral therapy, and family-based therapy.

That last one is another big change in the field that has happened since Stanford University researchers began showing in 2007 that it’s very helpful in treating children and adolescents to use parents as agents for positive change in a non-judgmental manner.

“Now we bring parents in right away to help with refeeding the child,” Dr. Breuner said.

It’s only a matter of time, I suspect, until we see special yoga classes for parents of children with eating disorders.

–Sherry Boschert (on Twitter @sherryboschert)

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The Jewish Doctor, Examined

The rich tradition of Jewish involvement in the medical profession is the subject of an exhibit now showing at New York’s Yeshiva University Museum. Trail of the Magic Bullet: The Jewish Encounter with Modern Medicine, 1860-1960 explores the social, cultural, religious, and scientific aspects of that relationship during the era of modern medicine.

Dr. Paul Ehrlich / Photo taken by Miriam E. Tucker with permission from Yeshiva University Museum

The exhibit’s title references Dr. Paul Ehrlich’s “magic bullet” salvarsan, the syphilis cure he discovered that was used until penicillin became available in the 1940s. One of five Jewish physicians profiled, Dr. Ehrlich (1854-1915) won the Nobel Prize in 1908 for his “Side Chain” theory, which helped explain how antibodies neutralize invaders. Born in Germany, Dr. Ehrlich never renounced his Judaism despite experiences with anti-Semitism.

Jews were often unwelcome in established areas of medicine such as surgery, so they embraced newly-emerging specialties including psychiatry, neurology and dermatology, according to the exhibit. In Germany, dermatology was called Judenhaut, or “Jews’ skin,” and psychoanalysis was known as the “Jewish Science.” A wall of the exhibit honors 28 Jewish pioneers in these fields, including psychoanalysis founder Dr. Sigmund Freud (1856-1939).

Another section illustrates the Jewish community’s role in establishing hospitals such as Newark (NJ) Beth Israel Hospital in 1924, as well as public health-oriented social service organizations and visiting nurse programs in the United States and abroad. While these institutions were founded to aid underserved segments of the Jewish population, they evolved to serve entire communities of Jews and non-Jews.

“Miss Beth” solicits funds for Newark Beth Israel Hospital in 1924 / Photo taken by Miriam E. Tucker with permission from Yeshiva University Museum

Discrimination and quotas, widespread nationwide until the 1950s, are addressed toward the end. One of several abhorrent displayed quotes is attributed to 1920-1935 Yale Medical School Dean Dr. Milton Charles Winternitz, addressing his admission committee: “Never admit more than five Jews, take only two Italian Catholics, and take no blacks at all.” Albert Einstein College of Medicine was founded by Yeshiva University as the first American medical school established under Jewish auspices, specifically with the aim of helping prospective Jewish medical students bypass such restrictions.

Magic Bullet ends with a modern examination of medical ethics from a Jewish perspective. A 15-minute film entitled Heal, You Shall Heal features physicians, rabbis, ethicists, and patients offering perspectives on genetic testing/pregnancy termination in the case of abnormality and end-of-life decisions. Rabbi Daniel S. Nevins, a dean at the Jewish Theological Seminary, says this: “As much as modern medical technology has given us a sense that we understand what is going on with the birth and death process, the truth is that these are moments of great mystery. It’s important for us to be humble in such moments.”

Trail of the Magic Bullet: The Jewish Encounter with Modern Medicine, 1860-1960 runs through Aug. 12, 2012.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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A Younger Kennedy’s Mental Health Crusade

Patrick J. Kennedy is no longer in Congress, but he’s still campaigning passionately on behalf of mental health. In a plenary talk at the annual meeting of the American Association for Geriatric Psychiatry (AAGP), the former democratic congressman from Rhode Island described his recent mission: An organization he founded called One Mind for Research, which “brings together the science, technology, financial resources, and knowledge required to create an unprecedented understanding of brain disease.” Its goal is to increase the investment in research by $1.5 billion each year for the next 10 years and to achieve a minimum 10% reduction in the cost of brain disease per year.

Courtesy of AAGP

The initiative was launched last May 25th on the anniversary of his uncle John F. Kennedy’s “Moonshot” speech, at the suggestion of his cousin Caroline. He said he told her at the time, “Great, instead of going to outer space, we’ll go to inner space!”

On a more serious note, Mr. Kennedy drew a parallel between President Kennedy’s focus on civil rights as a moral issue and the cause of the mentally ill, telling the audience of psychiatrists “What you all do in the field of mental health is to help lessen the marginalization of too many Americans…I think we have a historic opportunity now, with the implementation of the Mental Health Parity Bill and the [Affordable Care Act] to break down the segregation of mental health from overall health.”

Referencing his own struggles with substance abuse, depression and bipolar disorder and his role in Congress as chief sponsor of the parity bill, Mr. Kennedy decried the current insurance reimbursement system as being “wholly inadequate” for treating chronic mental conditions. “If we treated diabetics the way we treat alcoholics and addicts, we’d be waiting till we were cutting off their toes and they’d lost their eyesight before we paid for treatment,” he said, to applause.

He was equally emphatic regarding the politics involved in securing funding for One Mind’s 10-year plan. “If you consider how much money we put into neuroscience today compared to the burden of [mental] illness, any CEO in the country would be kicked out of their job for not doing enough research…it just doesn’t compute,” he said, again to applause.

He acknowledged there would be challenges. “I can’t tell you we’re going to be successful, but at least I’m going to do my part to see that we try something different.”

The AAGP plenary session was supported in part by an educational grant from Lilly USA, LLC.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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BP to Pay Spill-Related Health Claims

Gulf Coast residents who may have been made sick — or who may become sick in the future — as a result of the April 2010 Deepwater Horizon oil spill may now be able to make a claim against BP. The oil giant announced on March 2 that it had reached an agreement in principle for a settlement with the attorneys representing the thousands of plaintiffs in the massive case.

Overall, the company says it will make almost $8 billion available — about $5 billion will go toward health claims.

Photo by Alicia Ault/IMNG Medical Media

In a sense, it is opportunity No. 2 for the fisherman, shrimpers, restaurant and hotel owners, and hundreds of thousands of others who make their living or just live in the areas affected by the spill. BP had already set aside $20 billion — in June 2010 — to pay mostly economic damage and other direct economic claims.

At that time, there was an outcry about the lack of any dedicated funds to cover mental health issues or physical illnesses that might arise out of the oil spill. I blogged about that here, in an earlier post.

In the almost 2 years since the disaster, BP says it has paid “approximately $6.1 billion to resolve more than 220,000 claims from individuals and businesses” through the trust fund, known as the Gulf Coast Claims Facility. It has been administered by Kenneth Feinberg, not coincidentally, the man who also oversaw the claims process for the Sept. 11 Victim Compensation Fund.

According to lengthy article in the New Orleans Times-Picayune on the proposed settlement, Mr. Heisenberg is now stepping down and another special master will take over administration of the Trust Fund.

The proposed settlement — which will come out of the $20 billion Trust Fund — has one agreement to address economic loss claims and another for medical claims. For those who have a qualifying medical claim, there is essentially a 21-year statute of limitations. It’s likely taking into account that some conditions — such as cancer — may take that long to show up in clean-up workers or others exposed to either the oil or the chemicals used to mitigate the disaster.

BP is also making $105 million available “to improve the availability, scope, and quality of health care in Gulf communities.” The money will cover an expansion of primary care, mental health services, and access to environmental health specialists, according to the company.

If the agreement in principle goes into effect, the plaintiffs who eventually get paid will release BP from future liability claims.

Alicia Ault

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