Tag Archives: depression

Not This Life, Dear — I Have a Headache

A headache specialist's meeting doodle - is this picture worth a thousand words?

A headache is a mighty pain

That changes the defenseless brain,

It may go away.

It may come and stay.

Or rear again, again, and again.

Maybe not great poetry.

But certainly a statement – especially when we assume the author is a headache specialist.

I found this poem on a note pad left in a lecture room between sessions at the annual meeting of the American Headache Society, right after a talk on the genetics of migraine.

After a  lecture on the increased incidence of migraine in young soldiers with posttraumatic stress disorder, I found another note pad. This one depicted a stick-person, helplessly splayed across a tangled spider’s web.

Both, I think, represent the feeling of frustration that bonds headache specialists with their patients.

“We know what can turn it on, but how do we turn it off? That’s the question,” said Dr. Till Sprenger of the University of California, San Francisco. “We still don’t know.”

Headaches unremitting in the face of any treatment strategy are by no means a rarity. Medicines that benefit one may be useless to another. And drugs that can help can also hurt.

Almost anything used for a headache, from acetaminophen to opioids, can backfire if used often enough. Medication-overuse headaches are harder to treat and can start a cycle of using more and more drugs that become less and less effective. Triptans, the mainstay for many migraine patients, are most successful when used at the earliest signs of a headache. But they’re expensive, up to $32/dose, and most insurance companies impose a monthly limit. To save their pills for their worst moments, patients delay the dose, trying to figure out how bad the headache will be. The longer they wait, the less effective the medication.

The physicians at the American Headache Society know this. A number of speakers expressed frustration, not only at their inability to really help some patients but also at the still-rudimentary understanding of headache etiology – the only foundation upon which more effective treatments can grow.

The doctors at this meeting were a sympathetic lot or, perhaps more accurately, an empathetic lot. About half of the physicians I chatted with during breaks and in interviews said their own chronic headaches motivated them to specialize in treating others. They described their job as a mix of satisfaction and exasperation – because they know all too well the blessing of pain relief, the fear of impending pain, and the panic of unremitting pain.

Studies back up my very nonscientific observation of headaches among those who treat them. The most recent appeared in Headache, the American Headache Society’s own journal. It suggested that up to 40% of neurologists who treat headache suffer with their own.  Another 2010 study on migraine management noted that 48% of the  neurologists surveyed were themselves migraineurs.

While there no patients spoke at this meeting, Dr. Dawn Buse became their voice. Despite continuous evolution in headache medicine, her study showed that many continue to suffer.

“Forty percent have at least one unmet need regarding their headaches,” said Dr. Buse of the Montefiore Headache Center, New York.  The top reasons for continued problems? Dissatisfaction with current treatment. Continuing headache-related disability. Overuse of opioids or barbiturates. Other issues that presented in the survey were excessive visits to the emergency department or urgent care center and cardiovascular disorders, which can turn physicians off to the idea of a triptan-based migraine program.

The literature is replete with data confirming what headache physicians confront every day – migraine and other cephalgias worsen almost every quality of life measure.

A 2009 meta-analysis, coauthored by Dr. Buse and Dr. Richard Lipton, past president of the AHS, perfectly captured headache’s often all-consuming impact. Patients with a high headache burden “had higher lifetime rates of depressive disorders, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, specific phobias, and suicide attempts than controls, were more likely to have missed work in the preceding month, to assess their general health as ‘fair’ or ‘poor,’ and to use mental health services.”

The relationship between headache and mental disorders is a complex one, not entirely understood, Dr. Buse told me during an informal chat. She likened it to the famous chicken-or-egg conundrum. “There is some evidence of bidirectionality – that each one predisposes to the other,” she said. “But if you think about it, it makes intuitive sense. If you are afraid of your next headache, you’re likely to be anxious,” which makes a headache more likely and can increase its severity.

The same thing goes for depression, she said. The neurotransmitter dysfunction associated with depression may predispose to headache, but months – or years – of intermittent pain very probably increase the risk of becoming depressed.

It was easy to see the concern in her eyes, and the caring of everyone who spoke at the meeting. Many of them, I suspect, have seen the doodle come to life …  Caught in that spider’s web, knowing that something bad is coming, but having very little power to stop it.

– Michele G. Sullivan

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Video of the Week: Time to Get Rid of the Addiction Stigma

The National Institute on Drug Abuse (NIDA) has launched of its Addiction Performance Project – a CME program designed to help primary care providers break down the stigma associated with addiction. The program includes dramatic interpretation of a family’s struggle with addiction — the third act of Eugene O’Neill’s “Long Day’s Journey Into Night” —  followed by a dialogue among participants aimed to foster compassion, cooperation, and understanding for patients living with this disease.

Of the 23.5 million patients who needed specialized treatment for a drug or alcohol problem in 2009, nearly 90% had not received it. Research suggests that primary care providers could significantly help reduce drug use, before it escalates to abuse or addiction. However, many express concern that they do not have the experience or tools to identify drug use in their patients, according to NIDA press release.

Our reporter Naseem Miller talked with NIDA director Dr. Nora Volkow about the need for this program.

We’re trying to generate empathy, as opposed to the stigmatized reaction that a lot of people get with drug addiction … There is still significant stigma on addiction in health care — whether it’s primary care physicians or specialized physicians.

 

To learn more about the the program, read the story in Internal Medicine News.

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Video of the Week: Is Psychiatry Ready for Deep Brain Stimulation?

A panel of experts at the the annual meeting of the American Association for the Advancement of Science said that preliminary research into the use of deep brain stimulation (DBS) has shown promise for the treatment of a number of psychiatric disorders, including depression and obsessive-compulsive disorder.  Despite the possibilities that treatment with DBS may offer, caution is needed, according to Dr. Benjamin Greenberg of Brown University, who spoke with our reporter Esther French.

My strong advice would be that psychiatrists first need to think about whether they’ve really exhausted all conventional treatments … and there are a lot of treatments that one could potentially use, including one thing that is often neglected, which is residential behavioral therapy.

Dr. Greenberg estimates that it takes about 5 years to exhaust all other treatment possibilities but at that time, DBS becomes a treatment option.  DBS is currently used with success to treat movement disorders.

Be sure to check out our newest Web site, Clinical Psychiatry News, for the latest psychiatric medicine news.

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Video of the Week: Dealing With Suicide

For psychiatrists, dealing with suicide comes with the job. 

The nature of our work is such that we do look after people with serious mental illnesses.  It’s known that somewhere between 85% to 95% of people who die by suicide have been living with some type of psychiatric illness, whether it’s been treated or not.

– Dr. Michael F. Myers

While at the annual meeting of the American Society of Suicidology, reporter Damian McNamara talked with Dr. Michael Myers (SUNY-Downstate Medical Center) about how psychiatrists can cope with the suicide of a patient or colleague.  His first piece of advice: Don’t isolate.

For more great videos and the latest medical news, check out our new Internal Medicine News Web site.

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Tears When a Patient Takes the Podium

From the annual meeting of the American College of Obstetricians and Gynecologists.

Mary Jo Codey (Photo courtesy of Robert Menendez Senatorial Office.)

When physicians invite patients who have become advocates to speak at medical conferences, there’s usually a good reason. I’ve learned a lot from hearing a panel of intersex people speak at a meeting of psychiatrists and psychologists, and I’ve always been moved by hearing people who are living with HIV and AIDS address physicians, whether in small grand rounds or at the International AIDS Conference.

My jaded professional demeanor was blown apart, though, when I heard Mary Jo Codey speak this week. My eyes teared up. The eyes of physicians all around me teared up. When she finished, thousands of ob.gyns. in the auditorium gave her a standing ovation.

Codey, an elementary school teacher who loved children, suffered postpartum depression with both of her two pregnancies. She described the agonizing ordeal she went through before she was diagnosed, the multiple failed antidepressants and electroshock therapy, the judgmental attitudes that made her blame herself, the desire to hurt her baby, the desire to kill herself.

“Nothing that has happened in my life was worse, not even breast cancer and a double mastectomy. They can’t even compare,” she said. Finally, treatment with a monoamine oxidase inhibitor restored her mental health. When her husband later became governor of New Jersey, she launched a statewide campaign to raise awareness about postpartum depression and to improve education and resources on the subject.

The president of the American College of Obstetricians and Gynecologists, Dr. Gerald F. Joseph Jr., has made postpartum and perinatal depression part of a “presidential initiative” that included release last fall of a joint report with the American Psychiatric Association on Management of Depression During Pregnancy. In early 2010, the College also released a committee report on screening for depression during and after pregnancy.

By focusing the entire opening plenary session of the annual meeting on this topic, he sent a message about the importance of getting ob.gyns. to wrap their minds around the issue of postpartum depression. And by having Mrs. Codey speak, he guaranteed that they wrapped their hearts around it, too.

—Sherry Boschert
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Sex Differences Poorly Understood

From a workshop on sex differences and their implications for translational neuroscience research, sponsored by the Institute of Medicine.

Sex, sex, sex. That’s all they talked about at this day-long workshop in San Francisco, and it was more interesting than you might think. (Or maybe not, depending on what you’re expecting…)

Researchers from basic scientists to clinicians decried how too few studies look at sex — as in the differences between males and females (not sexuality or sex behaviors). The terminology is important, and they clarified up front that the topic of the day was sex, not gender.

Surprisingly, that clarification prompted one of the speakers to change her terminology on the fly. (She had been planning to refer to sex differences as gender differences.) That, as much as anything I heard that day, showed me how far the scientific and medical communities have to go to get the topic of sex differences front and center. In fact, the Institute of Medicine convened the workshop to assess progress since it called for more research on sex differences in its 2001 report, “Exploring the Biological Contributions to Human Health: Does Sex Matter?” (National Academies Press).

Why is this important? Although the impetus for better understanding of sex differences largely has come from proponents of improving the health of women (who long have been under-represented as research subjects), the lack of attention to biological differences between the sexes hurts both men and women.

Just one example: After more than 100 rodent studies showed that dextromethorphan (a common ingredient in cough syrups) potentiated the analgesic effects of morphine, a drug company launched a clinical trial in humans on treating chronic pain with the drug combination. It bombed. The company abandoned the formulation.

But a review of rodent studies in general found that 87% used only male rodents, didn’t specify the rodent sex, or didn’t assess sex differences in the few studies that included female mice or rats. Jeffrey S. Mogil, Ph.D. of McGill University’s Centre for Research on Pain, Montreal and his associates discovered that the potentiating effects of dextromethorphan on morphine work only in male rodents. Because the drug company’s clinical trial of the combination didn’t assess differences in response by sex, it may have abandoned a drug that might have effectively treated chronic pain in men, if not women.

At the workshop, fascinating talks described some of the progress made in studying sex differences in stroke, depression, pain and pain perception, sleep medicine, multiple sclerosis and neuroinflammation, and more. It was clear we’ve only uncovered the tip of the iceberg.

From the start, participants acknowledge an elephant in the room — politics. Ever since 2005, when then-president of Harvard University Lawrence H. Summers drew intense public criticism for what one workshop participant called “unfortunate wording” about sex differences, researchers have felt a chilling effect on public discussion about sex differences. The workshop attendees (many — perhaps even most — of whom were women) see it as just one more obstacle that must be overcome.

Physicians who may wonder what they can do to stay up to speed on consideration of sex differences can take an online course (for Continuing Medical Education credits) created by the National Institutes of Health and the Food and Drug Administration: The Science of Sex and Gender in Human Health.”

– Sherry Boschert (@sherryboschert on Twitter)
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Falls: The Humpty Dumpty Hypothesis

Image via Flickr user aturkus by Creative Common License

From the International Conference of Pediatric Psychological Trauma in Infants & Young Children in Los Angeles

Humpty Dumpty sat on a wall,

Humpty Dumpty had a great fall,

All the King’s horses and all the King’s men,

Couldn’t put Humpty together again.

Serious falls are among the most common injuries to children, representing 52% of injuries in infants and 43% of injuries in children aged 1-4, according to recent figures from the Centers for Disease Control and Prevention. Fortunately, most children who fall can be physically put together much better than hapless Humpty Dumpty, but new findings from Duke University suggest that their psychological sequelae may be harder to heal.

Dr. Helen Link Egger of the Center for Developmental Epidemiology in the Department of Psychiatry and Behavioral Sciences reported that preschool children (ages 2-5) who suffer any injury serious enough to require medical attention were 2.7 times more likely to meet criteria for separation anxiety disorder, based on findings of a longitudinal study of 666 children.

Those who suffered a fall were also 5.8 times more likely to meet criteria for depression.

“Now that’s a big odds ratio,” she said, explaining that the data translated into nearly 1 in 5 children who had fallen.

In well over half — 58%, the fall occurred prior to any depressive symptom.

The powerful link to depression was not seen in children who had endured other traumas, such as serious illnesses or injuries that required hospitalization. 

The chicken-and-egg question, which Dr. Egger said requires urgent research, is whether the falls themselves or the circumstances leading to the falls are most salient with regard to associations with depression.

“Are these children with depressed mothers? Children living in a household where no one is looking out for them?”

Even if it takes all of the King’s horses and all of the King’s men, it’s something we need to find out. 

—Betsy Bates
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