December 8, 2006
Troubled Children
Off to College Alone, Shadowed by Mental Illness

By LYNETTE CLEMETSON
Her mother called it a negotiable proposition. But to
Jean Lynch-Thomason, a 17-year-old with bipolar
disorder who started college this fall, her mom’s
notion to fly from their home in Nashville to her
campus in Olympia, Wash., every few weeks to monitor
Jean’s illness felt needlessly intrusive.

“I am so totally aware of the control you have over me
right now,” Jean said, sitting in her parents’ living
room one evening last June, before coolly reminding
her mother of her upcoming 18th birthday. “In a few
months the power dynamic is going to be different.”

For Chris Ference, 19, who is also bipolar, the
fast-approaching autonomy of his freshman year held
somewhat less appeal. His parents had always directed
every aspect of his mental health care. Last summer,
over Friday night pizza at his home in Cranberry
Township, Pa., he told them that assuming control felt
more daunting than liberating.

“If it was up to me, I would just have it so you could
make those decisions for me up until I was like, 22,”
he said. “I mean, you’ve raised me well up to now. You
know me better than anyone.”

The transition from high school to college, from
adolescence to legal adulthood, can be tricky for any
teenager, but for the increasing number of young
people who arrive on campus with diagnoses of serious
mental disorders — and for their parents — the passage
can be particularly fraught.

Standard struggles with class schedules, roommates,
and sexual and social freedom are complicated by
decisions about if or when to use campus counseling
services, whether or not to take medication and
whether to disclose an illness to friends or
professors.

Keeping a psychiatric disorder under control in an
environment often fueled by all-night cram sessions,
junk food and heavy drinking is a challenge for even
the most motivated students. In addition, the normal
separation that goes along with college requires new
roles and boundaries with parents, the people who best
know the history and contours of their illness.

Like Jean and Chris, young adults approach the move to
a new life differently, some with defiant
independence, some with avoidance. Each approach, say
psychiatrists, counselors, dormitory assistants and
other campus leaders, comes with its own risk. The
students who are most dependent on their parents may
be dangerously unprepared for the inevitable stresses
of college life. On the other hand, students who are
adamant about doing everything on their own may be
afraid to reach out for help when they stumble.

For parents, the anxious pride at seeing children go
off to college is often tinged with fear that their
child might fall apart, spiraling into depression or
becoming suicidal. Are they going to therapy as they
promised? Are they taking the right dose of medication
at the right time? Should they as parents inform the
school that their child has an illness? Is a fight
with a roommate part of a normal transition to college
life or a sign of impending trouble? Does an emotional
e-mail message written at 3 a.m. represent a
transitory moment of turmoil or a reason to get on an
airplane?

Once teenagers legally become adults, which in most
states happens at age 18, they, not their parents,
assume control over decisions about therapy and
medication. If trouble arises, parents may or may not
hear about it because college counselors are bound by
confidentiality when dealing with adult students.

The Trauma of Separation

For Jean, as for many teenagers coping with mental
disorders, just getting through high school was an
ordeal. After experimenting with home schooling, a
high pressure prep school and an outdoor learning
academy geared to nature activities, Jean, a bright
student with inconsistent grades but high SAT scores,
decided to forgo her senior year and find a college
that would take her without a high school diploma.

She was accepted at Evergreen State College in
Olympia, Wash., a nontraditional college of roughly
4,400 students that issues written evaluations in
place of letter grades.

Evergreen’s environmental focus — the campus has its
own organic farm, composting program and a contest for
commuters who bike, walk or carpool to campus — felt
like a good fit for Jean, who is passionately
committed to the environment and social justice.

A consciously quirky teenager who sews her own clothes
(to avoid crass consumerism, she says) and who prefers
bus trips to flying (to avoid contributing to the
pollution caused by air travel), Jean is disarmingly
straightforward and self-aware.

She said she stopped taking medications when she was
14 because the side effects left her feeling “out of
whack and emotionally inauthentic.”

She is determined to stay off medications during
college, and she devoted considerable advance thought
to possible triggers for her illness, like the long
rainy winters of the Pacific Northwest.

“I don’t feel vulnerable about this transition because
this is very much my decision,” she said. “This is a
very autonomous move, very much me structuring my own
life. I feel like I am putting myself in a situation
with really clear intentions.”

Jean’s parents, Amy Lynch, 52, and Phil Thomason, 53,
were hesitant when Jean, the younger of their two
daughters, refused to take medications after eighth
grade. Her childhood and early adolescence had been a
whirlwind of depression, rage and experiments with
different medications and treatments.

But when Jean was about 14, Ms. Lynch and Mr. Thomason
said, she began to seem more stable. Her developing
coping skills, combined with reports about negative
side effects of psychotropic drugs in children,
persuaded them to acquiesce to her demands to ride out
the swings of her illness drug free.

They said they believed Evergreen would be a good
college for Jean. Still, the move — to someplace so
far from home — made them anxious. In the months
before Jean left, Ms. Lynch said she wanted her to go
back on medication to smooth the adjustment to college
life, a suggestion that Jean adamantly rejected.

Ms. Lynch worried that Jean took for granted the tacit
stability of being at home.

When Jean’s depression sets in, she tends to close
herself off from people. At home, Ms. Lynch said, “I
can look at Jean and know in five minutes what’s going
on with her and how to respond to it.”

At such a distance it will be difficult to catch the
signs.

“I feel like we’re doing a high-wire act,” she said,
“and I am not sure we have a strong enough net.”

Rummaging through the accumulated possessions of
adolescence in her bedroom over the summer, Jean
singled out the items that she could not leave
without: her sewing machine, her coffee maker, the
social justice posters that covered her wall.

With her mother out of earshot, she acknowledged that
she understood her parents’ angst. “I get that this is
intense for everyone,” she said. “I do.”

Hesitant to Leave the Nest

The uncertain months between high school and college
were also anxious ones for Chris Ference and his
parents.

Still groggy from an early morning drive to campus,
his husky 6-foot-2 frame jammed into an auditorium
chair in the student union, Chris shifted
uncomfortably as a freshman orientation coordinator
welcomed new students and their parents to the Behrend
College, a Pennsylvania State University satellite
campus in Erie, Pa.

“Today really is the first day of your freshman year
of college,” the cheery administrator told the group
on a June morning more than two months before the
start of fall term.

Chris had initially been reluctant to go away to
college. Though eager to leave the rigid structure and
peer pressure of high school, where he told few
friends about his illness, he preferred the idea of
living at home during college and commuting to an
engineering program in nearby Pittsburgh.

It was his mother, Debbie Ference, a service director
with the southwestern Pennsylvania division of the
National Alliance on Mental Illness, an advocacy
group, who nudged him to move away.

He chose Behrend for its strong engineering program
and small student body of about 3,700.

A boyish and fidgety teenager who likes heavy metal
music, Xbox games and anything having to do with
electronics, Chris said he had given little advance
thought to his new responsibilities in college.

Just days before his orientation, he listened
passively as his father, Michael Ference, and Ms.
Ference talked about his care at school. They wondered
aloud about whether he would be able to continue
seeing his longtime therapist in Pittsburgh, more than
two hours away. They raised the possibility of putting
an advance mental health directive in place, so that
they could be contacted if Chris was ever in crisis
and unable to consent to parental notification.

They discussed how they worried about the possibility
of Chris mixing alcohol with his medications. Chris
huffed in annoyance and told them he was “smart and
moral enough” not to fall into that trap.

The fact that Chris was willing to engage in the
discussion at all was a sign, they said, of progress.

Chris was first hospitalized and received a diagnosis
of bipolar disorder at age 10 after a severe episode
of depression, mania and suicidal thoughts. He was
hospitalized again briefly in sixth grade, after the
lithium that had stabilized him for two years became
ineffective.

But successful therapy and medication since then have
kept the illness at a manageable level. He graduated
from high school with honors, and in his senior year
saw his therapist only every six weeks. A recent
medication adjustment has left him able to feel and
express more than he has in years.

“This whole move is like a coming-out process,” said
Mr. Ference, 50, a service coordinator for families
with autistic children. “Up to now it’s been all
parental motivation. But I think this is a healing
process for him after so many hard years.”

In a 2005 national survey of the directors of college
counseling centers, 95 percent of counseling directors
reported an increase in students who were already on
psychiatric medications when they came in for help.
While universities grapple with how to serve the
growing number of students with mental disorders,
students are taking the initiative by helping one
another.

Active Minds, a student-led mental health advocacy
organization founded in 2001 at the University of
Pennsylvania, now has 56 chapters at schools including
Georgetown University, Columbia University, the
University of South Florida and the University of
Maryland.

The National Alliance on Mental Illness has 30 campus
affiliates, with 18 more in formation, groups that are
set up as student clubs and are financed by school
activity budgets and fund-raisers. Programs like the
Jed Foundation, a suicide prevention program, and
National Depression Screening Day, held each October,
offer additional resources.

While the overall message from the groups and programs
focuses on the potential for success, students who
have been through the transition of leaving home for
college say it is also important to be honest about
the challenges.

Difficult Experiences

Stacy Hollingsworth, an honors student at Rutgers
University who suffers from major depressive disorder,
dropped out of college in the fall semester of her
sophomore year after the routine aspects of college
life left her so incapacitated that she became
suicidal and was hospitalized.

At home in Old Bridge, N.J., she could retreat to the
isolation of her bedroom when she was depressed — an
impossibility in her crowded dormitory. The staggered
class schedule left her lacking a dependable rhythm.
Even getting dressed and walking to the cafeteria
became an insurmountable task.

“I was in excruciating pain. I couldn’t breathe,” she
said.

Though she had been suffering from depression since
her early teens, she hid her struggle from family and
friends. She sought counseling help for the first time
in college, but still could not cope.

After a two-year absence and the loss of $15,000 in
state scholarships, Ms. Hollingsworth, now 22, is back
at Rutgers finishing her degree in exercise physiology
and psychology. She is founder of the Rutgers’
affiliate of the National Alliance on Mental Illness,
one of the organization’s newest student chapters.

At 37, Robert C. Haggard III, who three years ago
founded a chapter of the same organization at Washburn
University in Topeka, Kan., is still working on his
bachelor’s degree in studio art.

During his first attempt at college, right out of high
school, Mr. Haggard said, “I wasn’t honest with myself
that I needed assistance.”

He tried to blunt the increasing severity of his
bipolar disorder with alcohol, a common tactic for
students with psychological disorders, experts say.

He was on academic probation when, in 1992, he
withdrew from school. He struggled though several
jobs, a variety of medications, and a suicide attempt
at age 29 before he started to get his condition under
control.

It has only been within the past four years, he said,
that he has gained stability. “I study during the day,
sleep at night, eat right and maintain a lot of
structure and routine,” he said. “It sounds simple,
but it can be a hard place to get to.”

Dr. Richard Kadison, chief of mental health services
at Harvard, said there were things students with
mental illness could do before starting college to
increase the chances of a manageable transition.

Most important, he said, is establishing local health
support on or near campus. Maintaining a relationship
with a counselor from home can be helpful, but “you
don’t want to end up in an emergency talking to
someone at school that you have never laid eyes on,”
Dr. Kadison said.

Last-Minute Worries

After the opening session of freshman orientation at
Behrend College back in June, Chris Ference
disappeared into a pack of students to begin selecting
his classes.

His mother headed in the opposite direction and
wandered into a session on student support networks
led by Sue Daley, the director of the counseling
office. She listened intently as the counselor talked
about problems students had encountered in recent
years.

She winced when the counselor related the story of a
young woman who had a psychotic episode the previous
year, during which she ripped tiles from her dormitory
room ceiling because she believed the F.B.I. was
monitoring her.

“We sent her home so she could get her emotional self
together,” Ms. Daley told the group.

After the session, Ms. Ference complained that it
sounded as if the goal of the counseling center was to
get the “crazy kids” out of the way.

“I was offended by that,” she said to Ms. Daley. “I
want to be comfortable enough with this school that I
know you will take care of my son.”

In the car on the way home from the campus visit, Ms.
Ference mentioned her discomfort with the counseling
presentation.

“We definitely have to put some outside counseling
support in place, just in case you don’t like it
there,” she said to her son.

Looking through his thick pamphlet of brochures from
the day, Chris responded, “Hey, we get a discount on
computers and iPods!”

Ms. Ference took a hand off the steering wheel to rub
at the stress headache pulsating at her temple.

About the same time in June at Bongo Java, a trendy
coffee shop near her home in the Belmont-Hillsboro
section of Nashville, Jean Lynch-Thomason pulled out a
tattered journal, held together with silver duct tape.
A picture of herself in the third grade, taped to the
cover of the thick diary, stared back at her as she
gathered her thoughts.

As she prepared for college, she had been writing in
the journal several times a day.

More pensive than during the previous meeting when she
matched wits with her parents about her desired
independence, Jean confessed that she had been
thinking quite a lot about her move in the fall.

“There is a lot more fear and anxiety about this
transition than I am letting on,” she said. “We can
set up all the protective measures we want and still
there is just no way to tell what is going to happen,
and man, that’s hard.”

She remained determined not to let her mother fly out
to Washington to check on her. And she resolved to
limit her own trips home, to cut down on unnecessary
air travel.

But she said she felt confident that she had done the
most optimal planning possible. She had decided to
have an apartment by herself so that she could prepare
her own vegan meals. Living alone, she said, would
also afford her the privacy to sleep well and have the
solitude she craves when her depression sets in.

That solitude, she added, might be a double-edged
sword in a new environment where she would be more
reluctant to engage with people during dark periods of
depression.

“I am in a good, copacetic place right now,” she said.
“But I also know that there is every possibility that
things could go bad. I just sort of feel like if I get
out there and don’t do well, then I am letting
everyone down.”

Back at home soon after, she breezed past her mother,
confident as ever.

A New Perspective

Three months after arriving on campus, Jean’s anger at
her parents’ concern seems to have receded. Her
mother’s hotly debated first visit came and went in
October. There were no confrontations over medication,
no accusations of heavy-handedness.

Mother and daughter said little at all, in fact, about
the illness that has so defined their lives, and their
relationship, choosing instead to ride bikes, work at
a free store for the needy, and play in a fountain one
night in the center of downtown.

“I’m more settled, I guess,” said Jean, who will turn
18 next week. She was surprised that she so enjoyed
the visit. “I was in a good place. She was in a good
place. My illness just didn’t particularly seem
relevant.”

Some ideas that had made sense in the abstract — like
living alone — felt unwise after she arrived in
September and looked at a few apartments. When a
friend from Tennessee offered her a tiny crawl space
of a room in an overcrowded home he shared with
several other students off campus, Jean said it felt
just right.

“It’s not like I’m going up to people saying, ‘Hi, I’m
Jean, I’m bipolar,’ ” she joked. “But I’m surrounded
by beautiful supportive people, and I know if I need
it, they will call me out.”

She has maintained sessions by telephone with her
therapist back home every two weeks. But she has also
met people at the campus counseling center. She said
she liked that they encouraged holistic as well as
purely medical approaches to treatment, and that she
would not hesitate to seek help there if the need
arose.

Back in Nashville, Ms. Lynch said she may have
underestimated her daughter’s ability to make good
decisions for herself. The lushness and environmental
consciousness of Evergreen and the surrounding area
seemed to have a stabilizing effect on Jean, she said.
There was not a trace of the early signs of mania or
depression that Ms. Lynch could usually spot in her
daughter well before others.

She said she had decided not to raise the issue of
medication again. For now. “I may have a different
answer a few months from now,” she said. “But what I
know today is that she seems to have learned a lot
about coping. And that’s how we get through this, by
what we know any given day.”

Chris Ference has also changed since he packed his
things and left home in late August. Sitting on the
bed in his dorm room, sounding more mature than he had
a few months earlier, he said the transition was
smoother than he had anticipated.

But he was still working out some of the particulars
of dealing with his bipolar disorder. He told his
roommate about his illness in mid-October, only
because a reporter was coming to their room for an
interview.

“It’s cool. He’s cool. It’s fine,” he said, with a
hint of wariness. “It’s probably good for him to know
anyway, so he can understand it, in case I ever need
him to help me out.”

Discreetly taking his medications in a dorm room
typically crammed with engineering students until the
wee hours of the morning is also a challenge. In an
effort not to draw attention to himself, he said, he
takes his two medications late at night, right before
he lays his head down to sleep. If anyone notices,
they have not let on.

He and his mother met with Ms. Daley, head of the
counseling center, before school started. After the
unpleasant encounter at summer orientation, Ms.
Ference wanted some assurances that the school’s
services were adequate. She left satisfied, she said,
and Chris seemed comfortable enough with the
counseling center to go there if he needed to.

Chris said he doubted he would need help from Ms.
Daley or anyone else at the center. He has friends and
is playing guitar in a band, he keeps his partying
“under control,” and he loves his engineering classes.

He is under no illusions about his illness, he said.
He knows it will be something that he has to learn to
manage throughout his adult life.

“But things are just going so good,” he said. “So far.”



________________________________________________________________________________\
____
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Ask your question on www.Answers.yahoo.com

Cost Benefits of New Schizophrenia Drugs Doubted
Older Medication, Considered Equally Effective, Can Be
as Much as $600 a Month Cheaper, Study Finds
By Shankar Vedantam
Washington Post Staff Writer
Friday, December 1, 2006; A09

Treating schizophrenia with an older, cheaper drug,
rather than with heavily promoted newer medications,
reduces the cost by as much as 30 percent with no
apparent difference in safety and effectiveness,
according to the first study to examine the economic
implications of antipsychotic drug prescribing
practices in the United States.

The newer drugs, such as Zyprexa, Seroquel and
Risperdal, have cornered the lucrative U.S. market for
antipsychotic drugs at a cost of $10 billion a year --
or around $100 for every family.

The findings have roiled the field of psychiatry in a
fierce debate over the study's implications and have
triggered concerns it could lead public and private
insurers to limit drastically which drugs they will
pay for.

Earlier research had shown that the older drug was as
safe and effective as the newer medications. But
experts cautioned against assuming that the cheaper
drug would be as cost-effective once hospitalizations,
side effects and quality-of-life issues were taken
into account.

The new study, published today in the American Journal
of Psychiatry, concluded that when those factors were
included, monthly costs per patient were $300 to $600
lower with the drug perphenazine, which is no longer
under patent. The finding is the latest result from
the $42 million Clinical Antipsychotic Trials in
Intervention Effectiveness (CATIE), a federal study
into the treatment of schizophrenia.

In an indication of the widespread unease in the
psychiatric establishment over the results , one
senior doctor who helped conduct the study but not the
cost-effectiveness assessment said the new finding
faced stiff headwinds before it was published, and was
subjected to an extraordinary level of review.

"You are saying perphenazine is $500 cheaper," said
the doctor, who spoke on condition of anonymity
because of the sensitivity of the issue , to explain
why many psychiatrists weighing the study seemed
aghast. "Now the physicians feel defensive, because
people will ask, 'Why are you charging the patient and
insurance company $500 more when the drugs don't give
you anything more?' "

This doctor, the study's authors and several leading
psychiatric experts, including Thomas R. Insel,
director of the National Institute of Mental Health,
emphasized that the study does not mean that patients
doing well on more expensive drugs should be switched
to cheaper medication. Switching drugs involves
potential problems, and patients doing well on a drug
should be kept on it, they said .

But because many patients with schizophrenia need to
change medications frequently -- an earlier part of
the study found that three-quarters of patients
discontinue whatever drug they are on within 18 months
-- many could become candidates for treatment with the
less expensive drug in a short period of time.

"If they are chronically ill and are not on medication
or want to switch, it is certainly a rational choice
and would save money, and for the most part we can't
detect effectiveness differences," said Robert
Freedman, editor in chief of the journal, who co-wrote
an editorial accompanying the study.

Freedman and several experts said they were very
worried, however, that the choice of medications would
be taken from physicians and would be decreed by
insurers. That would ignore the complexities of
treating schizophrenia and the need for flexibility,
the experts said.

Patients who have tried perphenazine unsuccessfully,
for example, may not be good candidates to go back on
it. The federal study looked only at people who had
had schizophrenia for a long time, not newly diagnosed
patients. And overall, the fact that patients are
dissatisfied so often with medications, including
perphenazine, means that flexibility remains key.

In statements, drugmakers AstraZeneca, which makes
Seroquel, and Eli Lilly and Co., which makes Zyprexa,
said patients benefit from having individualized
treatment. The federal Centers for Medicare and
Medicaid Services -- Medicaid picks up three-quarters
of the $10 billion tab for antipsychotic drugs -- also
believes that physician discretion is essential, a
spokesman said.

Drug-industry critic Jerry Avorn, author of the book
"Powerful Medicine: the Benefits, Risks, and Costs of
Prescription Drugs" and a professor of medicine at
Harvard Medical School, said this is not a case of
difficult trade-offs between cost and quality.

"The cheapest drug produced an effect that was as good
as the more expensive drugs," he said. "The resistance
to this kind of finding comes from . . . the very
legitimate worry that boneheaded cost containers will
read this study and then try to get every
schizophrenic on every other medication to be switched
to the cheapest available product. I am a proponent of
educating doctors first rather than tying our hands."

Both Insel and Robert Rosenheck, the Yale University
psychiatrist who led the cost-effectiveness study,
said the message was not that the half-dozen expensive
new drugs should be replaced by perphenazine. Rather,
they said, the message of the CATIE study is that once
a range of side effects is taken into account, many
older antipsychotic drugs may have risks and benefits
that are similar to those of the newer drugs.

"It triples the size of the antipsychotic
armamentarium available to psychiatrists," Rosenheck
said. "Before CATIE, we had five to six drugs and we
had tremendous pressure to not use the other 15. What
CATIE has said is doctors should feel free to use
whatever medicine is right for their patient, and
there are 19 or 20 choices, not five or six."

Although both old and new classes of drugs have
similar effectiveness in controlling symptoms such as
delusions and hallucinations, the advent of the newer
drugs was hailed because they seemed less likely to
cause side effects involving involuntary muscle
movements.

But evidence has gradually accumulated that the newer
drugs do cause weight gain and serious metabolic
problems. Essentially, the editorial noted, the new
medications have resulted in a change in side effects,
rather than eliminating them.

Rosenheck said the study means that patients paying
for expensive new drugs out of pocket who wanted to
switch could try perphenazine without the concern that
they are getting inferior treatment. The magazine
Consumer Reports recently listed perphenazine, which
is sold as a generic drug, as a "best buy" among
antipsychotics.

While Rosenheck and CATIE lead scientist Jeffrey
Lieberman of Columbia University disagreed with the
authors of the editorial on how to interpret several
aspects of the study, everyone agreed that the trial
provides the best window in the country to date on the
treatment of schizophrenia. The editorial said the
study highlighted the need for new and better
treatments -- and perhaps a new and better mechanism
of financial rewards to spur their development.




________________________________________________________________________________\
____
Any questions? Get answers on any topic at www.Answers.yahoo.com.  Try it now.

I think that is a great idea.  We can start a topic each for STAR*D,
CUTLASS, STEP-BD, CATIE etc and post our opinions and take about it.

N. Soysal

-


-- In dcpsychresidents@yahoogroups.com, Mohan Kaza <mokaza@...> wrote:
>
> If it is possible, I think it would be fun to have a "critical
hour",  where us DC residents can voice our opinions about studies
that need to  be re-reviewed.  I don't want to be too critical, but
in my  selfishness, I think it would be fun to give us all a chance
to hear  the criticism of our colleaugues, and learn how to be more
critical of  articles we are expected to obey.  Just a thought - i
would have  kept this to myself, but Hind did such an incredibly
exceptional and  inspiring job in her efforts to unite the 4 pograms
in DC, that she  inspired me to make a statement.
>
>   We are very lucky to be around someone who has our best interests
in mind!!!
>
>
>   Mohan Kaza
>
> hind benjelloun <hbenjelloun@...> wrote:        Welcome to the
Residents' Journal, an e-publication to serve as a forum for your
articles and a gateway to features of the The American Journal of
Psychiatry that you may find useful in your training.  Each month we
will feature articles from the current American Journal of Psychiatry
that  we feel might have value to you in your training. We will show
you how  to use the Journal's features to maximize the impact of
these articles  for you and for any students you may be charged with
teaching.
>
>   You are welcome to forward this   e-mail to your colleagues, who
can register  to receive their own copy.  Comments, questions, and
suggestions  -- along with any difficulties in accessing the full-
text articles --  can be directed to Lisa Devine, Staff Editor, who
is responsible for the publication.
>
>
>
>   The American Journal of Psychiatry
>
>   Residents' Journal
>
>
>   For  those of you who are new to this e-publication, the
Residents' Journal  is an exclusive forum to share your ideas and
experiences in training,  clinical practice, research, and careers
with your colleagues. The  October 2006 Residents' Journal consisted
of four original  contributions from your peers about a wide variety
of experiences,  ranging from the uncertainty of diagnosis, to
beginning a research  career, to interactions in the emergency room,
and to the impression  made by one of our articles. The attached PDF
file contains these  submissions along with a new column from the
Editor-in-Chief, Robert  Freedman, M.D. A new Residents' Journal will
be part of the December  issue.
>
>   If you would like to submit a short piece for publication in the
Residents' Journal, please visit our website at
http://appi.manuscriptcentralcom/.  Once there you will need to
create an user account if you do not  already have one. Please
designate your submissions as "Resident  Journal," and please keep to
under 500 words. Your participation will  ensure the continual
success of this e-publication.
>
>
>
> ---------------------------------
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>
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Master's - in less than one year.
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Welcome to the Residents’ Journal, an e-publication to serve as a forum for your articles and a gateway to features of the The American Journal of Psychiatry that you may find useful in your training.  Each month we will feature articles from the current American Journal of Psychiatry that we feel might have value to you in your training. We will show you how to use the Journal’s features to maximize the impact of these articles for you and for any students you may be charged with teaching.

 

You are welcome to forward this e-mail to your colleagues, who can register to receive their own copy.  Comments, questions, and suggestions -- along with any difficulties in accessing the full-text articles -- can be directed to Lisa Devine, Staff Editor, who is responsible for the publication.

 

 

The American Journal of Psychiatry

Residents’ Journal

 

For those of you who are new to this e-publication, the Residents’ Journal is an exclusive forum to share your ideas and experiences in training, clinical practice, research, and careers with your colleagues. The October 2006 Residents’ Journal consisted of four original contributions from your peers about a wide variety of experiences, ranging from the uncertainty of diagnosis, to beginning a research career, to interactions in the emergency room, and to the impression made by one of our articles. The attached PDF file contains these submissions along with a new column from the Editor-in-Chief, Robert Freedman, M.D. A new Residents’ Journal will be part of the December issue.

 

If you would like to submit a short piece for publication in the Residents’ Journal, please visit our website at http://appi.manuscriptcentralcom/. Once there you will need to create an user account if you do not already have one. Please designate your submissions as “Resident Journal,” and please keep to under 500 words. Your participation will ensure the continual success of this e-publication.

 

---

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Mental Health Reform, Please
Virginia's mental health laws are stuck in the past.
Sunday, October 29, 2006; Page B06

VIRGINIA OFFICIALS are taking some encouraging steps
aimed at fixing the state's broken mental health
system, but this much-needed effort has come under
attack. The assault is misplaced.

Increasing numbers of mentally ill people in Virginia
end up on the streets, in court or in jail, instead of
in treatment, where they belong. Chief Justice Leroy
R. Hassell Sr. of the Virginia Supreme Court has
launched a commission to revamp state mental health
laws, including the state's outmoded criteria for
civil commitment, which provide emergency treatment
only when people are an "imminent danger" to
themselves or others. Justice Hassell wants those laws
examined, with the hope of presenting "reform
legislation" to the 2008 General Assembly.

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At a recent hearing, however, Sen. Kenneth W. Stolle
(R-Virginia Beach) warned the court not to overstep
its role by getting involved in policy. According to
the Richmond Times-Dispatch, Mr. Stolle, chairman of
the Senate Courts of Justice Committee, said he didn't
think judges should "tell us how we should deal with
mental health." Justice Hassell should be applauded
instead of criticized. Judges see firsthand the impact
of untreated people on the criminal justice system and
the inadequacy of laws that deal with the problem.
Their advice to lawmakers is invaluable.

There is a precedent, too. In the 1990s, family
violence was spotlighted as an issue by then-Chief
Justice Harry L. Carrico, and reform followed.

Coincidental with the state effort, Fairfax County,
through its so-called Beeman Commission, is analyzing
its own mental services during a time of increased
need and dwindling resources. These two efforts
highlight Virginia's desperate situation and the need
for solutions.



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http://www.currentpsychiatry.com/article_pages.asp?AID=4445&UID=
Vol. 5, No. 10 / October 2006

Medications with psychotherapy:
A synergy to heal the brain

Henry A. Nasrallah, MD
Editor-in-Chief, Current Psychiatry,
henry.nasrallah@...

Pharmacotherapy works for psychiatric disorders, and
so does psychotherapy. That’s why I provide both to
each of my patients and why Current Psychiatry
articles address combination therapy (for example, see
“Treating psychiatric reactions to medical illness,”).
Many studies have concluded that combining
pharmacotherapy and psychotherapy produces better
outcomes than either treatment alone.

The apparent synergy between verbal therapy and
medications is often observed but rarely investigated.
Does it occur because two different mechanisms of
action work better than one, such as when we combine a
dopamine blocker (antipsychotic) with a GABA agonist
(mood stabilizer) in a patient with bipolar mania? Or
do drug therapy and psychotherapy share a common
pathway that is enhanced when they are administered
together, such as when we combine two antidepressants
to manage a patient with treatment-resistant
depression?

What is psychotherapy’s mechanism of action anyway,
and do various modalities—cognitive-behavioral,
interpersonal, or supportive—have the same
psychobiological mechanism of action?

Psychotherapy’s mechanism
Given the limited evidence and lack of clear answers
in this area, it is reasonable to use recent advances
in neuroscience to speculate on how two ostensibly
different treatment modalities improve clinical
manifestations—the mood, thought, and behavior
alterations—of psychiatric brain disorders.

Emerging discoveries over the past few years suggest
the common pathway of psychotherapy and
pharmacotherapy may be neuroplasticity—synaptogenesis,
dendritic spines, and neurogenesis. In other words,
talking to a person or giving that person a
psychotropic are both likely to modify that person’s
brain structure.

Unlike any other organ, the brain changes continuously
in response to external and internal stimuli, such as
verbal, visual, tactile, and olfactory perceptions as
well as chemical stimuli. Neural tissue also changes
in response to experiences—stressful or pleasurable,
real or imagined, emotional or cognitive.
Psychotherapy represents a targeted, strategic, and
tactical approach to stimulate specific feelings,
recollections, and insights. These are encoded into
the recipient’s neurobiological pathways and
ultimately translate into a change in behavior or
symptoms.

Every therapeutic encounter produces neuroplasticity,
and—as with drug therapy—the cumulative effect of
repeated doses of psychotherapy consolidates the
improvement. One way to conceptualize this mechanism
is that psychotherapy refurbishes the patient’s brain
structure at the molecular level, restoring resilience
to a brain/mind system that was compromised by genetic
factors or environmental stress.

‘Re-Wiring’ the brain
Where does pharmacotherapy fit into this model? Here,
too, evidence is emerging that psychotropics may exert
their therapeutic effect not only through
neurochemical pathways but also by stimulating
neurotropic factors and inducing beneficial
neuroplastic changes.

Antidepressants, mood stabilizers, and atypical
antipsychotics (but not conventional neuroleptics)
have been shown to induce synaptogenesis, neurite
extension, and neurogenesis. These actions result in
“re-wiring” and “re-sculpting” brain regions such as
the hippocampus and subventricular zone.

Psychotropics are known to trigger gene expression
within hours for some genes and after days or weeks
for others (which may explain short-term alleviation
of some symptoms but delayed response of others).
Psychotropics’ neuroprotective and neuroplastic
effects also appear to help “replenish” brain tissue
destroyed by the neurotoxic effects of repetitive
psychotic, manic, or depressive relapses. Increases in
nerve growth factor, brain-derived neurotropic factor,
and fibroblast growth factor have been implicated in
brain tissue regeneration in serious psychiatric
disorders. Animal and human studies support this
model, but more research is needed.

Accelerating Neuroplasticity
Using this neuroplasticity model, we can reasonably
postulate that the convergence of psychotherapy with
pharmacotherapy may accelerate and expedite the
clinical improvement that hinges on “therapeutic
restructuring” of certain neural pathways. I find it
intriguing to think that by repairing brain tissue
with two different stimuli—talking and medicating—we
can mend the fractured mind of an ailing brain.

As neuroscientists explore more deeply this area of
research, we clinicians will continue to use
concomitant pharmacotherapy and psychotherapy to help
our patients navigate the road to recovery.

Current Psychiatry ©2006 Dowden Health Media





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APA Office of Communications and Public Affairs

Media Interview Alert

This is a special alert to watch CBS's "48 Hours" investigative news
program this Saturday, Oct. 28, 2006, at 10 p.m. (ET).  This edition
of the show features an investigation into the Church of Scientology,
and begins by recounting the tragic death of Scientologist Elli
Perkins.  Perkins was killed in 2003 by her son, who was suffering
from paranoid schizophrenia but was mostly treated in accordance with
Scientology protocols.  The program asks the question Did A Mother's
Faith Contribute To Her Murder? and then delves into broader issues,
including Scientology's opposition to psychiatry.

The APA's Office of Communications and Public Affairs (OCPA) worked
with "48 Hours" producers to provide factual information on mental
illnesses and expert opinions on forensic psychiatry.  APA member
Brian Joseph, M.D., of Buffalo, N.Y., will be a featured expert on the
program. In addition, producers consulted with Paul S. Appelbaum,
M.D., chair of the APA Council on Psychiatry and the Law.

For more information, please visit CBS's Web site:
http://www.cbsnews.com/sections/48hours/main3410.shtml.

Hi,

Join Doctor's Forum at http://www.doctor.vg

Depression Questionnaire May Change Treatment Plan

Karla Harby
Medscape Medical News 2006. © 2006 Medscape

October 6, 2006 (New York) — A phase 3 trial involving
1763 patients with depression from 17 psychiatric
centers has found that asking patients to fill out a
short quantitative questionnaire caused their
psychiatrists to change their treatment decisions 40%
of the time. Moreover, 93% of psychiatrists said that
the questionnaire was helpful in their practice.

The 1-page, 9-item Patient Health Questionnaire
(PHQ-9) is based on criteria for major depression and
dysthymic disorder from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition. Originally
designed for primary care physicians, the PHQ-9 is
free for clinical use and available from the Web site
of the MacArthur Initiative on Depression and Primary
Care.

The researchers also found, to their surprise, that
the PHQ-9 showed that rapid remission in depression is
quite rare. Using a score of 5 or lower to define
remission, after 3 months 39% of patients showed a
response to treatment, while only 17% were in
remission, said lead researcher David J. Katzelnick,
MD, Director of Healthcare Technology Systems Inc, in
Madison, Wisconsin. "I think we don't remember the
people who come in once or twice and then disappear,"
he said. "But they count."

Dr. Katzelnick and several researchers from
participating centers presented their findings in a
symposium at the American Psychiatric Association
(APA) 58th Institute on Psychiatric Services.

Of the 1763 patients, 75% were diagnosed with major
depression and the rest with dysthymia. The population
was demographically typical of clinical practice: 67%
of patients were women and 54% were between the ages
of 41 and 64 years. The study recorded 6363 patient
contacts, with 1378 patients having a second follow-up
visit, Dr. Katzelnick said.

Of those physicians who changed their treatment
decisions after reviewing questionnaire scores, the
most common change was to increase the dose of the
antidepressant (45%). Another medication was added 26%
of the time, antidepressant medications were changed
13% of the time, and the psychiatrists paid additional
attention to suicidal ideations in patients 3% of the
time.
The questionnaire was well-received by physicians and
patients alike, Dr. Katzelnick said. The 9 questions
can be answered by the patient in the waiting room, at
home, or during consultation with the physician.
"Clinicians said it did not take [extra] time to do
this, sometimes it actually saved time," Dr.
Katzelnick said.

Harold W. van Lonkhuyzen, MD, medical director of the
Penobscot Bay Medical Center in Rockport, Maine, and a
symposium attendee, has used the PHQ-9 in his own
practice. He was not involved in any of the trials.

"I find it useful for tracking patients' progress, and
for documenting patients' conditions when they return
to their primary care physician," he told Medscape.
"It helps in checking your own impressions, and you do
change management sometimes." But Dr. van Lonkhuyzen
also noted, "This is just one management tool. You
can't forego clinical judgment."

These 1-year trials are the result of a joint project
of the APA, the American Academy of Family Physicians,
and the American College of Physicians. The
uncontrolled trials reported here were conducted in 17
psychiatric treatment centers, with 12.5% of the
psychiatrists in solo practices, 62.5% in group
practices, and 25% being hospital-based. An additional
16 primary care environments participated in similar
trials, but those data were not presented.

Major funding was provided by the APA and from
unrestricted educational grants provided by 6
pharmaceutical companies.

APA 58th Institute on Psychiatric Services: Symposium
5. Presented October 5, 2006.




__________________________________________________
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Congratulations, Hind.
Nesibe

--- In dcpsychresidents@yahoogroups.com, enrico suardi
<enrico_suardi@...> wrote:
>
> Hello there. Congratulations to Dr. Binjelloun on
> being chosen as resident of the year by the Washington
> Psychiatric Society!
> She will be given the award at the WPS annual awards
> banquet on November 3rd, 2006 at the Italian Embassy.
> For more info, please visit:
> http://www.dcpsych.org/news/news_1006.htm
>
> Enrico, PGY2 at St. Es.
>
>
> __________________________________________________
> Do You Yahoo!?
> Tired of spam? Yahoo! Mail has the best spam protection around
> http://mail.yahoo.com
>

Congratulations, Hind.
Nesibe

--- In dcpsychresidents@yahoogroups.com, enrico suardi
<enrico_suardi@...> wrote:
>
> Hello there. Congratulations to Dr. Binjelloun on
> being chosen as resident of the year by the Washington
> Psychiatric Society!
> She will be given the award at the WPS annual awards
> banquet on November 3rd, 2006 at the Italian Embassy.
> For more info, please visit:
> http://www.dcpsych.org/news/news_1006.htm
>
> Enrico, PGY2 at St. Es.
>
>
> __________________________________________________
> Do You Yahoo!?
> Tired of spam?  Yahoo! Mail has the best spam protection around
> http://mail.yahoo.com
>

Hello there. Congratulations to Dr. Binjelloun on
being chosen as resident of the year by the Washington
Psychiatric Society!
She will be given the award at the WPS annual awards
banquet on November 3rd, 2006 at the Italian Embassy.
For more info, please visit:
http://www.dcpsych.org/news/news_1006.htm

Enrico, PGY2 at St. Es.


__________________________________________________
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You have been sent this message from hbenjelloun@... as a courtesy of
washingtonpost.com

  Personal Message:
  Thoughts?

  Mental Health Treatment by Video Growing

  By JAMIE STENGLE

  DALLAS -- Psychiatrists, often in need and hard to find in rural areas, are
increasingly turning to video to treat their far-flung patients, illustrating
one of the latest growth areas of telemedicine.

  To view the entire article, go to
http://www.washingtonpost.com/wp-dyn/content/article/2006/10/09/AR2006100900097.\
html?referrer=emailarticle


  Would you like to send this article to a friend? Go to
http://www.washingtonpost.com/ac2/wp-dyn/emailafriend?contentId=AR2006100900097&\
sent=no&referrer=emailarticle


Want the latest news in your inbox? Check out washingtonpost.com's e-mail
newsletters:

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© 2002 - 2006 The Washington Post Company

The last web address for this interesting article may have been
incomplete. Let's try this again.

http://www.washingtonpost.com/wp-dyn/content/article/2006/10/09/
AR2006100900097.html

Hind

http://www.washingtonpost.com/wp-
dyn/content/article/2006/10/09/AR2006100900097.html

The Washington Psychiatry Society Residents' Village website is
accepting submissions for the Artistic Expressions Section. This
section of the website will be devoted to offering members a diverse
display of the creative artistic talents of psychiatry residents in
Washington D.C. Encouraged entries include original and selected
poetry, prose, photography, film reviews, essays, links to music, and
any other interesting or relevant content our members decide to
contribute. Pls send entries in Windows compatible format. This section
will be regularly updated with new entries of original material and
interesting excerpts chosen by the contributors. Pls submit any
material by October 16 to j_gurrala@... for publication in the
inaugural launch of the website in January 2007.

Joseph P. Gurrala
Georgetown PGY-2

Hello,
Just wanted to let everyone know about a moonlighting opportunity-

The DC Dept of Corrections is starting a new project, w/ a large grant, to
provide mental
health assessment in the DC jail, SE DC, next door to DC General hospital and
the stadium.

The project starts Oct 1, w/ many new jobs available, but specifically, evening
and
weekend moonlighting positions for psychiatry residents. Pay is hourly, at a
competitive
moonlighting rate, w/o benefits.

You must have a valid DC medical license and DEA # w/ class II perscription
auth.
Malpractice insurance is covered by the grant sponsor; Unity Health Care.

If you are interested, please contact Dr Robert Keisling;
rkeisling@...

Just let him know you were referred by me-
Beverly Reader, MD
PGY2 resident
Georgetown University Hospital






--- In dcpsychresidents@yahoogroups.com, "Hind Benjelloun" <hbenjelloun@...>
wrote:
>
> Fellow residents,
>
> Tomorrow afternoon, we will be holding our first project meeting for
> the revamping of the current resident's page of the Washington
> Psychiatric Society (WPS) website. Please review this section at the
> WPS site under "Residents' Roundtable": www.dcpsych.org. We
> successfully gathered representatives from the four DC residency
> programs for the meeting tomorrow.
>
> We need your help. Please reply to the listserv and let us know what
> you would like out of the resident's section. This is vital to our
> mission to design a resourceful and interesting website. Some ideas
> from fellow residents have included moonlighting opportunities in the
> metropolitan area, information about malpractice insurance, and
> guidance regarding finding employment/starting a private practice post
> graduation.
>
> Please don't be shy and reply. Your suggestions are necessary.
>
> Thanks,
>
> Hind Benjelloun
> PGY2 Psychiatry
> Georgetown University
>

Fellow residents,

Tomorrow afternoon, we will be holding our first project meeting for
the revamping of the current resident's page of the Washington
Psychiatric Society (WPS) website. Please review this section at the
WPS site under "Residents' Roundtable": www.dcpsych.org. We
successfully gathered representatives from the four DC residency
programs for the meeting tomorrow.

We need your help. Please reply to the listserv and let us know what
you would like out of the resident's section. This is vital to our
mission to design a resourceful and interesting website. Some ideas
from fellow residents have included moonlighting opportunities in the
metropolitan area, information about malpractice insurance, and
guidance regarding finding employment/starting a private practice post
graduation.

Please don't be shy and reply. Your suggestions are necessary.

Thanks,

Hind Benjelloun
PGY2 Psychiatry
Georgetown University

Thank you all for signing up for our new DC Psychiatry Residents'
Listserv! This forum a place for us to share experiences, ideas,
resources, and wisdom. It is inclusive of Georgetown, George
Washington, and St. E.'s psychiatry residents. I am still in the
process of obtaining emails from the Howard residents to invite them
to our group. I also hope to soon include Uniformed Services
University psychiatry residents. Let us all please encourage our
fellow residents to join if they have not yet.

I hope to meet all of you at the upcoming WPS Resident's Happy Hour
at McFadden's (2401 Pennsylvania Ave., NW) this Thursday, September
21st, from 7-9pm!

Looking forward to great discussions! Please feel free to start one
if you feel inclined!

Warmly,

Hind Benjelloun
PGY2 Psychiatry
Georgetown University

hi everyone,
i hope this will be a reciprocal forum for local residents and thanks
to dr. roozegar and dr. beneloiun for starting up the idea.
thanks.
tehmina sheikh