Diet Soda and Cardiovascular Disease

The media is reporting an interesting study by a researcher at the University of Miami, Hannah Gardener (I believe based on an abstract presented at a conference - I cannot find a link to the actual study info). It finds that those who drink diet soda daily have a 61% greater risk of having a heart attack or stroke. (and who knows why in remembering this I'm thinking of diet cola? or a particular brand of diet cola?)

Is this surprising? Well as it is currently being reported by the media - that diet soda 'causes' stroke or heart attack - that is stunning! However we really need to have some more information about that study to appropriately digest it and decide whether it has anything to do with causality or disease outcomes.

As I note, I have not seen the actual study - just a couple of media reports (see links below) - so it is impossible to know... but here is what I would consider:

• At what point in life were people studied? Is it young people drinking diet soda and ending up with strokes or older folks?
• When were measures made of diet soda ‘exposure’ vs. when outcomes were identified?
• How does risk in diet soda drinkers compare to risk in drinkers of ‘regular’ soda?
• Who drinks diet soda? What cardiovascular disease (CVD) risk factors do they have already?
• What other things do diet soda drinkers do that could increase their risk? Is there a tendency for those who are overweight or obese to drink it? Is there a tendency for those who drink diet soda to exercise less? What is the overall health of diet soda drinkers as a group? Do we know that obesity and lack of exercise increase risk for heart attack and stroke? (I think we all know the answer to that)
• What other factors associated with greater risk of heart attack and stroke may be common to diet soda drinkers?
• How were these common risk factors managed in the study - were those with early signs of CVD excluded from the study?
• If all other risk factors were controlled for in the study is it still possible to get an erroneous result (yes, because there is probably great similarity between these factors which tends to result in difficulty modeling things statistically)
• Perhaps most important of all: What would be the proposed mechanism of how diet soda 'causes' heart disease or stroke? Is it additives of some sort? Is it caffeine? Is it artificial sweeteners?

From some of the reports I saw, the researcher was careful to say that all this result meant was that further examination of the role of diet soda was needed... I agree with that… but the media has gone way beyond that in some cases…

It's also interesting to think about how you could design a study to prove/disprove this... would we take a healthy group of people and randomize them to drink diet soda daily vs. some other non-diet 'placebo type drink' (i.e. not regular soda I am certain) and see if there is greater risk at the end of the study? How long would we need to wait to see outcomes?
It is tough to actually know and adequately study this question...

Here are the links... http://www.denverpost.com/nationworld/ci_17345702 or

http://health.usnews.com/health-news/family-health/heart/articles/2011/02/09/can-diet-soda-boost-your-stroke-risk or

http://www.dbtechno.com/health/2011/02/09/diet-soda-increases-your-chance-of-having-a-heart-attack/

Modeling Internet Addiction

Most of us use the internet regularly. It has replaced earlier forms of communication like writing letters, reading news or magazines, phoning, or visiting. Many would agree that it is easier and more convenient than more traditional forms of communication. I also think that the stimulation of using the internet is far more rewarding than other formats offer. I can’t back that up with evidence, but I do know I look forward to checking my email, text messages, etc in much the same way that once a day checking of my mailbox offered (at least until adulthood when bills were often the most frequent arrivals!). Remember the wonderful surprise of finding a letter from a friend addressed to you! We currently have all kinds of places to ‘check’ for stimulation and reward on our computers or other electronic devices.

I am sometimes amazed at myself and others when I see the interest involved in electronic devices… including laptops, ipads, ipods, iphones, androids, and handheld electronic games (like the Nintendo DS). Our internet service was out for a few days this week and we were frustrated and annoyed that we were limited and could not interact with or easily check our devices as usual. It is interesting to reflect on how much we do rely on various forms of electronic communication.

An interesting study was done by Kwon & Chung (2011) studying the use of internet games by adolescents. They applied Baumeister’s escape from self theory (1991) to the phenomenon of pathologic use of internet games. Baumeister’s model has been used to understand other self-destructive behaviors including suicide and addictions to both substances and gambling. This model brings together many of the factors that prior research identifies as associated with internet game addiction, for example depressive symptoms, differences between real and idealized perceptions of self, escape from self, and interpersonal problems involving family and friends.

This model does not directly investigate the role of impulsivity and sensation seeking in internet game addiction. Kwon & Chung (2011) find that differences between real and idealized self perception are associated with depressive mood, which is associated with escape from self and also associated with internet game addiction. The study uses structural equation modeling to identify the strength and type of associations. However this form of modeling does not really offer a cause and effect analysis of events, it is based on cross sectional data which means all factors were present at the same time in participants. But it does establish that these relationships are important in the addiction behavior.

The authors identify that in Korean adolescents, use of internet games begins quite early. I suspect this is also true in other locations. I wonder about the changes that might be taking place in our brains and our children’s brains as we feed ourselves the stimulation readily available from electronic devices today. It is quite different from growing up with TV and radio – which was less satisfying given that you could not find material at any time of day that was personally satisfying and stimulating like we can today. The major factor missing in the study by Kwon is that there is no accounting for potential physiologic effects of electronic stimulation. The immediacy of gratification and plethora of forms of stimuli are so different than for prior experience and generations.

I think I will spend some free time exploring the internet for information about physiologic effects :) (who’s addicted?!) and perhaps I will see if I can buy an electronic version of Baumeister’s book on escape theory! If you know of work that has been done on the physiology let me know- send me a link or do tell about it in the comments!

References:
Kwon, J.H., & Chung, C.S. (2011). The effects of escape from self and interpersonal relationship on the pathological use of internet games. Community Mental Health Journal, 47, 113-121. http://www.ncbi.nlm.nih.gov/pubmed/19701792

Here are references to Baumeister’s model if you are interested:
Baumeister, R.F. (1990). Suicide as escape from self. Psychological Review, 9, 90-113.
Baumeister, R.F. (1991). Escaping the self: Alcoholism, spirituality, masochism, and other flights from the burden of selfhood. New York, NY: Harper Collins.

Identifying Alzheimer’s Disease prior to disease onset

I am happy to see that progress is being made in identifying better ways to diagnose Alzheimer’s disease. On the other hand, I am also disturbed given the nature of getting a diagnosis like Alzheimer’s disease. The epidemiologist and researcher in me is always glad for a discovery like this. In designing studies we have a valuable way to identify people with an abnormality indicative of the disease. This improves the features of the study and its measure of identification of this disease. There is immense value in that. In studies where we can only approximate the outcome (i.e. in AD definitive diagnosis is usually only available by autopsy) our research is negatively impacted in looking for treatments or a cure for the disease. If a group of patients we ‘think’ have AD really do not, and we seek treatments based on their responses or physiology, then the potential for error in these studies is large. So for research in AD this is a huge finding… and very important to progress in the field.

Here is the link to the NYT article that reviews the study to be published today in Archives of Neurology… I’ll have to review the study later to evaluate it. http://www.nytimes.com/2010/08/10/health/research/10spinal.html?_r=1&th&emc=th

The question I’m left with really is… what do we do with the information once we have it? The article is a bit vague… implying maybe the doctor doesn’t tell the patient of the diagnosis. That is scary and a little like getting cancer more than 30 years ago… You could be dying in a hospital bed and no one would tell you the diagnosis.

With AD, we really don’t have ways to change the outcome. Do we want to be diagnosing people with Alzheimer’s earlier? If there was a real way to change the progression then there is no question… of course! But today, if I had the test, would I want to know the results? It is hard to say. Part of me says I could plan for the changes to come… I could mourn my loss of my ‘senior’ years… I could prepare my family for the worst… But these would be extremely difficult to do, even for the healthiest of us.

Would you want the test?

Dissolving Tobacco: ‘Candy’ to feed nicotine addiction

Who ever thought that tobacco companies would come up with a way to market a tobacco product that does not light up or need to be spit out? Camel Orbs and other forms (sticks or strips) are being marketed now. It is interesting, a dissolving product that delivers from 0.6 to 3.1mg of nicotine (depending on form vs. 1mg per usual smoked cigarette). It is made from ground tobacco, and flavored. You would think given the dose of nicotine delivered that it is considered at least an over the counter agent?

I learned of this from a recent newsletter for clinicians (Here is the link where the article is posted:http://www.smartbrief.com/servlet/wireless?issueid=41F0A8DB-0D52-4644-A460-C671DA25785E&sid=4424389f-4968-420d-b19a-428ead999285). I think they missed the boat on the focus to report: that babies or children might accidentally put the small tic-tac size ‘candies’ in their mouth and ingest toxic doses of nicotine. This report follows a study from Connelly et al.( 2010) in Pediatrics (http://pediatrics.aappublications.org/papbyrecent.dtl). This is a concern to be sure. Adults might shake out a few from their childproof container and leave them where a child could find them. In addition, the ‘candies’ are flavored, so they taste good and encourage eating more than one? An important point and users should beware.

A bigger concern, is that tweens and teens might be interested in trying this substance for the effects of nicotine without smoking! It even tastes good. Let’s see if we can hook a whole new generation on tobacco and call it candy this time. Not a good idea. There are enough other substances in the world to get hooked on. Do we really need a new one? I can see the rationalizing already, it isn’t smoked so won’t cause lung cancer, secondary smoke, etc…

When a product delivers a pharmacologically active agent like nicotine, shouldn’t it require strong regulation? More than that of a tic tac? Particularly when we have reams of data about how addictive the substance is? I don’t think this is much different than other nicotine products, which pharma created and I’m sure went through many hoops to get approved. Shouldn’t this product be treated the same way?

The New York Times coverage of this story yesterday, (here is the link: http://www.nytimes.com/2010/04/19/business/19smoke.html) identifies that in fact the FDA does regulate tobacco now… R.J. Reynolds did submit documents showing research and other material about this new ‘candy’, but the FDA still has 2 years to determine the safety of the product. I guess they can begin marketing it before we know its safety?

From what I can find, they are also available as ‘sticks’ (like a toothpick that dissolves) and ‘strips’ (like a breath mint strip). Here is a picture of the product, in case you are interested:

Psych RN Salary Low...

Well, just got some bad news... Advance for Nurses just arrived and the lead article is a New England Salary Survey for nurses. The good news? Nurse earnings range from an average of $22.50 per hour in Vermont to $39.88 per hour in Massachusetts. Connecticut nurses are doing pretty well at $34.18/hr. The problem is this: the hourly rate by specialty area for New England nurses ranges from $30.05/hr to $43.00/hr and guess which specialty is at the rock bottom? Psychiatric Nurses.

Why would this be? Is it mostly new nurses bringing down that average? New nurses (< 5 yrs at work) earn considerably less, $27.92/hr, while rates increase to $32.20 at 6-15yrs, and $40.30/hr with 16-25yrs experience. (Interesting that those with 26+ years experience have lower hourly rates on average ($39.42/hr)- that does not sit well with me either.) Mary Jane Krebs, APRN-BC VP of clinical and nursing services at Spring Harbor Hospital in Maine identifies the average age of psychiatric nurses is 47years. I don't think that supports the lack of experience argument.

Perhaps it is location of employment. I don't know the numbers, but I am sure many psych nurses work for state or federal (VA) facilities which have the lowest annual salaries ($66,823 vs. nonprofits of $71,061). That might be part of the reason. I don't think it is a good reason, but perhaps benefits packages are better? I suspect the work is very difficult in government facilities...

My worst fear would be that the stigma of working in psychiatry is alive and well. I can't tell you how many times I have heard that people who work in psych are crazy... I'm tired of that. As a group we need to actively thwart those who perpetuate this myth.

As a group we should be paid on par with all other specialties. We have extremely difficult jobs, and deserve to be paid well for our services.

Happy to Help Another Nurse Blogger!

Here's something different for my blog today... I was asked to post a link to the following blog. So here it is: “101 Blog Posts Every New Nurse Should Read” at http://nursepractitionerschools.org/101-blog-posts-every-new-nurse-should-read/ by Jennifer Johnson. I don't know Jennifer, but I briefly perused her blog, and it has some interesting blogs to link to about nursing and the experiences of both nurses and students. Happy reading to all of you on one of my favorite topics... Nurses and Nursing!

Helping People Get Proper Treatment for their Mental Health Needs

I had the pleasure of teaching a group of adult and family NP’s about depression and anxiety disorders last week. They have a large proportion of patients with mental health needs, who are unable to access specialty mental health care. Why is that? I was impressed with their questions and concerns about treatment of mental health needs in their care.

It is interesting, because others (specialists in psych) have questioned if primary care providers should be treating psychiatric patients without specialized knowledge and course work in mental health assessment, psychopharmacology, neurobiology, and treatment methods. While generally I agree that there is a great difference between a primary care provider managing psychiatric needs and a psychiatric mental health provider’s care, the reality is that they probably are not managing these needs by choice. I can see at least 4 reasons a lot of this care occurs in primary care by non-psych specialists:
1. Simple non-complex needs like depression improve with medications alone in some cases. (this of course ignores the fact that depression is a recurrent disorder that benefits from other therapies in addition to medication)
2. Psych specialty provider waiting lists are long (3-6 weeks consistently at least in Connecticut for adults, more than double this for children or adolescents). So many patients improve with meds within this time frame and lose the motivation to go for specialty care.
3. Lack of insurance coverage to cover specialty psychiatric care – this was reported by the students as being a common reason identified when they see patients… the question is why isn’t care being covered? What does this mean? Is it lack of mental health coverage (i.e. being told no, you will not be able to have that tx paid for by insurer), limits in coverage, or requirements to call in for approval ahead of time (which I don’t think should be required), or overall lack of insurance coverage (although they are at the primary care provider).
4. Stigma and stereotype of needing psychiatric care (despite the fact that probably 25% of all adults will at some point need some mental health care across their life). Unfortunately those with mental health needs remain second class citizens in health care.

So what is the real story? I thought we had legislation that changed things so that there was mental health parity? Why can’t people get their mental health care paid for? That would be a great study (there’s a good idea for your thesis!). I would love to hear from students and clinicians about the circumstances in which they see this happen every day.

Another area that came up as a concern for these primary care providers was what to do when a person is in both primary care complaining about mental health needs and in specialty care treatment for those same needs. The answer to this is simpler:
1. Have at least one psychiatric provider in their practice to manage these patients with complex needs. OR
2. Communication and collaboration between providers is essential. If someone is in specialty care and we see a problem with a physical condition then we should call the primary care provider. If the primary care provider sees unmet mental health needs they should contact the mental health provider. I realize this may mean that we have to manage the permissions to share information, but in this case it is imperative. Nearly every week my students tell me about their clients in the mental health setting that their preceptors are medicating for a variety of complex mental health problems who also receive some mental health meds from primary care. The common problematic agents are: benzodiazepines and other sedative hypnotics. This is particularly a problem in treating the dually diagnosed patient (mental health dx with substance abuse dx). Communication is very important. If the patient is in specialty care, then the primary care practitioner can’t be providing a different Rx to the patient for the needs already managed by the other provider. I am more confident that the psych specialty providers are not writing Rx’s for the medications to manage the physical care (I hope I am not wrong about this, as psych clinicians in general should not prescribe outside of their specialty area).

We are in an era where many Psych APRN’s are working 2 or more part time jobs to make a full time position. How could that be if there is a problem getting our patients into mental health care? Why are there waiting lists for people needing care? Why aren’t primary care practices hiring psychiatric providers like Psych APRN’s to help manage their patient’s mental health needs?

How could it be that the state of CT is cutting direct care psychiatric provider positions (or have a freeze on hiring clinicians) if there are waiting lists that preclude patients from getting the care they need? It isn’t just the state, other hospitals or facilities don’t seem to be hiring more psych practitioners either or making those providers full time. What is the deal?

How can these situations co-exist? How can there be a clear need for services, yet a lack of demand for full time workers in the area?

I suspect the culprit is a system forever in the mode of saving money and cutting spending, despite abundant needs in the population…

I would love to hear examples from those of you facing these problems… maybe it will help us to solve the problem! Please comment here or send me an email: joanne.iennaco@yale.edu

My Thoughts on 'Anti-Energy' Drinks

Let me be perfectly clear: I am not an expert on nutrition, nor do I research these agents or drinks. I do have an opinion though, which I shared on my blogs Wednesday and I will share today.

I was asked by someone if I knew anything about the effects of anti-energy drinks such as Drank, which just recently started being sold in Connecticut. The product contains three main ingredients: valerian root, rose hips and melatonin. Part of the question was if there was evidence of an effect of these ingredients on stress relief and/or relaxation. In addition I was asked if I know anything about the three main ingredients. I do not have special knowledge to answer these questions with, they are not my areas of study. They are excellent questions!

I do think this is an interesting twist on the use of nutrients and other agents in beverages. In fact I have not researched energy drinks to any great degree, except to look up some of the ingredients. I just have a long standing concern: people think just because something is a ‘natural’ substance (herb or vitamin or mineral) it is ok to take it however they wish. I also don’t think people understand the lack of protections we have, given the lack of required evidence of safety to put products like these on the market. People may also think because it is on the store shelf it must be safe.

Unfortunately the websites available about drinks of these kinds do not have specifics about the amounts of each ingredient. They do not identify specifically the labelling with nutritional information (at least that I could find on the website for Drank). I'll have to go to the store and see what the label says. Despite the ingredients mystery, they are very direct in suggesting this is a fun new way to relax though.

I do not know off-hand of the safety of the ‘anti-energy’ drinks. My concerns about safety would be similar to those of all energy or 'nutritional' drinks. Whenever we begin to use agents in food or beverage that are commonly consumed at meals or other times, we have to wonder about the effects of exposure (i.e. how many of these drinks might you drink in a day? What is the dose of the substance you get over the day?). Is it like water and you can drink as much as you want?. Over long periods of time and with penetration of these products in the marketplace there is increased population exposure. Because they are foods/drinks they are differently regulated. How many people do you know that would take 3 pills a day (valerian, rose hips and melatonin) without considering the safety? Drinking them seems to make them appear safe to people. That is my concern. What if they are on other medication? Could they interact and cause negative effects? Do they check with their health practitioner to be sure it won’t cause a problem?

The other concern is we may have studies of a substance like melatonin for example and consider it safe for some use in some dose, but are there potential interactions between the three substances in this particular drink? Also where is the long term evidence of safety of these substances (individually and combined) in such a common food/drink source? An absence of evidence does not equal an absence of negative effect. It just means we haven’t studied it in this way.

I suspect ‘anti-energy’ drinks will be popular in the marketplace… It makes you wonder whether people will be pumping up on energy drinks all day and then trying to settle down with the anti-energy drinks in the evening. I am sure the beverage industry is very excited about all this… It is like they are the new but unregulated pharma – without having to shoulder the costs of safety research and clinical trials.

I am sure I told you more than you are really interested in. I am not the ‘expert’ on these ingredients. There are many people I am sure who have much more knowledge than I do about these ingredients. (actually you might look at the medline plus search info for supplements from the national library of medicine, if you haven’t already found it). Here is the link to info about melatonin: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.html I would consider medline plus a trustworthy source of data on ingredients like this.

Of course as Mental Health Clinicians, we should also be inquiring about beverages like this, particularly given the lack of knowledge of amount of ingredient in each drink and that if one doesn't settle me down, maybe I will need a few... Something new to consider in our assessments.

‘Healthy Drinks’ Mask High Caffeine Content

I was glad to see the Journal for Nurse Practitioners take up an important issue to our health and well-being: Energy Drinks. Pohler, H. (2010). Caffeine intoxication and addiction. Journal for Nurse Practitioners. 2010;6(1):49-52. http://www.medscape.com/viewarticle/714855

These drinks are marketed as a healthy alternative to other choices like soda and coffee, but in my view they potentially have many negative implications. For the past two years, I have observed a 7th grade boy purchase two cans of Red Bull each morning when I purchase my cup of coffee. 2 cans of highly potent, caffeinated Red Bull, which is advertised to “revitalize body and mind”. Some days he buys Full Throttle (which CNN tells me ( http://www.cnn.com/HEALTH/library/AN/01211.html) nearly doubles the dose of caffeine per can (cans are bigger)).

How commonly do children buy these drinks? I wonder a bit about the groups that are the highest consumers of energy drinks like Red Bull or Red Star or Liquid Cocaine? Are we (and our children) unwittingly getting hooked on high doses of stimulants in ‘healthy’ energy drinks? Let’s not forget the little ‘shots’ available for purchase too, so you can quickly get your stimulant without a lot of drinking… Also, check the label of your vitamins, as often vitamin supplements have caffeine in them as well. I had that experience a while back. It isn’t pretty to see me after a cup of coffee and a vitamin with caffeine. We need to look at the labels of the products we buy!!!

Caffeine is one issue, each 8.3oz can of Red Bull contains 75mg of caffeine. The other ingredients have potential effects as well. Here are the ingredients of Red Bull: Carbonated water, sucrose, glucose, sodium citrate, taurine, glucuronolactone, caffeine, inositol, niacinamide, calcium-pantothenate, pyridoxine HCl, vitamin B12, artificial flavors, colors.

I appreciate Pohler telling us that ingredients like guarana and cola nut are synonyms for caffeine in an ingredients list. She also details the physiologic metabolism of caffeine into byproducts theobromine and theophylline (which can be found on labels of nutraceuticals).

Consumers need to be aware of what they are ingesting. I found in the store some vitamin labels might list the name of a stimulant (like guarana or caffeine) and on the external package not print the amount (mg) in each tablet (which made me think at the time of purchase there was no caffeine in there). I didn’t recheck the bottle label inside the packaging until a few days later when I realized I was jittery and overstimulated and knew I hadn’t increased my coffee consumption. My One-A-Day multi-vit actually gave me as much caffeine as my morning coffee. Time to change vitamins, and be careful about reading those labels!

While I readily admit a ‘habit’ (do I really have to call it an addiction?) of a 16oz hazelnut coffee each day, I haven’t moved to even try a product like Red Bull. I am also reticent to drink Vitamin Water and other ‘nutritious’ drinks because the additives that make them ‘healthy’ are not familiar to me. What is taurine? (ok, I looked it up, it is an amino acid) And Glucuronolactone? (an artificially produced stimulant – so adds to the load of stimulant in Red Bull). I recognize some of the nutritional ingredients like niacinamide, pyridoxine and vitamin B-12, which worry me a little less. However it goes back to my argument about using nutraceuticals in general: where is the evidence to tell us the use of ingredients in this way is really healthy? In addition the labels don’t tell us how much of each ingredient we are ingesting, and we all know that many vitamins, minerals and nutritional products can have toxic effects if we ingest too much.

Health professionals are well aware that drugs interact with one another. In addition, at times substances that are seemingly ‘good’ for us have negative effects. This is the reason I don’t drink beverages like that. Nor would I allow my child to drink them! Particularly on a daily basis in high amounts. Do we have long term data on children's brain development to tell us this is not harmful? Do we have any long term data that tells us that these ingredients together won’t harm our kidney function in the future? Or other body systems? What happens 10 years out with daily high dose stimulant, taurine, glucuronolactone and other ingestion? (actually caffeine seems better to me given our lack of knowledge of these other ingredients and the high prevalence and long term use of caffeine in our culture… unless of course some of the common chronic illnesses are fed by caffeine – which of course hypertension is one).

Am I the only one who is worried about the marketing and unwitting consumption of ‘healthy’ beverages like this? I am pleased to see Nurse Practitioners considering the implications of stimulant beverage consumption by their clients. As mental health clinicians we can be no less vigilant...

Changing Perceptions: Clozapine no longer a 'last resort'

(Original Post Date: December 7, 2009)
A thanks to one of my wonderful students, for sending along this article about Clozapine. http://www.currentpsychiatry.com/article_pages.asp?AID=8165 We actually just attend the Yale Master Psychopharmacology conference last week, where the speaker on Advances in Schizophrenia, Dr. Cyril D’Souza, was quite clear in his preference to see patients treated with Clozapine. Interesting to see this publicized in this way, given the initial introduction of this drug with such care. When introduced, it was suggested as the drug for those treatment resistant patients, with I believe the understanding that those not responding to other agents might find benefit in the drug vs. the risk of potentially life threatening agranulocytosis. This was later widened to include those with schizophrenia or schizoaffective disorder who were a suicide risk. Use of the drug has led to individuals being treated with clozapine while closely scrutinized for the development of life-threatening side effects. More recent studies have suggested clozapine has antiaggressive properties(per Krakowski et al, 2006) and offers superior symptom management (per CATIE results).This article suggests thinking more broadly about the use of clozapine, given studies showing its efficacy. As I translate the idea: rather than thinking of it as a 'last resort', we should consider it a ‘second choice’ after a first trial of antipsychotic medication is not effective. It seems to me that clozapine needs a new marketing strategy. Although we should expect that if we begin to use clozapine in a larger proportion of the population we will see its side effect, agranulocytosis, occurring in greater numbers (i.e. it will have the same frequency, but if more of your patients are taking it, the likelihood you will see a case of agranulocytosis will increase.) Whenever we do prescribe clozapine, we must carefully attend to the potential it has for this side effect, and be sure that we monitor individuals closely.
Posted by Joanne at 12:57 PM

And thanks also for the comment, which shows your use of this clinical information!

Joanne, I wanted to share a recent and ongoing clinical case (without going into too much detail) that I have been a part of at my current clinical site in a forensic setting. The article that I forwarded to you I had also forwarded to my clinical preceptor, a psychiatrist. Not more than a week or two after this conference and stumbling upon this article did it come to our attention that one of the inmates, had presented a couple of months ago in the midst of an acute psychotic episode. It is likely paranoid schizophrenia but with a mood component thus our differentials of adding a bipolar diagnosis per history or leaning towards schizoaffective. This inmate, prior to arrival, had been misdiagnosed with mood and anxiety disorders only (as far as we could gather from collateral sources). Nonetheless, we started slowly titrating up on Risperdal. First 1mg BID and so on up to 6mg according to response; we also concurrently followed the antipsychotic with adequate amounts of Cogentin, Amantadine and even some Klonopin to aide with anxiety as well as hoping to prevent and treat some already apparent EPS. Along with this titration we slowly introduced Depakote as well to stabilize mood. As we responded to symptoms with the Risperdal increases, the psychosis almost completely cleared. The turn around was rapid and the medications effective. BUT, of course this was too good to be true and by this time EPS and Parkinsonian symptoms had become too much to bear. The inmate was at times unable to eat or take pills because of shaking so badly. We had of course had “the benefits outweigh the risks” talk prior to administering the medication, but it was at this point that we attempted to back off several of the meds. We switched from Risperdal to Abilify to see if this might help decrease the EPS, but no changes were noted. It struck me as we were sitting pondering this difficult case, "Why not Clozaril!?" With its very good side effect profile (except of course the life-threatening agranulocytosis, ha) it would give the antipsychotic and even mood stabilizing properties without the same high risk for EPS. At first my preceptor and the nurses were very hesitant and questioned this high-risk medication yet soon at least my preceptor was on board and telling me the more consideration, the more sure it might work very well for this particular patient. We began a titration down off all meds and did basically a washout (in the safety of an inpatient setting) while keeping low-dose Klonopin onboard. So, the current status is that some Parkinsonian symptoms seemed to have decreased but the resting tremor remains. We are weekly monitoring WBC levels (for agranulocytosis as Joanne mentioned) and titrating the dose up. So far so good! I’ll try and update to let you all know how things are progressing…..Thanks again Joanne for posting on this topic, it’s really interesting as well as clinically applicable. ☺ (Comment Date: January 13, 2010)

Violence in College and University settings

Three separate examples of violence in college and university settings in Connecticut may have us wondering whether rates of violence have increased in recent years (http://www.wtnh.com/dpp/news/middlesex_cty/college_campus_safety_questioned). We certainly do hear a lot from the media about those events, which raise awareness that our campuses are not as secure as we would like to think. Somehow we think that if a young adult is a college student they are protected from the various factors that put youth of college age at risk. I suspect they are to some degree, violent homicides are probably much less frequent in those attending colleges and universities. See the American Psychiatric Nurses Association website (APNA) for a review of literature on workplace violence that includes data from colleges: http://www.apna.org/i4a/pages/index.cfm?pageid=3786.


These may be the only 3 homicides in CT Colleges this year, but think of all the homicides we have heard reported in the news (and many of them have gained much less coverage by the press). We should remember that homicide is a leading cause of death in this age group as a whole. Here is a table showing that data, which of course shows those 15 to 24yrs having the highest homicide rates:
Data Source: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf; & National V ital Statistics Report, V ol. 47, No. 9, November 10, 1998


This data does not suggest an upward trend. The rates actually look pretty stable (possibly lower than in 1996, actually).

Here is a table showing us some of the leading causes of death that include 15 to 24yr olds:

Data Source: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

As you can see Accidents are #1, Homicide is #2, and #3 is Suicide. (I wonder if this year's H1N1 will even cause a little blip here?) This data suggests that we should be far more concerned about accidents or accidental injury or death in this age group. Below is a chart showing the ranked causes of death in those age 20-24yrs (considered the college-age population, but does not mean it includes only college students). These 3 causes account for 70% of all deaths in this age group.

Data Source: http://www.statisticstop10.com/Causes_of_Death_College_Age_Adults.html;
National Center for Health Statistics, National Vital Statistics Reports March 7, 2005

We are wise to be concerned about homicide and violent behavior in this age group (it is certainly of concern given that it is the 2nd ranked cause of death). What are some of the reasons that our society is violent? I think there are many, here are some off the top of my head (sorry no data to support, just things I remember from various studies, or my ‘opinions’ which may not have supporting data!)
· Violence in the media (right back at you media for sensationalizing tragedies such as these in CT this year) including the news (and streaming news), movies, videos, and most recently: Reality TV!
· What about video games? I have seen data that suggests videos games where we actually shoot at others does increase our comfort level with shooting real human beings…. I believe the military actually researched this as a method for helping regular people like you and I to get over our inhibition about shooting a human being.
· Firearm availability (a very interesting thing to look at is how rates of these causes of death vary by availability); also interesting is how in regions of the country areas with high rates of homicide tend to have ‘lower’ rates of suicide and vice versa (see the reference for Death, Final Rates 2006: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf)
· Incivility and bullying in our world, at work, at school, at the grocery store… oh yes and what about our impatience and lack of understanding of others...

What would you hypothesize are reasons for the high rate of violence in our society?

Is there a breaking point for business? There certainly is for workers…

In the past two decades workers have constantly been pushed to do more with fewer resources and now it seems all too commonly for less pay. While many have lost their jobs, others have experienced pay cuts and demotions while companies attempt to balance their books in a bad economy. My question is whether there is a breaking point. At what point do businesses stop making corrections, realizing that the immediate cuts to change the cost of doing business are actually hurting the bottom line?

An example of some of the stresses experienced by workers is provided in the NYT article about a pilot whose wages were cut in half when he was forced into a lower position with his airline. This is far better than being out of a job, however this results in a variety of negative ramifications to the worker and his well being. Here is a link to the article: http://www.nytimes.com/2009/10/14/business/economy/14income.html?th=&adxnnl=1&emc=th&adxnnlx=1255521777-AqOMsLK3sCDCBUfOCqSfzA

The effects of such a change include: the demeaning aspects of being demoted (even if to save the job); anger (related to being demoted for no reason, having to work the same hours and probably similar tasks, loss of status); irritability and ‘flying off the handle’; constant worry about meeting financial responsibilities; working more than one job to make up for the loss; among a variety of other things. The work-family interface takes a hit as well, with all family members experiencing greater pressure and need to adapt to this external stressor.

Several other employers are cited in the article as following the same path, either cutting pay or decreasing employee work hours. The Bureau of Labor Statistics indicates that weekly pay of production workers (80% of US jobs) has decreased for the past 9 months. This decline is similar only to declines from the Great Depression.

Another form of pay cut is to increase workload for a job, which has also become increasingly common. Of course this change is not measurable in weekly pay of workers. I’m not aware of any systems to collect this information. This is an all too common experience: not filling open positions or cutting or laying off workers and redistributing work among those left behind. This experience is perhaps measured partly in scales of psychological demand, although I do not think that this is a precise measure of the practice. We do know that psychological demand, a common workplace stressor, has negative health effects, including increasing risk of depression and cardiovascular disease. I suspect in some types of work the risk of employee injury increases as well.

Another problem with the practice is that individuals often are afraid to speak up about these negative changes for fear they will be let go. Individuals tend to meet the increased needs they face, in an effort to help out, and to be perceived as someone willing to pitch in at the time of crisis. The problem is that the crisis never ends. How long do employees continue to work with increased demands or reduced pay or hours? That is the question…

I’ll have to look and see if the Bureau of Labor Statistics keeps any data on this problem, which is perhaps new, but all too common in our current economic reality.

Chronic Fatigue Syndrome: Hopes Raised with Discovery of Virus

Chronic fatigue is an interesting clinical syndrome that quite often gets an individual either referred to psychiatry or diagnosed with psychiatric problems. It has stumped clinicians in terms of effective treatments.

The current study discussed in the article below, has identified a retrovirus that was present in 67% of those with Chronic fatigue vs. 3% in the general population. This is promising, but not quite as sensitive or specific as one would wish.

This syndrome is a good example of how health care providers often marginalize conditions that they are not able to identify and manage well. Some of this results from the desire or expectation (unrealistic usually) that our health providers will identify, manage and alleviate our health problems. A result of this projection is the provider often feels a failure for not being able to cure problems that still have not had adequate study. Then I think the marginalization happens, and often the problem gets labeled a ‘psychiatric or mental health’ issue. When this happens it is as if the world is then saying it is all in your head. As if you are making it up! What a crime!

I have known many people with Chronic Fatigue who were quite well balanced and without psychiatric symptoms of any kind until this syndrome literally ‘took over’ their lives. I have also worked with patients referred to psych as a last ditch effort to ‘fix this person’. Unfortunately we cannot ‘fix’ those with this syndrome. I am certain that psychotherapy (and some pharmacologic agents) can be helpful to those coping with this problem. But I do not see it as that different than coping with many chronic diseases.

Perhaps health care providers need to be more comfortable with what we have not yet learned. If we owned up to what we were not certain of, the expectations of those we serve would also be lowered. Perhaps then those with real health problems would not be 'banished' to psychiatry.

Hopefully this study is a true step forward in our learning more about Chronic Fatigue Syndrome.

http://www.nytimes.com/2009/10/13/health/13fatigue.html?pagewanted=1&_r=1&th&emc=th

More on SSRI’s and congenital malformations...

A new study is available that examined nearly a half million children born in Denmark (oh, the beauty of having readily available data!) between 1996 and 2003 finds a higher risk of septal heart defects (OR 1.99, 95% CI: 1.13 to 3.53) in those filling prescriptions for SSRI’s overall. Here is a link to the study:
http://www.bmj.com/cgi/reprint/339/sep23_1/b3569 Pedersen, L.H., et al. (2009). Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study. BMJ, 339(231).

This looks like a study that was carefully carried out, and it does provide further data that there are risks to the child from the mother’s treatment with an antidepressant drug early in pregnancy. I have mentioned in prior posts my concerns about use of psychotropic drugs during pregnancy (here is the link to my prior blog posting:
http://blogs.yale.edu/roller/page/mentalnotes?entry=psychotropic_drugs_during_pregnancy) The prior studies seem to show that there was greater risk of problems with using fluoxetine and paroxetine (which led to warnings issued). Particularly at risk were women using SSRI’s in early pregnancy, who also smoke. This of course is quite applicable to most of the women we treat in mental health settings. It is a good reminder to discuss the risk with women as well as discuss and plan appropriately if the woman is planning a pregnancy.

This study found greater risk of septal defects with use of sertraline (3.25 times the risk) and citalopram (2.52 times the risk). Added info offered with this study is that risk of heart defects were even greater in those using more than one type of SSRI (overall risk of heart malformations OR: 3.42, 95% CI: 1.4-8.3; and risk of septal defects OR: 4.7, 95% CI: 1.7-12.7). That also suggests that in younger women we carefully examine our polypharmacy practices (yes, I have a prior post on that as well… http://blogs.yale.edu/roller/page/mentalnotes/20081208) and won't get into that now.

This study is a good example of how difficult it really is to know harmful effects of treatments. There is a need for large population based studies to answer questions like this. The authors of this study (which evaluated a half million liveborn children from 1996 to 2003) suggest that studies be carried out in larger populations to determine the true risk (as # of exposed children was n=1370 of the half million studied). (i.e. if untoward events occur at a very low rate(say < 1 in 10,000), then the n exposed (n=1370) may not be large enough to expect to get even one occurrence)

I don't think we can afford to take lightly the risk of medications during pregnancy. A careful and well thought out plan for how to protect both Mother and baby is important.

I wonder if the prevalence of antidepressant use in pregnant women is higher in the US?

Sports and Risks of concussion

A new study has found much higher rates of dementia in retired NFL players. Here is the link to the NY Times report on it: http://www.nytimes.com/2009/09/30/sports/football/30dementia.html?_r=1&th&emc=th
Evidence has been accumulating on this issue for several years, it will be interesting to see how it is handled by the NFL. Prior studies have also linked concussion to depression. This study was done by a pretty reputable group (Univ of Mich Institute for Social Research).

Of course this has implications for many children and adults who are injured in sports and other activities. I've heard from many school nurses who find that injuries on the field are being taken much more seriously than they had been previously.

Unfortunately I've also heard stories of children being knocked out (and not responsive) on the field who go back in to play after injury rather than going to be evaluated medically. It seems coaches, athletes, and parents need better education about the risks of 'playing through' an injury. Particularly given this new evidence.

The idea that football which already has a host of protective gear in use including helmets, has this problem is troublesome. How will we protect children and adult athletes from these injuries?

Evening event: Thursday Oct 1, 2009

We are hoping the word has gotten out to Psych APRN's in the area to join us for an evening of discussion related to the future of our profession (both Nationally and in CT) and networking. Hope to see you there!

LACE and the Advanced Practice Psychiatric Nurse (APRN)

There is a lot happening nationally in Advanced Practice Nursing. It is unsettling at times because it is unclear whether the voices of all Master’s prepared psych nurses are being heard. Given that whatever happens with LACE (which stands for Licensure, Accreditation, Certification and Education) recommendations will affect the ability of nurses to practice (and find work) in the future. I hate to think that a small group of nurses are chosen to decide the future of our profession without all members of the profession having input. This is an issue affecting our livelihoods and careers, and for this reason all the professionals involved should be represented.

The current proposal, approved by APNA (the American Psychiatric Nurses Association), involves APRN's in psych being considered a ‘population’ rather than a ‘role’. Examples of roles in Advanced Practice nursing are Nurse Midwife, Nurse Anesthetist, Nurse Practitioner, etc. Examples of populations, as currently defined are gender, pediatric, psychiatric/mental health (see the links below for further info). My view is that Psych-Mental Health APRN’s should be considered a role. Unfortunately this was decided by a small subgroup working on the model, and to my knowledge did not involve input from all involved. There are several problems with this decision:
1. We should have autonomy in defining the future of Psych Advanced Practice Nursing. We remain tied to NP and CNS group regulation. This is despite our clear differences in focus and role. These other groups do not understand or know what the Psych APRN role is, yet they define competencies and other standards that guide education, practice and certification.
2. We are not able to define the specific aspects of role unique to psych that are not applicable to any other specialty group.
3. We remain stuck with two kinds of psych APRN’s: NP and CNS despite the fact that these roles have been shown to be nearly completely alike. This means we also have 2 kinds of certification again despite the redundancy in role.

The other aspect of the models being considered are that our educational programs must provide a lifespan approach to education. I think this is fine, however I think we may be taking this a step too far in relegating that in the future all Psych APRN’s will be Family Psych NP’s. While it is an interesting population level solution for providing care to children/adolescents in rural areas, I think it will produce a very generic graduate without much skill in any population (this is expected to require 200 clinical hours for each student in each population group: child, adult, geri). We are all very aware of the differences in skills required to treat children and adolescents vs. adults and elders. I do not think this is the best plan for the entire profession. Graduates will have little focused experience with psychotherapy and medication management in any population group. In addition, I rarely see clinicians or students entering our program who are interested in working with all population groups.

Finally, I would like to see that planning is in place for articulation of all Master’s prepared psych nurses with the new requirements. For example,
· What will current child or adult CNS’s and NP’s do? Will they be allowed to practice as a ‘Family Psych NP’?
· What will Master’s prepared psych nurses do who have completed their educational preparation but are not currently CNS or NP certified or licensed as an APRN? This happens due to family obligations, practicing in a clinical or work site where certification is not required, and in some states due to lack of definition of roles related to APRN billing or prescriptive authority.
· Who will teach the new ‘Family Psych NP’? As we change certification and educational requirements we have not been vigilant about articulation for those with the most experience who have actually developed psych Advanced Practice roles. Will Psych CNS’s remain eligible to teach in Psych NP programs? Will the Adult CNS or NP be able to teach the Family Psych NP student? We have a shortage not only of direct care providers but of nursing faculty as well. What plans are being made for role articulation from the many current levels nurses practice from now?

This is an issue affecting all of our livelihoods, I think the voices of psych APRN's need to be heard by our national leaders. We cannot accept a group of 7 or 12 individuals deciding the fate of an entire professional group. Not when it affects whether you or I will be able to practice and make a living. I encourage all Psych APRN’s to be vocal about this. In addition Psych RN’s should also be vocal. This is their future as well, they may decide to take the next steps and further their nursing education.

The other side of this is that we can’t afford to complain about the resulting plans if we haven’t taken the time to learn about the issues and told our representatives what our wishes are.

Here is a link to the APNA website where you can begin to see some of the plans that are being made. I’d love to hear your thoughts!
http://www.apna.org/i4a/pages/index.cfm?pageid=3498 (on LACE)
http://www.apna.org/i4a/pages/index.cfm?pageid=3707 (on APRN Consensus Model)
http://www.apna.org/i4a/pages/Index.cfm?pageID=3717 (presentation on options for Psych APRN’s

If any of you are going to be in or around New Haven, CT in the next week, our APNA Executive Director, Nick Croce will be part of an evening event where we will hear the latest on Psych APRN issues. Consider joining us for the evening!

Signs of suicide

I was reminded by the article written about Finn Casperson’s death, of the signs often present when a person is contemplating suicide (http://www.nytimes.com/2009/09/16/business/16suicide.html?_r=1&th&emc=th). A prominent businessman, Casperson resigned from several boards he worked on as well as put his property up for sale prior to ending his life. While the ‘news’ side of the story relates to speculation that he had hidden his money away to avoid taxes and might soon be caught, this potential which obviously might be very stressful, is second to the fact that he also had kidney cancer. It is unfortunate that this angle was chosen for the story. It appears this businessman and philanthropist will now be dragged down in the desire for a story.

There were some cues to suicide in this story that are good reminders for us: his resignation from several boards, stepping down from civic and private positions that it appears he found quite meaningful and important; and placing his estate up for sale. Those seem to be signals of a person withdrawing from his life. We know that often prior to ending their lives, individuals do try to put things in order and take care of things important to them. Of course in the context of treatment for kidney cancer, it might be perceived that these were a way to limit activity and focus on getting well.

It is always important that clinicians consider stressors as well as actions taken by individuals in trying to determine their safety. Mr. Casperson’s story shows us a good example of this often overlooked sign, which we do try to recognize in those we assess who are depressed or overwhelmed by many stressful events.

We often discuss how difficult it is to really be certain that your assessment of someone’s mental state is accurate. Newer students feel their lack of experience contributes to having a less definitive knowledge of whether someone ‘is safe’. The article does not indicate whether Mr. Casperson’s family, friends, or caregivers had any awareness of the potential for suicide.

Unfortunately Mr. Casperson’s story (at least as told here) is a reminder that there are times we will not know how deeply a person is suffering, and that if intent on ending their life, individuals are quite capable of keeping this hidden from those who know them best. My heart goes out to his family and friends who suffer now with his loss.

A step in the right direction for those with disabling mental health problems?

I think I am pleased to see the state of New York taking a stand to protect the rights of those needing continued treatment and assistance living in the community. There is a link below to the article reported in the news today. http://www.nytimes.com/2009/09/09/nyregion/09mental.html?_r=1&th&emc=th

The reason I am unsure, is that I think this is one small example of the problems created for those with severe and disabling mental health conditions with deinstitutionalization. It will be interesting to see what the next steps are resulting from this ruling. My hope would be that individuals will get care more tailored to their needs.

Another concern is that there are many individuals in far worse condition who are not even in a housing program and receiving services. So on the priority list, I think I would focus on those who are homeless or end up incarcerated because they have a mental health problem. Hopefully this ruling will not result in addition to the ranks of the homeless or incarcerated.

We have a big problem in this country with redefining mental health treatment systems of care. There are problems everywhere with this. The adult homes in NYC are just one example of how a ‘good thing’ (deinstitutionalization and even community based adult homes) can go bad…

Will new pathways and classifications be developed to understand mental health problems?

Genes and Disease… Will genetic links help us discover new ways to understand people with mental health problems? Will these genetic links help in the discovery of new treatments?

Here is a link to an interesting ‘genes & disease’ map to consider…
http://www.nytimes.com/interactive/2008/05/05/science/20080506_DISEASE.html?ref=health#
I can find Schizophrenia and SAD, but I can’t seem to find Bipolar disorder or depression here… can anyone locate it? (psychiatric dx are in green)
Here is the associated article to figure out what the map means. http://www.nytimes.com/2008/05/06/health/research/06dise.html?pagewanted=1

It is interesting to think about the possibilities that arise from studies of these shared links. As the article suggests, there may be drugs used in one disorder that could lead to new discoveries of treatments for genetically linked disorders. This is indeed exciting to consider, particularly in mental health. However the potential for discovery also relates to the mechanisms of action of the drug within the pathway of causality to a particular disorder. So it does depend greatly on how that genetic link cascades out into the actual physiologic abnormality.

There is some discussion of classification of disease in psychiatry in the article as well. One view is that Schizophrenia and Bipolar share some common genetic links. Given this, Dr. Berrettini from Penn suggests we have not correctly categorized disorders. The other view is that even with shared genes the two diseases are distinct. We have all had the experience (or for our newest students will have the experience) of considering whether an individual’s problem is actually schizophrenia or bipolar, and of course there is schizoaffective to consider too.

It is interesting to consider whether the groupings and categorizations we use in psych mental health are helpful (and in what way?).

It is also interesting to brainstorm and open our views to other possibilities of how we might understand and categorize the difficulties of the people we work with and try to help.

What are your thoughts on these categories?

What are your thoughts on the usefulness of considering the genetic links between disorders?