Tuesday, November 30, 2004


As a sleep specialist, I am often asked about insomnia.
Here are some tips about dealing with insomnia:

Although it's tempting to use liquor as a cure for chronic sleeplessness, be warned: Liquor is quite expensive.

Getting more exercise can help combat insomnia. If you suffer from sleeplessness, try shuffling from the bed to the kitchen, opening and shutting the refrigerator door, and shuffling back to bed.

According to researchers at the National Sleep Foundation, there is an actual National Sleep Foundation. Yes, for real.

If you are going to take pills to help you sleep, be sure you take enough to knock yourself out. Watching Good Morning America while sleep-deprived and tranquilized is a hellish experience.

Use your bed for sleeping only. Conduct all reading, eating, phone calls, and sexual relations on the kitchen table.

Try counting sheep, rather than the number of times you've failed as a wife and mother.

If you got less than three hours of sleep the previous night, it's important to inform everyone you meet of that fact all day long.

Minimize noise, light, excessive temperature—all factors that could potentially disrupt rest—by sleeping indoors.

(adapted from http://www.theonion.com/)

Please Note: This is not meant to be taken as actual medical advice.

Psychiatric Diagnosis

An article in the New York Times discusses psychiatric diagnosis: http://www.nytimes.com/2004/11/30/health/psychology/30eat.html.

Criteria for psychiatric disorders are determined by committee. Political considerations (for example, the removal of homosexuality as a psychiatric diagnosis) often play a role in determining the contents of DSM, Psychiatry's diagnostic manual. Currently we have DSM-IV. Soon all will be forced to submit to DSM-V.

Monday, November 29, 2004

Bariatric Surgery

Obesity is becoming increasingly prevalent. One-third of the population is obese (Body Mass Index of 30 or greater). An additional one-third of the population is overweight (Body Mass Index of 25-29.9). The prevalence of obesity is even higher among some minority populations; over 50% of African American females are obese. Obesity increases the risk of hypertension, diabetes, and coronary artery disease.

Surgery for obesity (bariatric surgery) is increasing. I am involved in the bariatric surgery program at the University of Mississippi Medical Center. I screen these patients for sleep apnea (breathing pauses during sleep) prior to their surgery. Usually the surgeries go ok, but there are occasional complications. Nationally, the mortality rate is estimated at 1/50 to 1/1000. As a psychiatric consultant, I have seen several of these patients for depression after they have been in the hospital for months with complications, including fistulas and wound problems. One lady was hospitalized a total of 8 months within a 9 month period.

Medicare now covers bariatric surgery for most of the elderly, though work is underway to standardize the elgibility criteria: http://www.ama-assn.org/amednews/2004/12/06/gvsc1206.htm. We need outcome data in the elderly. Most of the surgical experience so far has been with younger patients. In younger patients, bariatric surgery improves survival in the long-term at the expense of increased mortality in the first several months post-operatively. The risk/benefit ratio in the elderly is uncertain. We also need more standardization of the pre-operative work-up for bariatric surgery in all age groups:

Monday, November 22, 2004


Kevin,MD ( http://www.kevinmd.com/blog/) recently discussed a newday article about medical interpreters:


Many smaller hospitals do not have trained interpreters available. Often family members/friends are pressed into service. This can create problems:

"We had a case where a patient was being treated for a venereal disease and asked the doctor how she could have contracted it. The doctor explained it, but her husband, who was interpreting, told her that she got it from a public toilet," Sala said.

Sunday, November 21, 2004

Developmental Disabilities

A collumn in Psychiatric News (the newspaper of the American Psychiatric Association) comments on the lack of training that psychiatry residents receive in treating adults with autism and mental retardation:


Child Psychiatry fellows receive plenty of experience treating this population, but once they reach the age of approximately 18-21, the patients are transitioned to often ill-prepared general psychiatrists.

Once a week I see patients at Mississippi's institution for the mentally retarded/autistic. I also see more functional patients at group homes. The most frustrating part of this assignment is that I have to invent psychiatric diagnoses for many of the patients in order to treat them with medications. Some mentally retarded patients are impulsive, have mood swings, or are violent. They are like my 4-year old son, except that they are six feet tall, weight 200 pounds, and can do a lot of damage when they get out of control. However, due to a consent decree between the Justice Department and this state institution, I am not allowed to treat their mental retardation. Instead I must give them an axis 1 diagnosis such as "bipolar disorder". A mentally retarded person with "bipolar disorder" is very different from a person with a normal IQ who has bipolar disorder. I don't mean to imply that I arbitrarily give these patients a psychiatric diagnosis. The full-time psychologists at the state institution have ultimate control over the diagnosis given the patient, and make sure that DSM-IV criteria are strictly followed. Something just seems wrong about giving the same diagnosis of bipolar disorder to someone with an IQ of 40 who has increased energy most of the time and is constantly pacing and a person with IQ of 100 who has clearly alternating depressive and manic episodes.

On the other hand, my experience is that depression in the mentally retarded is very similary to depression in the normal-IQ population. Depression is common among institutionalized individuals with an IQ of 50-70; these individuals often express frustration about not being able to lead a "normal" life.

I don't want to give the impression that mentally retarded individuals at the state institution are all medicated to control their behavior. Medication is only tried after behavioral interventions fail. Less than half of the residents of this state facility are receiving psychotropics.

Gradually, through experience and reading, I feel that I have gained competence in treating the developmentally disabled. However, I wish that I would have received more training during residency.

More on Antidepressants and Pediatric Suicide

Another article from the New York Times about antidepressants and Pediatric suicide:


Antidepressants and Suicide

The New York Times Magazine has a good overview of the possible link between antidepressants and pediatric suicide: http://www.nytimes.com/2004/11/21/magazine/21TEENS.html?pagewanted=1.

In the first several weeks of treatment, antidepressants can cause activation and this can increase suicide risk. In general, antidepressants over the longterm decrease the risk of suicide:

"The pharmaceutical companies are clearly making a product that most psychiatrists consider critical to treating depressed adolescents. Not prescribing these drugs may very well pose a greater threat than prescribing them. Studies have shown that areas in which antidepressant use among young people is widespread have experienced a dip in teenage suicide rates; according to Dr. John Mann, a suicide expert at Columbia University, fewer than 20 percent of the 4,000 adolescents who commit suicide in America each year are taking or have ever taken antidepressants."

Each patient responds to an differently to an antidepressant, and he must be monitored closely for side effects. My adult patients often need to take benzodiazepines such as klonopin or ativan to treat the anxiety, jitteriness, and activation that can be experienced during the first 1-2 weeks of antidepressant treatment.

Child and Adolescent Psychiatry is a difficulty field (which is one of the reasons that they make about $50,000 more per year than us general psychiatrists). There is currently a shortage of Child and Adolescent Psychiatrists. The new FDA black box warning on antidepressants and suicide is going to make pediatricians and family practitioners less willing to treat behavioral problems in children:

"while many child psychiatrists are unlikely to change their attitude toward S.S.R.I.'s, most pediatricians and general practitioners, who until now have written the bulk of these prescriptions, no doubt will. This could mean a lot of untreated children. There are only 7,400 child and adolescent psychiatrists in America; even in areas with high per-capita concentrations, the average wait to see one is six weeks. There is also the matter of cost. Many child psychiatrists charge steep hourly rates that are only partly offset by health insurance providers."

Part of my job as the Consult Psychiatry director at the U of MS is performing consults on pediatric patients (we have a shortage of child psychiatrists and our few child psychiatrists are not available to perform inpatient consults). Due to the legal risk, I now limit myself to triage of pediatric patients who I am asked to see for depression- I basically determine if the child needs transfer to a psychiatric ward or if he needs outpatient treatment with a child psychiatrist (of course, just recommending outpatient child psychiatric follow up doesn't ensure that it happens- it's a broken system out there, and not every child receives the help that he needs). With the current legal climate, I would never myself initiate treatment with an SSRI on a pediatric patient.