PMDD Walks Into DSM 5

 

PMDD, premenstrual dysphoric disorder is currently a diagnosis in the appendix of DSM IV, meaning that if a physician believes the patient has PMDD, then he/she must write Depression NOS (not otherwise specified). At the same time, there are currently drugs approved for PMDD, despite the fact that it has not achieved diagnostic status. Well, come May, 2013, after Bill Clinton speaks to the American Psychiatric Association in San Francisco, California, the DSM 5 will be announced and the criteria for mental illnesses, in the United States, at least, but probably around the world, will change, including more folks, causing a large stir about the wider scope of psychiatric disease.  DSM IV came out in 1994, making almost ten years of a classification system, which for the most part, has not matched the explosion in psychopharmacology. DSM 5 has taken a long time, mostly, as I can tell, because the debates over the diagnostic system were tense. So, it is very likely that PMDD will hit the light of day and now women who suffer from terrible irritability before their periods will merit a psychiatric diagnosis. The good news is that there will be more acceptance of the biology of mood swings, and then hopefully more acceptance of psychopharmacological interventions. The bad news is that some women, through no fault of their own, will be labeled, potentially increasing their premiums for health insurance, life insurance and disability insurance. The triad of emotional lability, irritability and anger, during the luteal, or last phase of the menstrual cycle, in about 2-5% of menstruating women, had been validated in the research over the past 20 years. This additional research, the DSM 5 committee argued, gave good reason for PMDD to be “promoted” to  a diagnosis and out of the appendix. PMDD now joins the ranks of a full blown mood disorder; it is in parallel with bipolar disorder, which also has prominent mood lability and irritability, but PMDD symptoms cease on the first or second day of menses. Plus, PMDD comes with physical symptoms of bloating and breast tenderness, making it easily distinguishable from bipolar disorder. What about heritability? You ask, knowing that most psychiatric diagnoses run in families. The heritability of PMDD ranges from 30-80% which is indeed, a wide range, but enough to merit a full diagnosis. What about treatment? PMDD is ameliorated with an SSRI (Prozac and his cousins), quickly, unlike when an SSRI is used to treat Major Depression. Also, intermittent or continuous treatment are both helpful, suggesting that a constant blood level is not necessary, but rather more serotonin in the premenstrual or late luteal phase, seems to do the trick. So, the world will change in May, 2013, the psychiatric world, that is, and hence all of us who work, love and/or experience others who suffer with negativity, irritability, and quickly shifting moods. Now, women who cycle in and out of these mind states will be legitimized on the one hand, and maybe, but hopefully not, stigmatized, on the other.

Why Would One Size Fit All?

 

http://www.latimes.com/news/opinion/commentary/la-oe-miller-drug-dosages-20130227,0,6503040.story

 

Dr. Miller talks about how, late in the game, dosages for Ambien are being modified for women. This seems so obvious. Anyone around alcohol knows that the average woman tolerates a lot less than the average man, of the same age. No one would go to a store and ask for a “shirt” without specifying the size. The individuality of drug response follows the individuality of our DNA. Personalized medicine is coming. Once we can take a closer look at the genome, then prescribing medication will be more specific, and hence more effective. In today’s world,  prescribing medication is like  shooting in the dark, hoping that for most people we are in the “range,” but we also know that we could be far afield. Like with smart phones, one day, we, physicians will say, can you believe that in the old days, we prescribed without knowing about the patient’s liver metabolism? I look forward to laughing at our current state of psychopharmacology.

Doctor, Patient and Pharmacies: An Oedipal Triangle

 

For years, pharmacies call me “demanding” a refill for a patient. Sometimes I have never heard of the patient. Other times, I just saw the patient and handed them a prescription. Still, other times, I have not seen the patient in quite some time. Without knowing the circumstances, pharmacists leave messages like “this is our third call,” as if, I have been a “bad girl” and not responded, as if I need to respond to a message that does not make sense. Today’s LA Times, exposes a practice that I have long suspected. Pharmacies call for refills, even when the patient does not ask for a refill, so that they can bill the insurance company. “That is why I don’t call back pharmacies unless the patient tells me ahead of time that I will get a call,” I want to scream to all who will hear. As I see it, the pharmacy represents an intrusion into my relationship with my patient. I work to help my patients, not the pharmacy. The pharmacy enters into my relationship with “demands” which I find out of place. One of the many advantages I have, by not having a staff, is that I am on the front lines with all of the administrative details of practice. My ship is small, but it sails. No intrusions allowed.

 

http://www.latimes.com/business/la-fi-cvs-caremark-20121024,0,6138463.story

SIG-E-CAPS

This is the mnemonic for diagnosing depression, according to our current manual, DSM-IV. Five symptoms, two weeks, seriously? Let’s review. Suicidal thoughts, are these active or passive? Perhaps they are related to a traumatic event. What if they go away in three weeks, then does the person still get a diagnosis of “Major Depression”. Interest in activities, is this losing interest or diminished interest? What if the person is fatigued, as a result of anemia, and this explains the lack of interest in activities? Guilt, my favorite criteria, since so much of guilt is unconscious, are we talking about conscious guilt? If so, very few people admit to this, particularly not int he first interview. Energy, see my comment on interest. Concentration, again, see my comment on interest. Appetite, decreased I can understand is a sign of mental dis-ease, but increased appetite is often a result of increased energy expenditure. Psychomotor changes, maybe a result of fatigue, or boredom, not necessarily depression. Sleep, same as appetite, in that it is often dependent on activity level.

So, am I dismissing our current diagnostic system? Yes and no. Symptoms must be taken in context. Context is understood through building a relationship where the patient increases trust, and therefore feels more free to display the context of his/her symptoms. A rush to judgment leads to a rush to medicate, leads to a patient not understanding his/her own mind. A delay in judgment could lead to needless suffering, but I would argue that the relationship building helps the suffering, so while I obtain a thorough history, I am also helping the patient symptomatically by providing a space for thought and reflection.

I want the patient’s history to become relevant again in psychiatry. This is a major reason I have this blog. I will repeat this point until my field changes its emphasis, or until I retire. I hope for the former.

Medication Meaning

Donny, forty-three, fights with himself over taking psychotropic medications to help his mood. He feels his medication symbolizes his “weakness,” his inability to help himself. His shame around his medication is projected outwards such that he feels that I am “forcing” him to be on medication. By making me the parent, he takes on the role of the child who is helpless and resentful. Over the years we have discussed this dynamic at great length. “I see your point,” Donny says, “but I have to say it is hard to hear that I am acting like a child.” “Yes, I know it is hard to hear that, but maybe if we can think about this together we can come to understand how hard it is for you to take responsibility for your decisions.” I say, trying to help Donny take more ownership over his life. “I just wish I were not on medications.” Donny repeats. “It is really your decision. Again, this is an example of how you are able to choose being on medications or not, and yet your words make it sound as if I am forcing you to take psychotropics.” I say, rounding this bend. “I am going to think about what you are saying without feeling hurt by it. I think you are saying something important, but I am not sure I can hear it right now.” Donny says with his characteristic sweetness.

Transferring Care

   Bella, twenty-four, has seen me since she was fourteen, when she was in the ninth grade and started to fail in school, after an academically successful experience in elementary and middle school. Bella’s mom knew she needed medical attention, so after many physicians, the two of them, along with Bella’s dad, landed in my office. She was a relatively straight-forward case of ADHD. After much hesitation from her parents, she went on Ritalin and her grades rapidly improved. Bella, it turns out, had a similar history to her biological first cousin who also had a robust response to stimulants, but Bella’s parents found this out after Bella started treatment. Fast-forward ten years and Bella has just started medical school in another state. She is doing very well, although she is struggling with getting her stimulant prescription filled. She reports that the doctors at Student Health Services do not “believe” in giving stimulants for students to do better at school. I send a summary of my medical records, which reviews my extensive evaluation process, her response to treatment and my contact information. Apparently, according to Bella, this is not good enough. They need more information. “What would they like?” I ask, knowing that I have fulfilled my legal requirement to give a summary of the medical records to the next treating physician, at the patient’s request. “They want to talk to you,” Bella says with tremendous frustration. “That’s fine,” I say, “but when I call they are not available, and they won’t put patient information on email, so I am not sure what else I can do.” I say, feeling bad for Bella, understanding her stated predicament. “I can send you prescriptions, but we will need phone sessions,” I say, knowing that phone sessions are always my second choice, given that face to face communication is so much more valuable, therapeutically speaking.  

    Transferring care is a challenge. Relationships with providers, like all relationships, are unique and hence they are hard to replicate. Bella may be at a University which is particularly antagonistic to prescribing stimulants to students, and/or Bella could be resisting the change in how she was getting her medication. Maybe, in other words, she misses our relationship. It is hard to say. I will talk to her about that this week. We have known each other a long time. I have watched her grow up and now, perhaps, I will watch her develop as a physician. If the stress of renewing her prescription leads us to return to work together, maybe this is a good outcome. On the other hand, she may need a physician closer to school. It is a tough call. We will see how it goes. One thing seems certain: Bella’s determination will serve her well. She is on a good path.

Zoloft Magic

Carol, seven years old, was easily aggravated. She worried about middle school even though it was four years away. She worried her parents would die, even though they were both healthy. She worried about being upstairs in her house alone, even though she had lived in the same house for her entire life. She worried when she was separated from her mom, be it at school or at a friend’s birthday party.  Carol tried play therapy and behavioral therapy. She enjoyed both experiences, but she still had her worries. As a last resort, Carol and her parents came to me. After much deliberation, we decided to give Zoloft a try. Both parents had histories of anxiety and both parents had positive responses to SSRIs in the past. Carol started on Zoloft and within a week, she was more “fun to be around,” according to Carol’s mom. Separation was no longer a problem. Carol reported that her worries “went away”. Carol had no side effects, only the positive benefit of not worrying all the time. Success-at least, for now.

See also…..http://shirahvollmermd.wordpress.com/2010/11/17/zoloft/

Therapeutic Ambivalence

  Maria, http://shirahvollmermd.wordpress.com/2010/01/24/i-dont-like-it-when-you-look-at-me/, thirty-three, comes to her monthly appointments “confessing” how she changed her dosages of medication. Her sister is a primary care physician, so she often “consults” with her and then changes her pharmacology accordingly. “You have problems trusting me,” I say, making her instantly uncomfortable. “I come here for a long time. I could get my medications from my internist, but I choose to come to you,” Maria says, bringing up some good points. “Yes, but at the same time, you feel the need to make your own decisions about medications, rather than discuss the issues with me. Both are true: you put a lot of faith in me, and you don’t want to be dependent on me, so you work independently.” I say, showing her the layers of her mind. “I guess I should go back up on the medication,” Maria says, as if I am concretely telling her to return to the dosage I prescribed. “The dose is not the important thing here at this moment. The important aspect of our conversation is your ambivalence in our relationship, which might reflect on how you have ambivalence in other relationships as well.” I say, trying to highlight the underlying issue of communication versus unilateral decision-making. I am trying to talk about her mixed feelings in our relationship which manifest themselves by her adjusting her dosage,  independent of my opinion. Maria looks like she wants to think about what I am saying. She leaves with some agitation, but she also looks like she appreciated the challenge to her thinking. Doing psychopharmacology, like in all doctor-patient interactions, bring up the issue of relationships, bringing to the forefront issues of communication and trust. Once again, the notion that a psychiatrist can “just do meds” is ill-founded. Understanding dynamics is critical to all relationships which are so loaded with deep underlying issues. Maria and I have work to do-psychodynamic work, that is.

Psychopharmacology Excitement

   Don Levin, I knew that name was familiar. I met him today at a speaker training meeting for a new and potentially exciting psychopharmacological agent, Viibryd. I looked at him, like I knew him from somewhere, and over the course of about thirty seconds, I said “are you the New York Times guy?” When he said “yes” I  started stamping my feet with excitement. Sure enough, his side of the story is so different than the New York Times, http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=2&scp=1&sq=psychiatry&st=cse, that although I appreciated the opportunity to rant, http://shirahvollmermd.wordpress.com/2011/03/09/i-repeat-where-did-the-listening-go/, I felt bad for feeling so negative about him and the state of my profession. Although I did not get the opportunity to go into detail with him, the gist of his message was that he faced a career transition and he made his best judgment under those circumstances, which were not outlined in the article. Meanwhile, we were both excited to learn that maybe the stalled psychopharmacology world is beginning to start up again. Prozac came out in 1988 and the world changed. Since then, we have stalled, such that after twenty-one years, the wonders of Prozac have fallen like the wonders of antibiotics. The first few years were exciting, and then it became old news. Don’t get me wrong. It is still exciting to see people go from suffering to enjoyment, as a result of a multimodal intervention which includes psychotherapy and psychopharmacology. It is still exciting to teach primary care physicians how they can help people have a better quality of life. Yet, the learning curve in this psychopharmacology world came to a flat line. Almost all of the newer medicines on the market imitated the wonders of Prozac. The nuances were helpful, but not that thought-provoking. As a result, both the field of psychopharmacology and the psychiatrists who identified themselves as psychopharmacologists, were losing their luster. We, as a field, are ripe for a new paradigm to treat depression and anxiety. Viibryd might provide this, which means there is hope not just to treat patients who have not responded to our current armamentarian of drugs, but there is hope to reinvigorate my profession. Dr. Levin, I apologize for using you as the springboard to talk about listening. Having met you, I now respect your decision to take a turn in your career which made sense to you at the time. The complexities of that decision, which you only hinted at, changed the notion that you somehow wanted to stop listening. It was really nice to meet you.

Psychopharmacology Ranting

The word on the street is that psychotropics are being prescribed for people who do not have mental disorders, implying that primary care doctors are overprescribing SSRIs, the class of medications most commonly used to treat anxiety disorders and depression. http://content.healthaffairs.org/content/30/8/1434.abstract. Here comes the rant. In point of fact, SSRIs are underprescribed by primary care doctors because in general, primary care physicians do not take the time to inquire about their patients’ mood state. The problem with this article, which has been picked up by the popular press, is that are diagnostic system is imprecise, such that it is appropriate to prescribe SSRIs to people who do not meet criteria for a mental disorder, but still have disabling symptoms which significantly impair their quality of life. Clearly, the problem is that primary care physicians are not documenting the indications for the SSRI, making it look like they are overprescribing them. The adage ‘if it is not written, it did not happen’ applies here. Primary care physicians, in general, are not trained to document the symptom which triggers the prescription for psychotropic medication. They are trained to document a diagnosis, such that when the patient does not fit in the category of a mental illness, then the physician prescribes the medication but does not communicate in the chart the basis of that prescription. This then becomes a problem of documentation, not a problem of overprescribing. This is also a problem of training. Primary care physicians need to be trained by psychiatrists to prescribe SSRIs, not by other primary care physicians, which is what is most commonly done now. Psychiatrists who work with psychotropics every day are more skilled at the important nuances of treatment, so they should be the ones coaching the primary care docs about psychopharmacology. This seems obvious, yet it is not usually done. One reason is the lack of respect for psychiatry as a field. Those doctors trained before 1988, trained before Prozac came out, and as such, their view of psychiatry is that it is a field which does not have a lot to contribute to the walking wounded. That is, to them psychiatry is a field which is only useful for chronic mental illness. My hope is that as more doctors are trained ’post-Prozac’, then more physicians will have respect for psychiatrists who can help them improve the quality of their patients’ lives. I hope and I rant. That is not a contradiction.