Head-Meds For Kids…Or..Medicine for the Child’s Mind?

 

May 6, 2016,  I am booked. Geez, that is advanced planning. Three hours, I have, to discuss medicating kids to mental health professionals dedicated to working with children. As usual, I expect to gain far more than I give, as this audience are folks who have spent years fine-tuning their skills to work with disadvantaged youth who struggle with coping with their circumstances. Nature and nurture will be discussed heavily, as the decision to medicate a child is never easy, simple, or straight-forward. The decision is made after a thorough history, but whose history? The parents, the child, another clinician, or all of the above? Yet, my first order of business is generating a title. I have a series of lectures which begin with Medicines for the…fill in the blank. Originally, I kept a similar title for all of my talks as a way of picturing my book on psychopharmacology for the lay public. Each talk was a chapter in my book, such that “Medicines for the Mind” was the large title and then there was “Medicines for the Female Mind”, “Medicines for the Old Mind,” and “Medicines for the Child’s Mind.” Yet, as the book has receded in my task list, and, as a patient once said to me, “you want to know about my head meds,” I began to think about changing my title. My next lecture on adult psychopharmacology will be entitled “Head Meds” but for my “kiddy talk” I will stick with “Medicines for the Child’s Mind.” I want to emphasize that the complexity of working with children is that their minds evolve as time goes on, such that all practitioners are made humble in that we never know whether we had an impact or maturation finally kicked in. I suppose the same is true of parenting. Parents take credit for “how well their children turned out,” when, in fact, it could very well be that their brain was developing in a non-linear fashion such that the child surprisingly became a responsible adult. Oh, so we return to nature vs. nurture, in which I will say that if the child does well it is nurture, and if he does not, it is nature. I hope I will get a laugh.

Neuroscience Comes Alive!

 

http://www.latimes.com/news/science/la-sci-transparent-brain-20130411,0,313957.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.

Brain Plasticity

Schizophrenia is a problem with brain mapping, so says Sophia Vinogradov MD, a psychiatrist from UC San Francisco. As such, cognitive enhancing programs might, and she said might at least twenty times during this one hour Grand Rounds, improve the outcome of this dreaded disease. She reminded the audience, filled with psychiatrists, that it was only twenty years ago that we were all taught that the brain stopped changing somewhere around age fifteen. Now, we know that the brain changes throughout one’s lifetime, albeit at different rates of change as we age. Learning, she reminded us takes place with repetition. I think we all know that! More specifically, she taught us that the first time we learn a new skill, we are tentative, but with intensive repetition, that skill, like playing scales on a piano, becomes automatic. I think we all know that too. This automatic quality to a new skill is evidence that we have created a new “brain map”. As such, we can train our brain, if we apply intense repetition, to form new neural connections, and hence new skill sets. Little children, it seems to me, need less repetition to develop new brain maps, and hence their brains are more plastic. Aging, in other words, demands from us that we have to work harder to acquire new ways of thinking, but the good news, is that we can expand our brain, literally. Phew!

 

http://www.psychiatrygrandrounds.com/namedlectures/may.html

Sleep, Memory and The Brain: Science Validates Common Sense

Do you want to learn new material? Go to sleep. I knew that in college. An awake mind is more efficient. Do you want to do well on a final exam? Go to sleep. I knew that too. Sometimes  I think that my college success was based on knowing this principle and thereby shunning the notion of an all-nighter. It felt to me that I had better retention with more sleep, so sleeping was my tool to academic accomplishments. Yesterday, Matthew Walker MD said the same thing, http://psychology.berkeley.edu/faculty/profiles/mwalker.html at UCLA Psychiatry Grand Rounds. The hippocampus, the part of the brain responsible for memory, is more responsive after sleep, be it a nap or a night-time rest. He had pretty brain pictures, randomized controlled studies, and a videotape of a Harvard University undergraduate trying to get a thirty page paper done on no sleep at all, demonstrating that sleep changes brain function for the better.

Now, although he was a wonderful speaker, I felt like I already knew what he was saying, when of course, the science of it all, is brand new. The lecture became more engaging as he said we not only sleep to learn, we also sleep to “forget” the emotional association of memory. Sleep, he says, often strips the emotional aspect of the event, while still preserving the narrative memory. “What about PTSD, I asked my colleague/audience neighbor?” Almost immediately, as if he heard me, he said that “in PTSD, one is unable to strip the emotion from the memory, and hence the sleep in PTSD is characterized by nightmares.” Wow, that makes sense to me. The adage that “time heals all wounds” is mostly true, because as we sleep every night, the emotional aspects of memory fades, except in extreme trauma, where the emotion can persist for years and years after a devastating event. This was the most intriguing part of the lecture. Sleep not only refreshes the learning aspect of our brain, it also refreshes our baseline emotional state-most of the time. My take-away was that the value of sleep trumps almost everything and although sleeping medications are a last resort, getting people to sleep can be a key intervention for mending mental health. I knew that. Now, I have science to back me up. Thank you, Dr. Walker.

 

http://www.youtube.com/embed/giKIFuw5fy“