CAMHblog: Posts http://www.camh.ca/blog/Lists/Posts/AllPosts.aspx RSS feed for the Posts list. Wed, 19 Jun 2013 10:52:53 GMT Microsoft SharePoint Foundation RSS Generator 60 en-US CAMHblog: Posts http://www.camh.ca/blog/_layouts/images/siteIcon.png http://www.camh.ca/blog/Lists/Posts/AllPosts.aspx DSM Diary: Part 3 http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=94 Contributor: David Goldbloom
Category: Care and Treatment
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​May 20

For a change, I decided to spend the morning at a research session unrelated to DSM5.
 
And I am amply rewarded, reminded that research and debate on classification systems is among the least interesting and clinically meaningful areas of research.
 
William Bunney is preoccupied with techniques to relieve depression within 24 hours rather than 4-6 weeks, and reviewed such low-tech interventions as sleep deprivation (and a theory that it changes gene expression in clock genes that control circadian rhythm), deep brain stimulation (not for first-time callers to the mental health system!) and ketamine intravenous infusions. All of these techniques produce reliable and reproducible improvements in 24 hours, but the challenge is to keep someone well.
 
A presentation on tic disorders in children covered the evolution from psychoanalysis through antipsychotic drugs to the latest in behaviour therapy (habit reversal therapy), with the head of child psychiatry at Weill Cornell arguing that drugs are rarely needed now. It's good to see child psychiatry moving beyond its late arrival to medications toward other evidence-based interventions. Similarly, a leader in obsessive compulsive disorder showed persuasive evidence that exposure and response prevention is likely the best approach to obsessive compulsive disorder, either alone or as an adjunct to antidepressants, and in her latest study antipsychotic drugs as an adjunct were no better than placebo and far worse than exposure and response prevention. The room never filled for this very rich and clinically relevant symposium.
 

May 21 

I took my usual front-row seat early for a session I was sure would be packed to the gills: perspectives on good psychiatric management in the treatment of borderline personality disorder.
 
Presenters included my friend and CAMH colleague Shelley McMain who has done one of the major research clinical trials of dialectical behaviour therapy versus good psychiatric management in borderline personality disorder, along with Paul Links, a former Toronto colleague who is now Chair of Psychiatry at the University of Western Ontario. They were joined by John Gunderson of Harvard and the woman who runs Gunderson House, the extraordinarily expensive, 60-day inpatient unit at McLean Hospital. Surprisingly, the crowd was sparse - despite most attendees being clinicians.
 
Shelley presented the results of her major trial comparing dialectical behaviour therapy and good psychiatric management (GPM) in a randomized design. The bottom line at the end of treatment and two years later was no difference between the two.
 
John Gunderson went on to characterize GPM - or, as I described it in a question afterward, being a “generic psychiatric mensch”. It is now packaged as a specific form of treatment, complete with manuals, workshops, etc. It appears to be little beyond being a good psychiatrist. And, when I asked, they had not evaluated the GPM model for any condition other than borderline personality disorder.
 

Mindless Neuroscience?

For my final APA encounter, I attended a session on psychiatrists who write for the public, since this is something I do from time to time. About 100 people showed up.
 
It was chaired by Richard Friedman, who has written for the New York Times regularly over the last 10 years. Lloyd Sederer spoke next. He is now the mental health editor of the Huffington Post. Norman Rosenthal, a prolific author, followed him.
 
Sally Satel was the final speaker. She is the author of Drug Treatment: The Case for Coercion, PC MD (how political correctness is corrupting medicine) as well as the forthcoming Brainwashed: The Seductive Appeal of Mindless Neuroscience. She speaks skeptically of "neuro-entrepreneurs", who promote things like neuromarketing. She wrote her new book with some trepidation because she respects the vast majority of neuroscientists.
 
Ten years ago, she was the subject of a protest at the APA in San Francisco, describing her as a "right wing fanatic" because of her PC, MD book in which she critiqued the psychiatric survivor movement. The American Enterprise Institute gives her the freedom to write what she wants, especially in the policy realm. She acknowledges it as a right of centre place but describes herself as a centrist.
 
Her book One Nation Under Therapy is a challenge to the assumption  of vulnerability in the wake of trauma. In her style of challenging assumptions, she finds thinking about addiction as a chronic and relapsing brain disease neither clinically helpful nor satisfying. She has also critiqued disability payments for veterans with PTSD who haven't been through any treatment at all. She gave a marvelous analogy to giving people full disability for a motor vehicle accident before they have had any surgery and rehabilitation. Diagnosis is not the same as prognosis. Despite all this, she doesn't embrace the title "right wing psychiatrist".
 
She spent the first five years of her academic career in substance abuse at Yale testing out new drugs for addiction. She was turned off by the “entitlement culture” at the VA where she worked and saw it as a barrier to rehabilitation.
 
People seemingly upset with her talk - the most engaging and provocative talk of the symposium - kept walking out as she spoke. It was an amazing display of intolerance.
 
I didn't learn anything special from this symposium, although it was interesting to see these very public voices in psychiatry in person. But it was an appropriate finale to the conference for me, after sitting for six hours per day over the last four days in windowless aircraft hangars.
 
The conference and the trip are over for me; I've discarded my admission badge and packed up my bag. I'm eager to be home. My suitcase is now weighted down with DSM5 publications – along with the sense that the new classification system is neither a major advance nor a major difference to the practice of my profession. It won’t make previously well people ill or previously ill people well. It’s a tool which, like all tools in medicine, requires clinical judgment in its use and respect for the larger individual, family and social context in which its many described symptoms reside.
 
 

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Body Description: For a change, I decided to spend the morning at a research session unrelated to DSM5. And I am amply rewarded, reminded that research and debate on classification systems is among the least interesting and clinically meaningful areas of research.
BodyDescriptionLong: For a change, I decided to spend the morning at a research session unrelated to DSM5. And I am amply rewarded, reminded that research and debate on classification systems is among the least interesting and clinically meaningful areas of research.
Featured: Yes
NewsThumbnail: http://www.camh.ca/blog/PublishingImages/2013/June%202013/David-Goldbloom_thumbnail.jpg
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Tags: Treatment
Published: 6/17/2013 11:46 AM
]]> Kate Richards Care and Treatment Mon, 17 Jun 2013 15:44:44 GMT http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=94 DSM Diary: Part 1 http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=92 Contributor: David Goldbloom
Category: Care and Treatment; Mental Health in the Headlines
Body:

​I have always kept travel diaries, if only to remind myself of where I have been, what I’ve eaten and what I’ve done, given the unreliability of my memory. They are not usually about work but rather about escape from work. What follows is a distilled account, leaving out excruciating details of my hotel room and meals that bookended the 6 hours per day of psychiatric meetings in windowless rooms that I dutifully attended. The launch of a new diagnostic coding system seemed a nodal event in psychiatric history, at least based on media coverage. It turned out to be something rather less than the discovery of penicillin, fire, or even falafel.
 
 

May 17, 2013 

It has been probably a decade since I attended the annual meeting of the American Psychiatric Association (APA) –  a mammoth, overwhelming conference, typically attracting 20,000 psychiatrists from around the world.
 
This year heralds the release of DSM5, an event that should be dry and technical but instead has captured the public imagination and stirred controversy and fear about the encroaching medicalization of human experience – not to mention the fear of the threat to our identities that mental illness poses. As I am in the midst of writing a book about psychiatry for the general public, this seemed like an opportune "field work" research endeavour. 
 
On the evening flight to San Francisco, the plane was loaded with more psychiatrists than the 13/100,000 population ratio that exists in Canada. Had the plane gone down there would have been a sudden and major service gap.

 

May 18, 2013

The massive Moscone Convention Center, which spreads out over many city blocks, was jammed by 8 a.m. with psychiatrists from around the globe registering for the meeting. I stood in the kind of line usually associated with airport security to get my badge, guidebook and bag. The course on DSM5 I wanted to attend was sold out.
 
DSM-5_APA.jpegThen I moved into the eye of the storm - the APA bookstore. Thousands of copies of DSM5 and the cottage industry of related books were flying off the shelves, with long queues to pay like people waiting for tickets to a rock concert. I joined in, lured by the 20 per cent discount for members as well as the need to "drink the Kool-Aid" and familiarize myself with the new diagnostic criteria.
 
I emerged into the warm sunlight and a large protest group chanting "Hey, hey, APA, how many kids did you drug today?" and waving placards that said “Childhood is not a disease”. Nearby, a truck with a large video screen and loudspeakers played a film denouncing the DSM, complete with interviews with psychiatrists and psychologists describing the committee work and voting process as less than science. In other words, the annual conference was in full session.
 
 
I went back inside for an afternoon session on anxiety disorders and DSM5. There are now fewer such diagnoses, a vaunted but only technical victory - because OCD and PTSD have been moved to other chapters and agoraphobia has been simplified. These are imperceptible alterations, like invisible weaving. The same applies for panic attacks, panic disorders, generalized anxiety disorder and social anxiety disorder. It made me realize that I didn't know the old criteria in the kind of talmudic detail that would allow me to recognize each of the slight changes.
 

Stay tuned:

This is the first of three blogs written by Dr. David Goldbloom about his experience at the annual meeting of the American Psychiatric Association where the DSM5 was officially released. Stay tuned for Part 2, when the controversial new bereavement amendment will be put under the spotlight.

 
Body Description: On the evening flight to San Francisco, the plane was loaded with more psychiatrists than the 13/100,000 population ratio that exists in Canada. Had the plane gone down there would have been a sudden and major service gap.
BodyDescriptionLong: It has been probably a decade since I attended the annual meeting of the American Psychiatric Association (APA) – a mammoth, overwhelming conference, typically attracting 20,000 psychiatrists from around the world. This year heralds the release of DSM5, an event that should be dry and technical but instead has captured the public imagination and stirred controversy and fear about the encroaching medicalization of human experience – not to mention the fear of the threat to our identities that mental illness poses.
Featured: No
NewsThumbnail: http://www.camh.ca/blog/PublishingImages/2013/June%202013/DSM-5_APA_thumbnail.jpg
Medium Image:
Tags: Treatment; Stigma
Published: 6/10/2013 1:37 PM
]]> Kate Richards Care and Treatment; Mental Health in the Headlines Mon, 10 Jun 2013 15:58:29 GMT http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=92 DSM Diary: Part 2 http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=93 Contributor: David Goldbloom
Category: Care and Treatment; Mental Health in the Headlines
Body:

​Another sunny and warm day, even at 6:45 a.m. as I approached the hall, where a 12-kilometre fun run (from the Bay to the Breakers) had started. There were over 50,000 participants (some running, some walking, some being carried aloft) having a ball, mostly in outlandish costumes and many men and women in no costume. As in completely naked. Jogging and being completely naked are not entirely compatible in terms of attractiveness, but relaxed pride in nudity was really something to see. It may have been a Guinness Book of Records event for collective happiness.
 
Fortunately, I got to the room for my morning symposium 30 minutes before it started, securing a front-row seat.  Ten minutes before it started, every one of the hundreds of seats were taken. By 8 a.m., there were at least 100 people sitting on the floor.
 
Fun fact re DSM: They have changed from Roman to Arabic numerals from DSM-IV to DSM 5 in order to be in the lingo of upgraded computer software: there is already talk about DSM 5.1.
 
The session focused on treatments for bipolar disorder. Roger McIntyre, a former resident of mine who is already a full professor, gave a talk full of evidence and rococo turn of phrase - "disambiguating data" - to make arguments for antipsychotic medications as primary treatments. Antidepressants took a drubbing and lithium was modestly sustained.
 
John Geddes, the Oxford psychiatrist who designed the BALANCE effectiveness trial of lithium in Europe (which showed it to be superior to Epival), sat near me in the front row. Afterward, he and I had a chat and I asked why ECT (electroconvulsive therapy) had not been mentioned once in a discussion of treatment of acute mania and depression in bipolar disorder. He agreed and it is included in his Lancet review of treatments for bipolar disorder published last week.
 

DSM5 and Depression:

The session on DSM5 and depression featured major luminaries. Once again, the changes to depression seemed stunningly minor, even the controversial removal of the bereavement exclusion criterion for making a diagnosis - which is offset by ample text in DSM5 that explains the differences between grief and depression, more so than in past editions (including the one edited by Allen Frances). 
 
Depression_Bereavement_resized.jpg
My notes from a talk by Sidney Zisook, an expert on grief, on Major Depressive Disorder and the bereavement exclusion include this statement: THE DECISION INEVITABLY REQUIRES THE EXERCISE OF CLINICAL JUDGMENT BASED ON  AN INDIVIDUAL'S HISTORY AND CULTURAL NORMS. There are also some helpful tools in a footnote to differentiate grief from a Major Depressive Episode (MDE) and p.168 has more on normal sadness.
 
According to Sidney Zisook, Allen Frances saw DSM5 approval by the Board of Trustees of APA as "the saddest day" of his career. His objections (and Sidney Zisook's responses in parentheses) are summarized below:

  1. Bereavement is a normal response (most bereaved individuals do not experience MDE)
  2. Bereavement symptoms not likely to recur (not upheld by science; they do recur if you control for severity and persistence)
  3. Even with bereavement exclusion in place in DSM-IV, diagnosis of severe cases is still possible (but MDE is a diagnosis with a range of symptoms)
  4. Medicalizes sadness and grief (Huh? studies show that deaths in breast cancer and heart disease are higher in bereaved individuals. Does that medicalize grief?)
  5. DSM5 limits bereavement to 2 weeks (grief can last a lifetime without being MDE, or if grief lasts> 2 weeks it will not automatically be diagnosed as MDE)
  6. Pharma bonanza (studies have shown for years that antidepressants work for bereaved individuals with MDE symptoms and there is no rush for a new indication; plus, the DSM is not a treatment manual).

 
Acute grief is a difficult, emotionally taxing process that often lasts longer than two months, whether or not there is a co-occuring MDE. Removing the bereavement exclusion criterion does not medicalize grief, does not stigmatize the bereaved person, does not imply that grief morphs into depression after two weeks or two months, does not place a time limit on grief, and does not mean antidepressants should be prescribed.  It opens the door to careful clinical attention and allows the clinician to provide education, support and treatment, according to Zisook.
 
I left the room with the sense that the "sky is falling" pronouncements on DSM5 were over-vaunted.
 

Stay Tuned:

This is the second of three blogs written by Dr. David Goldbloom about his experience at the annual meeting of the American Psychiatric Association where the DSM5 was officially released. Stay tuned for Part 3 that will expolre new research into clinical treatments for depression and borderline personality disorder. Click to read Part 1.

 

Body Description: Fortunately, I got to the room for my morning symposium 30 minutes before it started, securing a front-row seat. Ten minutes before it started, every one of the hundreds of seats were taken. By 8 a.m., there were at least 100 people sitting on the floor.
BodyDescriptionLong: The session focused on treatments for bipolar disorder. Roger McIntyre, a former resident of mine who is already a full professor, gave a talk full of evidence and rococo turn of phrase - "disambiguating data" - to make arguments for antipsychotic medications as primary treatments. Antidepressants took a drubbing and lithium was modestly sustained.
Featured: Yes
NewsThumbnail: http://www.camh.ca/blog/PublishingImages/2013/June%202013/Depression_Bereavement_thumbnail.jpg
Medium Image:
Tags: Stigma; Treatment; Depression; Bipolar Disorder
Published: 6/13/2013 10:03 AM
]]> Kate Richards Care and Treatment; Mental Health in the Headlines Thu, 13 Jun 2013 13:56:09 GMT http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=93 Saturday Star section on CAMH: the inside scoop. http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=91 Contributor: Public Affairs
Category: Awareness and Education; Mental Health in the Headlines
Body:

​Over the past four weeks, the Toronto Star has taken an inside look into some of the stories that shape CAMH. On June 8, CAMH will be featured in a special supplement themed ‘closing the gap’ which profiles the many ways we work to help transform the lives of those we serve. From research and innovation to clinical treatment and community supports, CAMH is breaking new ground and giving hope to those with addiction and mental illness.

CAMH client Cassandra is interviewed by the Toronto Star about her experience in the Partial Hospital Program.

Science that serves people and leads to more effective treatment is at the core of CAMH’s research enterprise. This is made evident by Dr. Jim Kennedy’s work in the area of personalized medicine and Dr. Romina Mizrahi’s work on stress factors and psychosis. The special supplement looks at the work happening at CAMH’s PET Centre and the Tanenbaum Centre for Pharmacogenetics to show the impact behind the science, speaking with clients who have benefitted from CAMH innovations.

Affecting change to help our clients live their best lives is a theme that emerges from CAMH’s clinical programming. The special Toronto Star section provides an exclusive look at CAMH’s new Irma Brydson Inpatient Unit for Youth with Concurrent Disorders and how staff work closely to provide specialized, client and family-centred care to some of the most vulnerable youth in the province. Client stories including Cassandra (pictured above) from CAMH's Partial Hospital Program show that with treatment and support, people with mental illness and addictions can live successfully in the community.

It’s the people who make an organization great, and CAMH is privileged to have many outstanding leaders who are shaping the future of mental health. This includes Dr. Peter Szatmari, head of our new collaboration with Sickkids to develop an integrated Child and Youth Mental Health Program. Dr. Aristotle Voineskos who has risen from student to leading scientist guiding the work of new residents in the Kimel Family Translational Imaging-Genetics Laboratory, is also featured.

These and many more CAMH stories will be featrued in the Toronto Star this weekend, so pick up a copy and let us know what you think!

Body Description: On June 8, CAMH will be featured in a Toronto Star special supplement themed ‘closing the gap’ that profiles the many ways we work to help transform the lives of those we serve.
BodyDescriptionLong: On June 8, CAMH will be featured in a special supplement themed ‘closing the gap’ which profiles the many ways we work to help transform the lives of those we serve. From research and innovation to clinical treatment and community supports, CAMH is breaking new ground and giving hope to those with addiction and mental illness.
Featured: No
NewsThumbnail: http://www.camh.ca/blog/PublishingImages/Toronto-Star_Logo_resized.jpg
Medium Image:
Tags: Stigma
Published: 6/6/2013 10:59 AM
]]> Kate Richards Awareness and Education; Mental Health in the Headlines Thu, 06 Jun 2013 14:43:39 GMT http://www.camh.ca/blog/Lists/Posts/ViewPost.aspx?ID=91