PSYCHIATRY UPDATE

Victor Bloom MD

The latest news on the psychiatric front includes good and bad news. The good news is that the latest generation of anti-depressants, the SSRI's, actually work. They have a better therapeutic ratio than the previous anti-depressants, which mean they are generally more effective and have minimal side effects. They are only effective, however, when the diagnosis is correct--- a neurochemical imbalance. In the case of such an imbalance, the usual brain mechanisms that moderate and modulate emotions, is not working properly. As a result, not only are patients depressed and unhappy, but they are irritable and quick to anger and/or tears. They are over-sensitive to the slings and arrows of everyday life. Inevitably they are miserable day after day and are hard to get along with.

This neurochemical imbalance often takes the form of manic-depression, in which the moods cycle from euphoria (mania) to sadness (depression). Sometimes these labile (changeable) moods are triggered off by external events and sometimes they occur randomly and without warning. Cycles may last hours, days, weeks or months. Often they are regular and predictable, such as every six months. They sometimes start in childhood, sometimes in adolescence or young adulthood, and sometimes make their presence known in the later years, such as middle aged people and the elderly. Most often there is a family history of moodiness and temperamental individuals. In the most severe cases there is psychosis (loss of contact with reality) with mania causing grandiosity and depression leading to suicidal preoccupation and/or attempts.

Not all manic-depression is severe or extreme. What used to be called, 'cyclothymic,' are the mild to moderate cases of mood swings which can be disturbing and disruptive, leading to irritability, anger outbursts, impulsive behavior or withdrawal and isolation. Some resort to self-medication with alcohol or other street drugs and abuse of nicotine and caffeine. These people can also be helped with medication and psychotherapy.

The most severe cases usually require hospitalization and precautions which guard against impulsive and suicidal behavior. If medication does not work, oftentimes electrotherapy will be beneficial. Usually there is a therapeutic milieu including OT (occupational therapy) and RT (recreational therapy), group therapy and individual psychotherapy. Most hospitalization plans provide for 30 days of inpatient treatment and a limited number of outpatient visits. Often such coverage is inadequate and additional therapy can be purchased out of pocket. Many mental health organizations are working toward legislation requiring insurers to cover psychiatric conditions on a par (parity) with physical conditions, as more and more researchers find that mental conditions have a physical cause.

Because of the trend toward biological (pharmacological = medicine = drug) treatment, and the cost-cutting measures of third party insurers, (leading to managed care and HMO's), the coverage for psychotherapy has been drastically limited, to the detriment of quality-of-care. Patients are often seen for only 15 minutes once a month or even more seldom, in which symptoms and side-effects are reviewed and medications added and/or deleted, as optimum medical (drug) management is sometimes achieved by trial-and-error. If one medication doesn't work, maybe another will. Things can get very complicated if three, four and five or more drugs are prescribed to be taken simultaneously, with some drugs having an additive effect and others with an antagonistic and opposite effect. Sometimes prescriptions are added by one doctor after another, with the patient not remembering to tell the latest doctor what they are already taking.

The mass of evidence of efficacy and outcome studies in the treatment of mental illness shows that the best results are from treatment programs which have a combination of psychotherapy and drugs, not drugs alone or psychotherapy alone. Psychotherapy helps the patient deal with a developmental life history of dysfunctional interpersonal behavior, with many bad memories and feelings stored in the brain's memory bank, associated with defensive and avoidant behavior that have disrupted otherwise healthy relationships. A good psychotherapist can help a patient with emotional and relationship problems understand the basis for irrational and inappropriate behavior, and suggest ways to improve communication and relationships. Key relationships in the family and workplace are analyzed to give insight to help improve them.

Hope for the mentally ill is advanced by brain research and the accumulation of psychotherapy experience by clinical practitioners. More and more the word is out that psychiatric medications work and psychotherapy works. The bad news is that irresponsible cost-cutting has drastically limited insurance coverage for psychiatric conditions. Citizens should contact their legislators to correct this situation and contribute to the various mental health organizations, which are working toward parity and increased benefits.

Dr Bloom is Clinical Associate Professor of Psychiatry, Wayne State University School of Medicine. He is a member of the American Academy of Psychoanalysis and on the editorial board of the Wayne County Medical Society. He welcomes comments at his email address--- vbloom@comcast.net.