Forest Path - photo by Hein van den Heuvel

- Reminders:

a.  Scheduling Return Appointments to Avoid Case-Closure:  Patients should recall that their cases will go inactive by default if they are not seen within five months of their last clinic visit.  When a case becomes inactive, this means that the doctor will not be able to refill a patient’s prescriptions until the patient is seen again in clinic and the case is then re-opened.

b.  Annual Physical Exams:  Every prospective or active psychiatric patient should have an annual physical exam to screen out possible physical disease which can either masquerade as primary psychiatric disorders or complicate existing psychiatric disorders.  Contact your primary care provider (PCP) for your annual physical exam, and make sure that all routine lab tests are done.  These should include:

1.  Complete Blood Count (CBC)

2.  Chemistry 21 Panel (Chem-21)

3.  Urinalysis (UA)

4.  Thyroid Stimulatiing Hormone (TSH)

5.  Electrocardiogram (EKG)

6.  Vitamin B-12 level (B12)

7.  Erythrocyte Sedimentation Rate (ESR, or Sed Rate)

8.  Folate level

9.  Other:  men:  PSA level, testosterone level females:  estrogen, progesterone, & testosterone level

For more information about other screening tests, please talk with Dr. Firnberg.

- New Medications:

New medications recently approved by FDA are now available for depressive and anxiety disorders.  These include Cymbalta (duloxetine) and Pristiq (desvenlafaxine).  Each is an improvement over older medications such as venlafaxine XR (Effexor XR), since these newer medications do not generally cause the weight gain and reduced libido that venlafaxine does.

Another new medication approved by FDA for ADHD is Vyvanse (lisdexamfetamine).  Vyvanse has a novel mechanism of delivery which reduces the usual side effects from stimulants such as anxiety, irritability, or insomnia.  As a result, Vyvanse seems to be better tolerated.  Ask Dr. Firnberg for more details.

- Medications Going to Generic:

Zaleplon (Sonata), an ultra-short half-life medication for insomnia has recently become available in generic form.  This is welcome news for patients on insurance plans which would not cover it previously.  Also, zaleplon’s short half-life has meant:  a) it wears off by morning so that no a.m. grogginess persists; b) even though it is ‘first-cousin’ to Valium-class medications, addictions are rare to non-existent, since it is not around long enough for the body to develop an addiction to it; c) it can be taken when one awakens halfway through the night without worry that a.m. grogginess will occur.

Another medication which recently went to generic form is risperidone (brandname was Risperdal).  Although FDA-approved for psychotic disorders and bipolar mood disorders, it is also commonly used in low-doses as augmentation with standard antidepressants/antianxiety agents for treatment-resistant or more severe cases of depression or anxiety.  Talk with Dr. Firnberg about this very helpful option for treatment.

- Warnings About Some Herbal Products:

The Dietary Supplement Health and Education Act (DSHEA) of 1994 removed food and nutritional supplements (including herbs) from regulation by the FDA.  As a result herbal supplement manufacturers are not required to publicize evidence of efficacy, or possible adverse effects, of their products.

Torres del Paine, Patagonia, Chile

The April 2009 issue of Psychopharm Review (vol. 44, no. 4, www.LWW.com), lists four common herbal products, some of which have questionable efficacy and some of which must be taken with care because of possible adverse effects:

1.  Valerian (valeriana officinalis):  Often taken for insomnia, has shown little benefit for sleep in most placebo-controlled studies.

2.  Kava Kava (piper methysticum):  Often taken for anxiety, it is questionable still from controlled studies whether it helps anxiety.  It can also be hepatotoxic — nine people have died from liver failure from kava.

3.  Ginkgo (ginkgo biloba):  Taken to help prevent dementia, controlled studies have yet to verify this claim.  It also may cause intracranial and intraocular bleeding.  Patients taking blood thinning medications, such as aspirin, ibuprofen, warfarin, or valproate, should consult their doctor before taking ginkgo.

4.  St. John’s Wort (hypericum perforatum):  Often taken to help anxiety and depression, St. John’s Wort has been shown in double-blinded, placebo-controlled studies to be as effective as standard SSRI antidepressants, such as fluoxetine (Prozac) or Lexapro (escitalopram).  However, it induces the p450 liver enzyme system, and can lead to more rapid metabolism of some drugs (oral contraceptives, anticoagulants like warfarin, methadone maintenance for opioid dependence, statin drugs to reduce cholesterol, and cyclosporine to suppress rejection of  liver transplants).

If a patient takes St. John’s Wort (SJW) while on oral contraceptives, the contraceptive effect could be diminished, leading to possible conception.  Patients taking anticoagulants with SJW would be more likely to have a stroke.  Those taking methodone with SJW could experience acute opioid withdrawal.  Those taking statins for high cholesterol with SJW would be at greater risk for cardiovascular events, such as heart attacks.  Those taking cyclosporine for liver transplants with SJW would be at greater risk for acute liver transplant rejection.

Anyone considering taking the herbal products above should consult with their doctor prior to doing so.  In particular, those taking the above medications which are metabolized by the p450 liver enzyme system should be careful not to take St. John’s Wort unless they have first discussed it with their doctor.

- New Developments in Psychotherapy:

a.  Benefits of Long-term Psychotherapy:  In the most recent issue of American Psychiatry News (Jan./Feb. 2009, vol. 2, no. 1), emerging empirical research has begun to confirm the benefits of long-term (“psychodynamic”) psychotherapy for patients, compared to shorter-term (or “cognitive-behavioral”) psychotherapy.  Shorter-term therapies have been the rage in recent years, because they have been supported by more data than longer-term forms.  As a result, advocates of longer-term (“psychodynamic,” or “analytic”) therapies have been on the defensive as to how to justify such time, effort, and financial expenditures by patients and therapists, even though the long-term forms have seemed in clinical practice and intuitively to be better in the long run.  The problem for advocates of longer-term forms has been the difficulty in demonstrating its efficacy from clinical studies.  This report from American Psychiatry News lends new support to what advocates of long-term therapy have seen in their practices and understood empirically — that longer-term forms of psychotherapy bring about more profound and enduring changes for the patient than shorter-term therapies.

b.  Saying Goodbye to ”Blank Screen” Therapies:   One relic of older, Freudian-style psychotherapies which is gradually falling off the radar screen is the “blank screen” form of psychotherapy — that in which the therapist interacts minimally with the patient, discloses minimal amounts of things about himself to the patient, and redirects any questions directed to the therapist about himself toward the patient by saying, “Why do you ask that?”  Research has shown that the “blank screen” technique actually increases anxiety in the client and makes the client worse, rather than better.  When queried about what traits in the therapist the patient deems most helpful for healing patients consistently rank self-disclosure as the single most important factor in their healing (see Learning Psychotherapy, by Bernard Beitman and Dongmei Yue, New York:  Norton, p. 39).  Self-disclosure means that the therapist acknowledges faults, just like any other human being, and allows targeted, limited self-revelation to occur to allow the patient to identify with the therapist.  However, therapists, when queried on the issue of self-disclosure, ranked self-disclosure far down the list of traits which they think are helping the patient.   It is this disconnect between what the patient is experiencing as most helpful and what the therapist thinks is most helpful which is addressed by the latest research.

This newer technique of therapy which embraces limited, targeted self-disclosure is called, “intersubjectivity theory,” and is found in the newer literature in psychoanalysis.  For more information about intersubjectivity theory, talk with Dr. Firnberg.  You may also check the literature emerging from the newer analytic institutes, such as the Newport Psychoanalytic Institute (www.npi.edu), or the Institute for Contemporary Psychoanalysis (www.icpla.edu or www.icpny.edu).  You may also check out books such as, Relational Psychoanalysis:  The Emergence of a Tradition, ed. Stephen Mitchell & Lewis Aron (Hillsdale, NJ:  Analytic Press, 1999), or Relational Concepts in Psychoanalysis, by Stephen A. Mitchell (Cambridge, MA:  Harvard Univ. Press, 1988).

- Off-Label Use of Psychiatric Medications:  Is it advisable, safe, or even legal? Patients often research psychiatric medications online before trying them, and, if a particular medication has not been approved by the FDA for their particular disorder, may refuse to try the medication, suspecting the psychiatrist of inappropriate guidance in their case, even malpractice.  The resulting suspicion and roadblocks to initiating therapy can be exasperating.

A recent article in Current Psychiatry (Feb. 2009, vol. 8, no. 2) by Douglass Mossman, M.D., director of the Weaver Institute of Law and Psychiatry at Univ. of Cincinnati College of Law, and professor of psychiatry at the Univ. of Cincinnati College of Medicine, entitled, “Why off-label isn’t off base,” dispels much of the confusion over off label use of psychiatric medications.

Dr. Mossman explains a number of things:

a) Off-label use of psychiatric medications is legal.  FDA approval means that drugs may be sold and marketed in certain ways, but the FDA does not tell physicians how they can use approved drugs.  Federal statutes make clear that FDA approval does not “limit or interfere with the authority of a health car practitioner to prescribe” approved drugs or devices “for any condition or disease” (Food, Drug, and Cosmetic Act, 21 USC, 396).

b) Courts endorse off-label prescribing.  One appellate decision says, “Because the pace of medical discovery runs ahead of the FDA’s regulatory machinery, the off-label use of some drugs is frequently considered to be ’state-of-the-art’ treatment” (Richardson v. Miller, 44 SW3d1, Tenn Ct App. 2000).

c)  Off-label use is not only legal, it is often wise medical practice.  Many drugs now approved by FDA for a particular use were first used off-label for this purpose.

d)  Off-label use does not make the patient into a human guinea pig.  Since the FDA has usually found that a medication has sufficient safety through prior clinical research, the safety factor is not usually an issue — efficacy is the primary issue in off-label uses.  When a physician prescribes a medication which has proven to be safe in order to possibly help a patient, the courts do not view this practice as unreasonable risk.

d)  As a result of the above, off-label use of medications does not require special informed consent.   The general informed consent forms which patients fill out at the beginning of their treatment, usually as part of a general contract for treatment, will suffice for legal purposes.

e)  What is important in off-label use of medications is that:

(1)  the individual physician must keep up with the latest usage of various medications by reading current journals, continuing medical education, collection of articles on current usages, knowing why a certain medication may work for a particular patient;

(2)  the physician must explain to the patient the current usage of a medication, its risks and possible benefits in any off-label use;

(3)  the physician engage in ongoing informed consent at every stage in the off-label use of a medication.  He should have current data and literature available for the patient to read about a possible off-label use of a medication.

- New in Philosophical Counseling:  Deus Absconditus or

Deus Intelligibilis?

Modern movements of skepticism, such as atheism and agnositicism, conceive of God as being either nonexistent or, at the very least, unknowable with the mind.  On the other hand, within the church and among several world religions, arguments for the existence of God have usually been probabilistic in nature, affording the believer with little in the way of knowing with the mind whether the truth-claims of his or her faith can be verified.

However, there is an ancient tradition, long-neglected and sometimes actively suppressed in both modern sacred and secular contexts, which affirms the knowability of divine existence with the mind.  This tradition is rooted in the thought of Plato, Plotinus, and Augustine, and it teaches that divine existence is indeed a matter of knowing with the mind, as a person directly apprehends intelligible divine attributes.

This is exciting news for skeptics and believers alike who are troubled by a “knowledge gap” in regard to the existence of God.  For more information, talk with Dr. Firnberg.  Come rediscover and reclaim a lost world of transcendent verities and certain knowledge — your own!

- Obstructive Sleep Apnea — The Silent Killer II

Obstructive Sleep Apnea (OSA) is a condition in which the airway becomes obstructed during sleep by the collapse of the soft palate and tongue, leading to multiple near-waking arousals during the night through the ‘emergency’ effort of the diaphragm.  This sudden contraction of the diaphragm is triggered by the respiratory drive center in the brainstem, when it senses a drop in oxygen content in the blood.

What makes Obstructive Sleep Apnea so dangerous if not detected and treated is that, when a person goes for long periods without taking a breath while asleep, the coagulability of the blood increases.  This increases the chances of having a blood clot in the veins of the brain or other parts of the body, leading to stroke, heart attack, or other adverse cardiac events.

High blood pressure (hypertension) has been called, “the silent killer.”  This is because the arteries of the body do not have pain sensors in their walls, so a person often cannot perceive that he or she has high blood pressure.  Because it is not perceived by the patient, it therefore often goes undetected and untreated, leading to heart attacks or strokes.

In an analogous way, Obstructive Sleep Apnea can be described as “the silent killer II,” because, when a patient has nocturnal apneic (stopped breathing) episodes, the patient does not come to a full waking state.  Therefore the patient usually does not recall the apneic episodes and will not be aware that he or she has the disorder, increasing the chance that it will not be detected and treated.  Often it takes an observant spouse or family member to bring it to the attention of the patient.

Obstructive Sleep Apnea (OSA) is usually caused by a combination of genetic and environmental factors.  Environmental factors include:  a) having braces at too early an age, which may push back the maxillary (upper tooth) ridge, which pushes back the mandible (lower jaw) and consequently the tongue;  b) gaining weight through life; c) advancing age, which reduces the elasticity of soft tissue, and c) smoking.

If you feel unrested upon awakening, snore loudly, have gained weight over the years, smoke tobacco, or have been told by family members that you hold your breath up up to a minute while sleeping before taking your next breath, then talk with Dr. Firnberg or your primary care provider (PCP).  You may also visit good websites for more information (www.sleepnet.com, and www.sleepapnea.org).  Patients with untreated sleep apnea have ten times the risk of nocturnal sudden death compared to those without sleep apnea, so don’t delay seeking help!