Daniel Carlat- "Dr. Drug Rep"

I recently heard an NPR podcast- an interview with Dr Daniel Carlat, the famous (infamous?) author of The Carlat Report . It was a sad but truthful narration. a veritable laundry list of all the demons, the myths and the dark realities of Psychiatry, the undercurrent I find myself wading against every day.

If you like, you could get access to that interview by clicking on this link (thanks Arnab Jijaji!)

Dan Carlat is also known for a piece he wrote in The New York Times called "Dr. Drug Rep".

I've always felt seduced and confused by my feelings about the glamorous world of the pharmaceutical industry. I've implored almost every teacher I've met - "I really really want to enjoy the delicious food and the good wine and the fancy restaurants and the dozens of compliments an MD may receive as a by product of an affiliation with a drug rep! Can you please sell me ONE point that convinces me that I will be enjoying these fun things NOT at the expense of my poverty-stricken, vulnerable, downtrodden, marginalized mentally ill patients ?"

It's been 8 years and I'm still waiting for that one convincing argument. I don't think I've been a particularly difficult or unreasonable listener. I'm just waiting to be dazzled (or budged-I'll take budged). Please! I can almost taste that free, succulent steak..... Won't you help a poor psychiatrist ensnared by his scruples?

NPR report : Children Labeled 'Bipolar' May Get A New Diagnosis

Here’s some news regarding the possible future of pediatric bipolar disorder:

http://www.npr.org/templates/story/story.php?storyId=123544191&sc=emaf
I’d love to hear people’s comments on this.

How I assess for mania in children

Disclaimer: This blog is merely a personal opinion about psychiatric issues.It does not equate to a psychiatric consultation and does not imply doctor-patient relationship.

In my humble opinion, in the world of Child Psychiatry, there is nothing murkier than the answer to this question “What does pediatric mania look like?”

It seems that there are several differing opinions endorsed by different schools of thought spread across USA. One such school emphasizes the importance of severe irritability as a strong indicator of pediatric mania. I do not belong to this school of thought- I think many clinicians overemphasize the importance of severe irritability. When a child is referred to my clinic to assess for possible bipolar disorder, I screen for a whole range of relatively specific and non-specific symptoms (I say ’ relatively’ because I do not think there is any symptom of pediatric mania that is 100% specific- not even euphoria).

This is how I approach my interview:

RELATIVELY SPECIFIC SIGNS OF PEDIATRIC MANIA :

1. Decreased need for sleep

· “I want you to think about Jimmy’s sleep patterns. Is Jimmy the kind of child who fights going to sleep, is up till extremely late hours and then wakes up in the middle of the night- 3 am, 4 am, 5 am, up-and-ready, demanding to play, waking everyone else up?”

· Does this happen almost every night?

· When he does have nights like these, how is he the next day? Is he tired or is full of energy at school?”

· Many parents will tell me that their child fights going to sleep and is up till late hours of the night. If they report that the child is generally tired in school the next day, to me this rules out decreased-need-for-sleep

· Common reasons why kids have initial insomnia: poor sleep hygiene, anxiety

2. Dare-Devil Acts

· In my mind, genuine dare-devil acts differ from the impulsive acts seen in ADHD. Here’s how I look at it: if a child with ADHD jumps of a wall, hurts himself and says “that was dumb! What was I thinking?”, in my mind that rules out dare-devil-acts.

· I ask parents this : Would you say Jimmy is a fearless child? For e.g., have you ever had a situation when Jimmy was about to jump from someplace high and you said’ Jimmy- if you do that you could die” and Jimmy responded ‘I know, and I don’t care! Here I go! Woohoo !!!” (a child with ADHD is more likely to say “ No I won’t mom, I’ll be fine! Watch!”)

3. Psychosis

Hearing things, seeing things, delusions. This is extremely rare!

4. Mood lability

Remember :

· Happy –to- sad in 1 second = emotional reactivity (depression/anxiety/certain personality organizations)

· Happy-to-sad-to-happy in 2 seconds = true mood lability (maybe Mania)

NON SPECIFIC SIGNS OF PEDIATRIC MANIA

1.Irritability

· C Children with mania will show intense rages over trivial matters (the other day Jimmy trashed his entire room because he spilt ink on his shirt!)

· O Often outbursts will be triggered by hearing the word ‘No’, but a word of caution to the reader- this scenario is not specific and can be seen in kids with ODD, anxiety, depression, Reactive Attachment Disorder, Fetal Alcohol Effects and Pervasive Developmental Disorders!

2. Distractibility/ Racing thoughts

· I will ask the child this : Jimmy, do you ever feel like there are so many thoughts in your head at the same time that you need a stop sign?

· More Common reasons for distractibility : Anxiety, ADHD

3. Disinhibition

· C Children with mania will often talk in a disinhibited manner, like an inebriated person saying non-PC things at a party (usually the comments are about things that would embarrass parents in front of others). This is a non-specific symptom.

· C Common reasons for disinhibited speech: ADHD(not thinking before one opens one’s mouth), PDD(being clueless about why something would be socially inappropriate and embarrassing for others)

4. Hypersexual behaviors

· This includes behaviors such as roaming around the house naked, groping others’ private parts and breast areas, and excessive masturbating (Is there any age where masturbating is inappropriate? I don’t think so, but other clinicians may beg to differ)

· Other reasons that could explain hypersexual behaviors : Sexual abuse, Reactive attachment Disorder, exposure to pornographic material

5. Grandiosity

· C Children with mania will often say things such as “I can do that better than anyone else. I am the best baseball player/student/singer in the world.” Observations from adults may suggest otherwise J

· S Such bravado could also be a defense against poor self esteem or anxiety

ALSO CONSIDER:

1. Adverse response to antidepressants/stimulants

· Remember- what other conditions could explain irritability/aggression on stimulants ? Anxiety.

· Sometimes the stimulants themselves can cause a side effect called ‘dysphoria’, wherein children become very ornery (due to overdosage of dopamine/nor-epinephrine)

· Kids with PDD, and kids with mental retardation or in-utero exposure to alcohol may be extra sensitive to the serotonin in antidepressants, and may become agitated.

2. Family history of Bipolar disorder (make sure diagnosis is not ‘self-made’- please click here to visit my blog about how I asses for mania in adults)

HOW I ASSIMILATE ALL THIS DATA INTO A FINAL CONCEPTUALIZATION

1.Once I have asked all of these questions, I make a sort of checklist of the symptoms that could suggest mania.

· I I would like you to envision an instrument like those applause-meters they show on TV shows, where the louder the noise the audience makes, the higher the dial goes.

· With every symptom that the parents/child endorsed, the dial turns a little bit more on the “Bipolar-o-meter” (if you will). Non-specific symptoms make the dial turn a little bit, specific symptoms make the dial turn a lot.

2.Next, I ask questions to assess for competing etiologies, i.e., I look to see if there are any conditions that could explain certain symptoms

· For e.g., a history of sexual abuse could explain why Jimmy gropes private parts, and why he has to put on an aura of bravado and has intense rages when left alone in a room with a man, and why he has a hard time paying attention when he is in a new place. Similarly, if the child has PDD, this could explain why the child seems uninterested in being polite and subservient with adults, which may come across as grandiose).

· With every such finding, the dial on the “Bipolar-o-meter” starts coming down a bit

3.Finally, I look at the Bipolar-o-meter and have a discussion with the parents about the probability of mania. (Just to be clear, I don’t literally draw a ‘Bipolar-o-meter’ on a sheet of paper, it is more of a metaphor. I hope I haven’t confused you!) The discussion could sound like any of these:

• Mr. and Mrs. Smith- based on the standards used today, there is a way the medical community conceptualizes and describes ‘childhood mania’. Based on what you have told me today, I feel that your child does NOT fit that description. Can I guarantee that your child will never develop mania in the future? Of course not. But based on what I see and hear today, it seems like it is unlikely that your child has bipolar disorder.
• · Mr. and Mrs. Smith- based on the standards used today, there is a way the medical community conceptualizes and describes ‘childhood mania’. Based on what you have told me today, I feel that your child may show the following features that remind me of this description : they have decreased need for sleep, they show a pattern of engaging ion dare-devil acts, there is a certain sense of grandiosity that you describe and I see in the session today, you report a pattern of intense rages over trivial issues, and last but not least, you describe hypersexual behaviors in the absence of any known exposure to sexual content or trauma. Can I be 100% sure that your child has bipolar disorder? No. But I think it might be worthwhile to consider the risks vs. benefits of a trial of a mood stabilizer.

Whew! That was a long post. Thanks for hanging in there!

In my next blog, I’ll discuss some more points about pediatric mania.

How I assess for mania in adults

Disclaimer: This blog is merely an opinion.It does not equate to a psychiatric consultation and does not imply patient-doctor relationship.

Unfortunately, it seems that my clinic is booked out till September 2010 for initial evaluations. So, I thought I may start sharing with local medical providers some of the techniques I use in my practice. Hopefully you may find some of this helpful for your own practice.

One of the most common referral question my clinic gets is this : does this person have bipolar disorder?

I think I may safely say that the term “Bipolar” has now entered the American vocabulary as common parlance (much like ‘ADD’ or ‘psychotic’). Unfortunately, it is used with the same looseness that these other terms are used. Even more unfortunate is the fact that through a series of events, it somehow finds its way into medical records. I don’t think any one individual or institution is to blame. It is what it is. Now what is to be done about it?

Here is how I approach an evaluation for Bipolar disorder. It is not the only approach or the best approach. It is merely my approach.

· As you know, in order to be diagnosed with bipolar disorder, you need to have experienced an episode of mania or hypomania. This is how I assess for an episode of mania/hypomania:

I say to the patient this: “I am going to describe a person to you, alright? Now, you and I have had an episode of the common cold. We’re doing kinda alright, and then one day we wake up with a stuffy nose, headache, sore throat, tiredness (symptoms of a common cold).These symptoms stick with us from 4- 14 days and then, they go away.

Similarly, this person I am talking about has an episode. During this episode, instead of a headache and a stuffy nose and sore throat, they start showing the following symptoms out of nowhere: they start experiencing a decreased need for sleep-I’m not talking about a situation where you wish you could fall asleep but find yourself unable to do so (the insomnia seen in depression, anxiety), I’m talking about a person who’s feeling ‘I don’t need sleep! Let’s get some stuff done!’ During this episode, people around this person start noticing that he or she has been talking more than usual, and that they get distracted more easily than usual. They may start doing random projects around the house, often moving to the next project before the first one is completed. They may start showing greater interest in sex, and may become more disinhibited, they start doing impulsive things, like spending money they don’t have or driving recklessly. (An important point to keep in mind in explaining this episode is that these behaviors are a distinct change from their baseline behaviors. So if at any point, if the patient says ”Oh I’m always like that”, that point is null and void and does not going into assessment of a manic episode.)

And then, just like a common cold, these symptoms disappear, vanish. Often, the person ‘crashes’ for a few weeks- kinda like a person coming down from a meth binge. In fact, many people may suspect that this person may have been on a meth binge, considering how they’d been acting!

Now- I want you to imagine such a person having such an episode. I want you to keep that image in your head. Got it? Good. Now- does this person remind you of yourself? Have you ever had a distinct episode like this in your life?”

When I put it this way, 90% of my patients who come in wondering if they’re bipolar end up saying” No, that doesn’t sound like me”

· So why do so many people wonder they are bipolar? The most common reason I hear is ‘mood swings’.

Let me be clear about this point: ‘mood swings’ does not equate mania. The most common manner in which people describe ‘mood swings’ in my clinic is this: “I’ll be having a good time, and doing just fine, and then something stupid or trivial happens and Bam! I get mad or sad or upset.” What the patient has just described is either Emotional Reactivity or Poor Frustration Tolerance. The most common psychiatric reasons for these symptoms is depression or anxiety. This is very distinct from the phenomenon of Mood Lability that one sometimes sees in mania- where you go from happy-to-sad- to –happy again.

· Thus,

Happy –to- sad in 1 second = emotional reactivity (depression/anxiety/certain personality organizations)

Happy-to-sad-to-happy in 2 seconds = true mood lability (? Mania)

Hope this helps. In the near future, I will write about how assess for pediatric mania.