Category Archives: Mental Health

Tricare to Provide Free Confidential Counseling for Military Dependents

July 29, 2010 Dr. Pullen

As our US Military personnel face not only harm’s way in Afghanistan and Iraq, but repeated tours of duty, their families, dependents in military jargon, also face the difficulty of separation and anxiety and depression. Effective just hours ago, through TriWest, the Western US region of Tricare, the government provided health plan for eligible military dependents, has opened secure on-line and telephone counseling services for dependents. This can be accessed confidentially and without cost to eligible military dependents. The new Behavioral Health Portal offers a live-chat line by phone or instant messaging with professional counselors called the Tricare Behavioral Health Contact Center. IT offers the Tricare Assistance Program, with the acronym TRIAP, much like many private EAP (employee assistance programs) for confidential immediate access to help. It even offers video conferencing with professional behavioral health providers in a program called Tri-West Tele-behavioral Health Care Network for those who prefer a visual aspect to their on-line counseling. For those more interested in just finding on-line resources in a library format, they have a virtual library of resources called Tri-West’s Behavioral Health Portal.

This is good news for military dependents in the Tri-West region. Look for similar programs in other Tri-Care regions also. There is increasing concern about the suicide rates among active duty personnel in Iraq and Afghanistan. In 2009, for the first time, the suicide rate among active duty males was higher than in age-matched civilians. In 2009 through late November more active duty personnel died of suicide than were killed in either Afghanistan or Iraq (at least 234 suicides vs. 297 killed in Afghanistan and 144 killed in Iraq). Numbers are not available for civilian dependents of active duty personnel, but this has to be a concern for them also.

If you know of any military dependents who may benefit from these services please forward this article to them, or let them know of this newly available service. Our armed forces members and their families face tremendous stresses as the deployments happen over and over again. They deserve the best we can offer, and this seems to be a step in the right direction.

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Living With Cancer

July 3, 2010 Dr. Pullen

This is a topic close to home. My wife was diagnosed with Stage 3C cancer of the ovary a bit over a year ago. She was a chemotherapy superstar, had few complications, and has been in remission since her treatment finished last October. Still we know her chances of a cure are fairly low. Understanding statistics is a mixed blessing. Even though her chances of this cancer never recurring are pretty low, her chances of living quite some time with cancer if it recurs, while maintaining a reasonably good quality of life are high.

We tend to think of cancer as a disease that you may get, have treatment for, and either be cured of the disease or die from the disease. In a way that’s correct, but what’s easy to forget is that there are lots of people who get cancer, are treated, don’t get a cure, but for whom treatments are fairly effective at holding the cancer in some degree of control and they live for long periods of time with cancer. Living with cancer is different than living after cancer. This is more common now than ever before, as new medications are developed that can treat cancer and often give short or moderate duration remissions, or simply prevent progression of the cancer.

Several types of cancer are particularly common and also have treatments that while not curative can be effective enough to allow a person to live with their cancer for a long time. Among others these include breast cancer, ovarian cancer and prostate cancer. Living with cancer, as differentiated from living after having had cancer, requires rethinking how you approach life. We tend to think of our lives as having a youth, an early adulthood, the mid-life years, the older active adult years, and old age. Couples who have good relationships often plan to get old together, and think of a future in terms of decades, rather than in terms of years. All of the online retirement planners ask you what you want to use as a life expectancy. I’ve always entered something like 85 years, thre actuarially correct answer for a healthy 55 year old.

When a person has a disease that they know they will die from in a few months it requires rethinking how to spend your last days. This is a type of thinking that although painful and difficult, is a way that we intuitively understand. What’s really important to me. I cannot put off for tomorrow what needs to be done today. Short term planning and thinking is something that is conceptually concrete. Most of us can wrap our brains around this scenerio.

When a person has a cancer they have been told cannot be cured, but that they have a good chance of living with for some ill-defined number of years, maybe 2-3, possibly 5-10 or even more, this requires a different type of thinking. Oh, and by the way add that maybe you’ll be getting some sorts of treatments that will make you sick, or have low blood counts and require you to avoid being around lots of people, but we don’t know when or whether you’ll need these treatments. Living with both the relative certainty that you have a cancer that is not curable and also many uncertainties (how long you have, how will you tolerate the treatments, how good will your quality of life be, how will your family and loved ones cope, ….) is different and has its own challenges. Finding the right balance:

living in the present vs. planning for the future
addressing your feelings and needs to grieve while enjoying every day
needing support and help but wanting to be treated normally
laughing and crying
Enjoying the everyday pleasures vs. doing the things you’ve always wanted to do but never made time for

Lots more I’m sure I haven’t thought of yet.

I don’t profess to be an expert on how to live this life. under these circumstances. I expect I’ll learn more about it over the next few years. I pray that I’ll be up to whatever decisions come my way, but right that’s about as specific as my prayers have evolved.

Any advice, resources, and anecdotes are welcome in the comments. If you’d like to submit a guest post on this or other subjects use the contact tab above to send the post to me to consider for this blog.

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30 Years of Progress – Antipsychotic Therapy

April 28, 2010 Dr. Pullen

Last week I posted about the progress in the treatment of depression over the last 30 years. Today I’m going to discuss what I think is an even more dramatic improvement in pharmacologic management of psychiatric disease. The treatment of major psychosis, especially schizophrenia, but also bipolar disorder, has had revolutionary breakthroughs with the new generation of antipsychotics. Although these diagnoses are far less common than depression, they are a devastating problem for the individuals and families they affect. When I was in training, and really until the last 15-20 years, the antipsychotic medications were also called “major tranquilizers.” This is because when taking them patients were essentially tranquilized. Examples of these medications were thorazine, haloperidol and others. Patients taking these medications were sedated, slowed in their thinking, and very dull. (Think of scenes from “One Flew Over the Cuckoo’s Nest”) In addition to these poorly tolerated side effects the medications often led to irreversible involuntary movement disorders called tardive dyskinesias. This is when patients would develop lip smacking, twitching of muscles, and other involuntary muscle movements that sometimes did not go away on stopping the medications. As primary care physicians we were very reluctant to prescribe these medications, and psychiatrists had to closely monitor patients to try to balance the horrors of untreated major psychosis with the risk of development or worsening of very difficult and sometimes irreversible side effects. When treated with these meds patients may not have been psychotic, but they were rarely very functional.

In about 1990 a group of meds known as second generation antipsychotics were developed. The first of these was clozapine which is difficult to use because of the potential to cause agranulocytosis. It was followed shortly by risperidol, olanzapine and others. These were a huge improvement in our arsenal of antipsychotic meds, since they are much less sedating, often leave patients able to function in society, be fairly alert, and feel better on the meds than off. Many schizophrenic patients are now stable on long term antipsychotics and function in society far better than was possible on the older medications. Also the tardive dyskinesias are almost unheard of with these medications. Now we have to watch for other side effects like weight gain with some, and an increased risk of developing diabetes, but these are relatively tame side effects compared to treating a patient with a drug that made them nearly a walking zombie. With these drugs many patients are treated successfully by primary care physicians, and function out of institutions free of the intrusive and destructive psychotic problems of their disease. Even newer drugs continue to be developed and give us more options to fine tune treatment of major psychosis.

Also read: Depression: It Helps when the Treatment is Not Worse Than the Disease

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Depression: It helps when the treatment is not worse than the disease

April 20, 2010 Dr. Pullen

Fourth in the series of major breakthroughs in medical care in the last 30 years is the development of tolerable and effective treatment of depression. In my residency training from 1980-83 every resident dreaded seeing a patient with depression. The side effects of the medications we used were almost worse than the depression itself, and it seemed like there was just very little we had to offer. We encouraged exercise, referred patients for counseling, and prescribed medications that made patients feel terrible. When Prozac came out in 1987 it was incredibly popular. It was so effective that it spawned a cult movement to spread misinformation about its use. Why? It was really the first effective antidepressant that did not cause predictable and significant side effects long before it helped with the depression symptoms. Prior to Prozac, the tricyclic antidepressants (TCA) amitriptylene, imipramine, desipramine and other similar drugs were the primary antidepressants available. Those drugs cause major sedation, constipation, dry mouth, and weight gain. To try to allow patients to come to tolerate those side effects we would start at doses we knew were too low to help, and slowly taper up in dose to a dose that might work. It often took 8-12 weeks or more to get noticeable improvement. In addition we needed to give very small supplies because these medications taken in only 4-5 times the daily effective dose could cause fatal overdose. Nearly every weekend on call in those days we had one or more ICU admissions for TCA over dosage, and many deaths were attributed to these medications from accidental and intentional over dosage. It was a tough sell to a depressed patient to ask them to take a medication and to have to tell them that they would probably feel worse for the first 8-10 weeks before they started to notice improvement. With Prozac we had a drug that we could start at a dose that often worked, and could see benefit within 2-3 weeks in most cases. A whole slew of additional selective serotonin reuptake inhibitors (SSRIs), Zoloft, Paxil, Celexa, and others followed, and now we have these medications and several other classes of meds that are effective and generally well tolerated.

Now when we see a depressed patient who is a candidate for medication, we can choose from several effective and well tolerated medications, and when discussing the side effects we can emphasize the only common annoyance, delayed orgasm from most of these meds. We no longer have to feel apologetic for prescribing a medication expected to make things worse before helping. I feel like depression is now one of the most gratifying problems that I see patients for in the office. In the last few years with generic versions citalopram, fluoxetine, paroxetine and sertraline we have inexpensive options too.

Check out the first 3 posts in my series of observations in medical progress over the last 30 years:

Vasectomy: Faster, Safer and Better than before the No-Scalpel Technique

Now we have Effective Treatment of Congestive Heart Failure

Peptic Ulcer Disease – From Curse to Cure

Also enjoy: 30 Years of Progress – Antipsychotic Therapy

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Professional Victims

March 24, 2010 Dr. Pullen

I often see patients in the office I think of as professional victims. They just seem to always have terrible luck. They make choices that might at face value seem fine, but seem to always work out poorly. Dr. Friedman in yesterday’s NY Times writes about a theory as to why these patients failure to find happiness or success may be subconsciously self-fulfilling.

Sabotaging Success, but to What End?

By RICHARD A. FRIEDMAN, M.D.

Published: March 22, 2010

“You could say I’ve been unlucky in love,” a young man told me during a recent consultation. He went on to describe a series of failed romantic relationships, all united by a single theme: he had been mistreated by unsympathetic women who cheated on him.This was not his only area of disappointment, though. At work, he had just been passed over for a promotion; it went to a colleague whom he viewed as inferior.I asked him about his work as a computer scientist and discovered that he worked long hours and relished challenging problems. But he also did some curious things to undermine himself. Once, for example, he “forgot” about an important presentation and arrived 30 minutes late, apologizing profusely.What was striking about this intelligent and articulate young man was his view that he was a hapless victim of bad luck, in the guise of unfaithful women and a capricious boss; there was no sense that he might have had a hand in his own misfortune.I decided to push him. “Do you ever wonder why so many disappointing things happen to you?” I asked. “Is it just chance, or might you have something to do with it?”

His reply was a resentful question: “You think it’s all my fault, don’t you?”

Now I got it. He was about to turn our first meeting into yet another encounter in which he was mistreated. It seemed he rarely missed an opportunity to feel wronged.

Of all human psychology, self-defeating behavior is among the most puzzling and hard to change. After all, everyone assumes that people hanker after happiness and pleasure. Have you ever heard of a self-help book on being miserable?

So what explains those men and women who repeatedly pursue a path that leads to pain and disappointment?

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Broken Hearts

February 13, 2010 Dr. Pullen

An article in the NY Times by Ron Winslow gives an example of the ‘Broken Heart Syndrome” and a fair description of the pathophysiology of this condition. Basically it is a transient dysfunction of the entire pumping action of the heart associated with pain that can mimic a coronary occlusion and “Heart Attack.” It can sometimes be fatal. All the more reason to tell your loved ones you love them, and keep matters of the heart in the front of your mind. To all those I lovein so many different ways: Happy Valentine’s Day! I love you!

Hearts Actually Can Break

By RON WINSLOW FEBRUARY 9, 2010

Dorothy Lee and her husband of 40 years were driving home from a Bible study group one wintry night when their car suddenly hit the curb. Mrs. Lee looked at her husband, who was driving, and saw his head bob a couple of times and fall on his chest.

In the ensuing minutes, Mrs. Lee recalls, she managed to avoid a crash while stopping the car, called 911 on her cellphone and tried to revive her husband before an ambulance arrived. But at the hospital, soon after learning her husband had died of a heart attack, Mrs. Lee’s heart appeared to give out as well. She experienced sudden sharp pains in her chest, felt faint and went unconscious.

It shows that dying of a broken heart isn’t just a metaphor.

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A Canadian perspective

February 2, 2010 Dr. Pullen

Will Meek PhD, a Vancouver psychotherapist, posted to his blog a brilliant perspective on how to get past being fixated i n the past froma traumatic experience. He calls it “Remembering vs. Reliving.” I read this first after seeing the link on “Grand Rounds” at Dr. Rob Lambert’s blog “Musings of a Distractible Mind.” I had one of my posts, Remembering to Take Your Medicine mentioned on this grand rounds.

Remembering vs Reliving

We have all lived through things we wished we had not experienced, some of us more than others. Coping with these memories, images, or feelings can be quite difficult. Something I notice when people talk about their painful past experiences is that many seem to be transported back to the time period it happened in. This is referred to as “reliving“, and it is understandable why we put so much effort into avoiding this material if our only way to work with it is to experience it all over again.

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Drinking less your New Year’s resolution?

January 3, 2010 Dr. Pullen

As we enter the New Year many of you have probably made a resolution. Mine is related to a previous post on not putting off having fun. Often these resolutions deal with getting more exercise, eating more, drinking less, or stopping smoking. I thought over the next few days I’d comment on each of these issues. Today I’ll address drinking too much.

First what’s too much? Hey, I like a nice beer or glass of wine, so what’s the problem. Most experts agree that for men drinking less than 4 drinks on a given day, and less than 14 drinks on a given week, and for women less than 3 drinks on any given day, and less than 7 drinks in a week, is probably safe. (no sexism here, just men metabolize alcohol faster and are generally bigger people) There is even some evidence that moderate amounts of alcohol may have beneficial effects on HDL cholesterol and heart disease. None-the-less alcohol abuse is the third leading cause of preventable premature death in the US. (behind tobacco use and poor eating and exercise lifestyles) Most experts differentiate between at-risk-drinking, alcohol abuse, and alcohol dependence. At risk drinking is defined as drinking above the 3-4 drinks in a day more than 12 times a year. This is estimated to apply to about 21% of Americans. Most people in this category just need to drink less and be careful not to put themselves in a position to have life-altering consequences. (driving, handling firearms, etc.) Often they can just modify their drinking behavior, and do not need to abstain.

Alcohol abuse (5% of Americans) and alcohol dependence (4% of Americans) together constitute what are called alcohol use disorders. Here is a table from an article in American Family Physician July 1, 2009.

Diagnostic Criteria for Alcohol Abuse and Dependence

Abuse: Patient must meet one or more criteria without meeting criteria for dependence
Determine whether, in the past 12 months, the patient’s drinking has repeatedly caused or contributed to the following:
	Risk of bodily harm (drinking and driving, operating machinery, swimming)
	Relationship trouble (family or friends)
	Role failure (interference with home, work, or school obligations)
	Run-ins with the law (arrests or other legal problems)
Dependence: Patient must meet three or more criteria
Determine whether, in the past 12 months, the patient has experienced the following:
	Not able to stick to drinking limits (repeatedly exceeded them)
	Not able to cut down or stop drinking (repeated failed attempts)
	Spent a significant amount of time drinking (or anticipating or recovering from drinking)
	Continued drinking despite problems (recurrent physical or psychological problems)
	Spent less time on other matters (activities that had been important or pleasurable)
	Shown an increase in tolerance (needed to drink more to produce the same effect)
	Shown signs of withdrawal (tremors, sweating, or insomnia when trying to quit or cut down)

note: The threshold criterion for any alcohol use disorder is a dysfunctional pattern of substance use causing clinically significant impairment or distress.

In general people who meet the criterion for alcohol use disorders need to obtain help to find a way to abstain from alcohol. Your physician can help you find resources to move toward this goal.

Also Enjoy:

Lyrica vs Gabapentin: A Family Doctor’s Perspective

Pradaxa

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