Dr. Harold Koplewicz2013-05-22T01:09:59-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/author/index.php?author=dr-harold-koplewiczCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Dr. Harold KoplewiczGood old fashioned elbow grease.The NIMH Declares Independence From the DSM-5tag:www.huffingtonpost.com,2013:/theblog//3.32479602013-05-10T12:56:39-04:002013-05-10T12:56:45-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
No one, however, questioned a central assumption: DSM-5 would be used far and wide. That is, until now. Last week, in a blog post that has generated much interest and handwringing, National Institute of Mental Health (NIMH) director Dr. Thomas R. Insel announced that his organization would effectively ignore the DSM-5 when funding mental health research going forward.
Many think this is a huge development. The announcement was described in some blogs as the NIMH "abandoning" the DSM, and as "a potentially seismic move." Let's take a look.
Essentially, Dr. Insel said the DSM has created a coherent landscape of psychiatric diagnosis, but that its categories of disorders do not stem from any measurable causes or underlying biological conditions in the brain. His words:
The strength of each of the editions of DSM has been "reliability" -- each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.
It is no secret that the DSM is a clinical tool more than a scientific one, designed to compensate for the often unknown "etiology" or cause of psychiatric illness. This has been true since we began perceiving mental illnesses as real diseases of the brain. Lacking objective diagnostic tests -- for now -- the manual creates a set of clinical categories so that doctors are on the same page, and so that research into treatments could be effectively compared.
Dr. Insel's "abandonment" of the DSM is in fact a symptom of his optimism that we are now or will soon be able to discover the "real," biological causes of mental illness. The DSM is inconsistent with this science. "We cannot succeed if we use DSM categories," he writes. "The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories."
In summary: For what we need to do in mental health research -- for what it is becoming clear we can do -- the DSM approach is not appropriate. Even if it is still the best way to diagnose disorders and deliver treatment and knit the mental health care system together, it must begin to be supplanted by a new science-based framework.
Dr. Insel has a framework in mind, and the NIMH will move toward funding research based on a new paradigm called Research Domain Criteria, or RDoC, first mentioned online by NIMH two years ago. "RDoC is a framework for collecting the data needed for a new nosology," or classification scheme, Insel writes. "That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories -- or sub-divide current categories -- to begin to develop a better system."
After the somewhat alarmist response to his online posting, Dr. Insel spoke to the New York Times to clarify his views. The DSM is still of vital importance to mental health clinicians, he said. However, "biology never read that book." To put this another way: RDoC aims to represent what the brain really has to say about its own dysfunctions and what causes them. The goal is to listen to the brain with the tools of emerging science and to let it dictate new categories and associations that will lead to the new and better diagnostic tools and treatments. This is heady stuff, but it's also possible, which is why we should greet the development of RDoC and Dr. Insel's announcement with enthusiasm, not fear.
What does this mean for the family in the doctor's office this weekend? What we are seeing is shift toward two different approaches in psychiatry, one focused on clinical effectiveness, another on the needs of scientific inquiry. As Dr. Nassir Ghaemi writes in Medscape Psychiatry, the NIMH has decided "that we need two sets of diagnostic criteria: one for practice (DSM-5) and one for research (RDoC). The one for practice can be based on 'pragmatic' decisions about diagnostic criteria; the one for research should be 'real.'"
Dr. Insel concludes his posting on a optimistic, even ambitious note: "RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders."
But whatever the promise of biological psychiatry is -- and I believe it is immense, and have dedicated the Child Mind Institute to exploring the brain with all the available tools -- its transformative effect on clinical practice is years distant. Only time will tell how these two systems will eventually work together. But it is heartening that the field is proactively preparing for this future.
Dr. Insel will be discussing these issues in a webcast May 21 at 8 p.m. as part of the Child Mind Institute's Speak Up for Kids. For details, click here.
Harold S. Koplewicz, MD, is a leading child and adolescent psychiatrist and the president of the Child Mind Institute, whose website, childmind.org, offers information on childhood psychiatric and learning disorders.
For more on mental health, click here.]]>The Barriers to Mental Health Care for Kids and How to Overcome Themtag:www.huffingtonpost.com,2013:/theblog//3.31810092013-05-01T11:52:05-04:002013-05-01T11:52:12-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/Speak Up for Kids campaign. I thought I would take this moment to reflect on what we're doing together, and why.
In the wake of the Newtown shooting, President Obama called for a national conversation about mental health. But that conversation really begins in your home and your community, and it doesn't start and stop with individual tragedies. We will never know what exactly went wrong in the Lanza family. But we know that something did go terribly wrong, and that the family was so profoundly isolated that no one knew. Isolation, frustration, and hopelessness are the worst possible thing for mental illness.
And yet, this is the case with many kids and families in this country, and around the world. The violence is rare. But the suffering is there, every day, silent.
This May we are encouraging you to help start the conversation in your community by being a person who someone can feel comfortable talking to openly about a child who needs help. By being brave enough to be honest about your own worries and concerns. By being a person who makes other parents feel safe enough to speak up. A person who replaces stereotypes about mental illness with facts, who encourages people to try to get help.
We need resources and more specialists with expertise to make care more available. We need more and better research to create the treatments of tomorrow. But a lot of what we need starts with you and me, in our personal acceptance and honesty and openness in talking about mental illness with our families, our friends, and with other parents who may be struggling. That's why we call this month SPEAK UP FOR KIDS month.
I kicked off the Speak Up for Kids campaign with Cynthia McFadden at childmind.org/speakup on May 1st at 9 a.m. EST with a discussion about the barriers to children's mental health care and how we can overcome them, to make sure every kid has the opportunity to reach his or her full potential. That's just the beginning -- the message, the conversation and the issues will be raised all month long by leaders in the mental health care field, advocates, and families and kids who have struggled with mental illness. We hope you'll join us online to listen and learn but ultimately to speak up. We can't afford to be silent any longer.
Harold S. Koplewicz, MD, is a leading child and adolescent psychiatrist and the president of the Child Mind Institute, whose website, childmind.org, offers information on childhood psychiatric and learning disorders.
Read more blog posts by Dr. Harold Koplewicz here.]]>Defending Psychiatrists and the DSMtag:www.huffingtonpost.com,2013:/theblog//3.29735192013-03-29T08:00:10-04:002013-03-29T13:32:29-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/Click here to read an original op-ed from the TED speaker who inspired this post and watch the TEDTalk below.
In Jon Ronson's rather entertaining TEDTalk, he has a little fun at the expense of psychiatrists. That's fair, but let's look at what he says. He asks: "Is it possible that the psychiatric profession has a strong desire to label things that are essential human behavior as a disorder?"
To which I would answer: The psychiatric profession has a strong desire to find a way to help people who are suffering -- and the family members who struggle alongside them. Suffering is, of course, "essential human behavior," but when people are miserable, and suicidal, and dangerous to themselves and others, we have an ethical obligation to try to help them. And to alleviate their suffering, we need to understand it.
In his TEDTalk, Ronson notes that the psychiatrists' diagnostic and statistical manual (the DSM) has grown over the years from a pamphlet to door-stop size, and he wonders out loud whether the expanding list of psychiatric disorders is really just a way to pathologize more and more ordinary behavior. This is not an off-base question, and it is an excellent time to revisit it because the manual is about to get even bigger when the fifth edition is published next month. But our "strong desire to label things" arises from our desire to better understand impairing behavior -- so we can help.
That, you see, is the point of the DSM and all those proliferating disorders.
Psychiatrists make checklists of behaviors and group them into disorders in order to understand them, and to be able to share that understanding with other clinicians and researchers.
Disorders change when our understanding changes, and we see that behaviors that have been grouped together should be separated--as is the case with one of the new disorders, Disruptive Mood Dysregulation Disorder (DMDD). I know that's a mouthful, but it's an important new way to group together children with very severe, frequent tantrums and irritability. Until now many of these children received a diagnosis of bipolar disorder, but clinicians have seen that not all of them become adults with bipolar disorder. So there may be something different going on here, and the new diagnosis is an effort to add nuance to mental health care -- not generate more patients. These kids are among the most troubled kids we see, and we aren't satisfied with what we've been able to do for them. We need a better way to identify them, as the first step in finding a better way to help them.
By the way, we're not talking about "regular kids" with ordinary tantrums here: We're talking about kids who are uncontrollable and dangerous to themselves and others, kids who, in an earlier era would simply have been locked up. (It is a testament to how far we have come that "out of sight, out of mind" is now anathema.)
These are children so anxious they can barely leave their rooms, for whom going to school is impossible. Kids so prone to violent meltdowns that their parents can't handle them. Kids who are suicidal. -- Dr. Harold Koplewicz
It's true that psychiatric disorders, like many medical illnesses, are often on a spectrum -- a lot of us are a little anxious, or a little depressed, or a little ADHD, or even, as Ronson says, "a little psychopathic." But in the same way that when your blood pressure goes past a certain point on the scale we say you have hypertension, when kids get outside the typical range on scales for things like anxiety, opposition, sadness, hyperactivity, impulsiveness, inattention, we say they have a disorder. But not, and this is very important, unless that behavior is causing them serious impairment.
People who think that we psychiatrists are going around gleefully diagnosing ordinary behavior as disordered and giving kids medication like candy aren't really seeing or understanding the children we treat, and the parents who bring them in. These are children so anxious they can barely leave their rooms, for whom going to school is impossible. Kids so prone to violent meltdowns that their parents can't handle them. Kids who are suicidal.
I'd be the last person to say that there's no such thing as misdiagnosis -- just like medical doctors, psychiatrists are sometimes stumped, and sometimes make mistakes. And kids who have a 7-minute visit to the pediatrician and come out with a prescription for ADHD medication are definitely not getting good care.
But I want to make the most important thing here clear: Since we can't yet diagnose mental illness with blood tests or DNA tests, we can only do it by very carefully observing behavior. And those lists of behaviors in the DSM, and other rating scales we use, are tools to help us look at behavior as objectively as possible, to find the patterns and connections that can lead to better understanding and better treatment.
There will always be some ordinary, perfectly healthy people who fit some of the criteria for a disorder -- or many disorders, as Ronson jokes he does. If we look only at that, we trivialize the people who are really, seriously impaired, who we are trying to understand, and help.
Ideas are not set in stone. When exposed to thoughtful people, they morph and adapt into their most potent form. TEDWeekends will highlight some of today's most intriguing ideas and allow them to develop in real time through your voice! Tweet #TEDWeekends to share your perspective or email tedweekends@huffingtonpost.com to learn about future weekend's ideas to contribute as a writer.
]]>Silver Linings Playbook: An Irreverent But Real Look at Mental Illnesstag:www.huffingtonpost.com,2013:/theblog//3.26165112013-02-05T18:13:55-05:002013-04-07T05:12:01-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/Silver Linings Playbook have had a field day with the "crazy" jokes: "Psycho-comedy." "It's crazy good." "A crazy-boy-meets-wacky-girl romance." "Crazed but uncrazy lovers." "Certifiably nuts."
This is, of course, because this romantic comedy, nominated for eight Academy Awards, is not just about cute screwball behavior (though there's plenty of that) but about real mental illness, which it approaches irreverently, but also frankly and with unusual empathy. In Silver Linings Playbook the mania and the meltdowns have a serious side, and a diagnosis.
Our hero, Pat Solitano, is a charming and volatile young man with bipolar disorder who has just been released from eight months in a psychiatric hospital to which he was committed after beating up his wife's lover. He's practically vibrating with intensity as he returns to his parents' home, armed with new knowledge about his disorder, required visits to a therapist, and medication he's disinclined to take. Obsessed with the delusion that he's going to win back his wife -- who, by the way, has taken out a retraining order against him -- he spends a lot of time running around the neighborhood to keep in shape (and, we hope, burn off some of that energy), wearing a garbage bag over his clothing to induce more sweating.
From the beginning, Pat is appealing and scary in equal measure, and when he meets his match in a sultry and seriously-depressed widow named Tiffany, the result is edgy and unpredictable attraction, and, to me, it's riveting.
But this isn't a movie review, so whether or not the movie eventually veers into disappointing conventionality, or whether or not the Hollywood ending is too sweet isn't really the point. The depiction of mental illness is sharp and engaging, with immensely-talented leading actors, Bradley Cooper and Jennifer Lawrence, playing flawed but terribly-likable people.
And they're surrounded by more of the same: family and friends who are odd and obsessive themselves, but also warm and forgiving and unembarrassed by eccentricity.
Part of the message of the movie is that it takes a lot of mutual support for people to be their best selves, whether or not mental illness is involved. And that if we're not afraid of mental illness, and we don't try to hide it, we can help people manage their symptoms and live up to their potential. It's when Pat realizes who his real love interest is that he is motivated to take his medication and give up his delusions.
The movie also places Pat's struggles in an interesting context. His father, played by Robert DeNiro, is a Philadelphia Eagles obsessive with full-blown rituals and a history of outbursts at games that have gotten him banned from the stadium. You find yourself thinking there's a familial element to Pat's disorder, genetic loading of some kind.
But the theme of sports rituals and superstitions helps make a bigger point: that in the broad spectrum of human behavior, the dividing line between what's considered normal and what's not can be pretty hard to discern. This comes into focus most forcefully in a funny scene in the parking lot at an Eagles game, where even Pat's mild-mannered Indian psychiatrist is wearing face paint and getting pumped up. When the pregame partying degenerates into mayhem, Pat, who is the one with the diagnosis, is the last guy to succumb to the frenzy.
The movie has been marketed with YouTube videos of football fans talking about their superstitions, ranging from a guy who can't wash his jersey unless his team loses to a woman who has to hold her breath before every snap. (Eagles quarterback Michael Vick, by the way, has to eat exactly three chocolate chip cookies the night before every game.)
Budweiser has recently made a bunch of commercials about football fan rituals that has the tag line: "It's only weird if it doesn't work." Which is, in its own way, a kind of advertisement for the openness the movie promotes. There's a recognition that mental illness is real and needs to be treated that way, with therapy and/or medication -- whatever works. But the feelings and behaviors involved aren't alien to any of us. The more we accept that, and the more we aren't ashamed or afraid, the better off we all will be.
Harold S. Koplewicz, MD, is a leading child and adolescent psychiatrist and the president of the Child Mind Institute, whose website, childmind.org, offers a wealth of information on childhood psychiatric and learning disorders.
For more on mental health, click here.]]>Speculating About Adam Lanza's Mental Statetag:www.huffingtonpost.com,2012:/theblog//3.23117782012-12-17T13:20:10-05:002013-02-16T05:12:01-05:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
We do know that whatever was going on in the mind of 20-year-old Adam Lanza when he went on this appalling shooting spree, it did not come from a place of good mental health. But to blame this violence on Asperger's or a personality disorder, as many media outlets currently are, is a serious mistake.
At this point, any comment on the psychiatric profile of Adam Lanza, the 20-year-old man responsible for these murders, is complete hearsay. We don't know whether he had a history of psychiatric illness or if had been exhibiting signs of a psychotic breakdown. Unfortunately, that hasn't stopped extensive speculation that Lanza had Asperger's disorder, or a personality disorder, and even obsessive-compulsive disorder. Much has been made of the reports that Lanza was a smart but quiet kid who carried a briefcase to class instead of a backpack and felt at home with computers, perhaps more so than with his peers. By themselves these traits do not indicate any diagnosis at all, although we have been quick to dissect them in the search for meaning.
These amateur diagnoses based on unconfirmed information are very harmful. To my mind perhaps the worst is the suggestion that the unimaginable nature of this violence -- the fact that children were targeted -- somehow indicates a lack of empathy that can be associated with autism spectrum disorders. This is completely untrue. Individuals on the spectrum are in no way predisposed to this kind of violent behavior. Ample research proves otherwise. And while individuals with autism may be less adept at picking up nonverbal social cues, they are just as capable of experiencing emotional empathy as anyone else. I have known many autistic children who would be crushed knowing that a sibling, a parent, or even a spider was suffering.
Trading in rumors and misinformation sensationalizes real disorders and leads to stereotypes and bigotry. It fuels the stigma that mental disorders are dangerous or scandalous and prevents people from seeking the life-changing help they need. And because untreated psychiatric disorders are more likely to result in violence, it makes tragedies like this one more likely to happen again. So let's stop speculating about the things we don't know and start focusing on what we do know.
We know that when we see someone suffering, we shouldn't look away. And when we see young people coughing, wheezing or bleeding, we insist that they get attention. But when we see young people with disturbing behavior, or young people in clear emotional distress, we ignore them and hope these problems will go away.
The first signs of 75 percent of all psychiatric disorders appear by the age of 24. We need to be on the lookout for signs of distress in young people to get them help as soon as possible. Research shows that early intervention improves the outlook for anyone with a psychiatric disorder -- and drastically reduces the likelihood of violence.
As a nation, we need to change our attitude about mental illness. We need a better plan for giving mental health care parity with other medical care. Improving access to the best evidence-based interventions should be a national priority. The economic cost as well as the human cost of untreated mental illness makes that clear.
Finally, we know our first graders should never fear for their lives when they sit down in a classroom. We know we need to do everything we can to make sure this never happens again.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For expert advice on how to help children cope with frightening news, go to childmind.org, which offers resources on trauma and resilience as well as a wealth of information on childhood psychiatric and learning disorders.
For more on mental health, click here.]]>Tips for Parents on Talking to Kids About Sexual Abusetag:www.huffingtonpost.com,2012:/theblog//3.16012502012-06-18T12:50:29-04:002012-08-18T05:12:12-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/ New York Times Magazine piece this past weekend by Amos Kamil detailing allegations of decades-old sexual abuse and impropriety by teachers at Horace Mann, one of the top private prep schools in the city. But although there were certain appalling details in the article, I was not. This isn't because of any specific quality of Horace Mann -- any more than the Penn State scandal was a necessary by-product of Happy Valley. I wasn't shocked because as a parent and a professional who works with children, I know that no institution is safe from predators.
These dangers are everywhere -- they do not pay heed to the power of good names or august environments. Reading the article, I was immediately reminded of Dr. Melvin Levine, who committed suicide in 2011 after years living under the specter of abuse allegations. Over a long and distinguished career, Dr. Levine became one the most respected pediatricians in the nation and a leading advocate for children with learning disabilities and the development of new strategies to help them succeed. Across the country, parents felt that they could trust him, and that he had the best interests of their children in mind. In a way, this was undoubtedly true. In other ways, it appears, this was manifestly not the case.
Unfortunately, we delude ourselves into thinking that certain situations are without danger. That is why it is incumbent upon us as parents to know the people who come into contact with our children, and not to let assumptions about stature, expertise, or fame get in the way of sober assessment and parental instinct.
In all honesty, however, there is only so much we can do. Once they reach a certain age, our children spend the majority of their waking hours away from us, and in the end it is incumbent upon them to know when to steer clear, when to say no, and, most importantly, when to speak up -- and loudly. For our kids to learn these skills, we need to educate them. And that is the best thing we can take away from the Horace Mann story. As the Bronx DA contemplates an investigation, which I think is appropriate, parents should take this opportunity to speak to their children openly, honestly, and in a developmentally-appropriate way about the realities of the world outside. Some pointers:
Tell them what to expect: Be clear about what is and what is not appropriate behavior to expect from other adults. This can be as simple as "good touch, bad touch," but should also include more subtle conversations. Is someone paying much more attention to you than the other children? Do you feel uncomfortable but you don't know why?
Tell them to speak up: Speaking up about possible abuse is always the right thing to do. Tell your kids that not only do they not have anything to feel bad about if they are in an uncomfortable situation or have been abused; they also should not worry about hurting an adult's feelings by telling a parent or other caregiver.
Model directness: Do not worry about being intrusive. If you are worried about an adolescent boy, you can just ask him, "Is someone touching you?" If the answer is yes, he'll tell you. If he isn't, he may well yell at you, but that's par for the course. Being concrete about what you are discussing, even with younger kids, is necessary. Muddying the water with euphemisms doesn't help anyone.
Model openness and honesty: The most crippling part of sexual abuse, which lasts far longer than any physical violation, is shame. Shame prevents kids from saying no, from speaking up, from processing their experiences in a healthy way. And shame comes so much easier to kids who are already embarrassed by their bodies and uncomfortable talking about sex. Help your child be knowledgeable, savvy, and comfortable in his own skin.
Parents may balk at the prospect of this conversation (or series of conversations, as it should be). Many have worried to me that they will terrify their children by telling them about what is a real but relatively rare danger. Of course, we don't want our kids to be fearful of the world. My response is that it is precisely the kids who are confident in their ownership of their bodies, confident in the support of their parents, and confident of their assessment of the motives of those around them that tend to avoid abusive scenarios in the first place, or quickly report an adult who is acting inappropriately. Though Kamil's story contains many horrors, it is also shows how a well-prepared young person can act in the face of abuse. These were children who were unafraid to speak up at the time, and as adults appear to have little shame concerning their run ins with alleged sexual predators.
Parents, teachers, school officials, anyone who helps raise children: prize honesty. Administered early, it is a potent antidote to shame. And shame, over the years, can turn dark. Long after it has enabled an abuser to take advantage of a child, it can still hurt. One of the abused students Kamil profiles committed suicide. Another will only allow the author to identify him by a letter that occurs in his middle name, even more than 30 years later. This is sad, chilling, and upsetting. And unfortunately, denial just perpetuates the damage. We can help adults who have suffered with the memory of abuse. But it is infinitely easier to teach children how to respond the right way to a wrong touch the first time.
For more on mental health, click here.]]>Speak Up for Kids Mental Health This Weektag:www.huffingtonpost.com,2012:/theblog//3.14781072012-05-04T13:28:46-04:002012-07-04T05:12:04-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
The message we want to send is that kids who are struggling should get help before their impulsivity becomes dangerous, before their anxiety becomes crippling, before their failure in school makes them decide they're "stupid," before their disruptive behavior gets them in serious trouble.
Childhood psychiatric disorders should be treated before they become adult disorders, which are much tougher to fight. And kids should get help before they miss out on the main task of childhood and adolescence -- learning -- because they're too anxious to try new things, too distracted to pay attention, too despondent to be engaged, too hyperactive to concentrate.
When I became a child and adolescent psychiatrist nearly 35 years ago, it was because I saw an opportunity to have a positive effect, to prevent struggling children from becoming very disabled adults. And our ability to alter the course of a life for the better has only improved since then, along with the tools we use to treat kids.
We've made enormous strides in understanding children, how they think and develop and how they're different from adults. We now have specialized, targeted behavioral therapies that really can transform young lives, as well as more effective medications.
But the public perception of child and adolescent mental illness hasn't changed along with the possibilities that have opened up to treat or even prevent it. That's why we started Speak Up for Kids. Because stigma and misinformation STILL stand in the way of kids getting treatment that could really change the course of their lives.
Where we have areas of progress -- like effective medications for ADHD -- there's a backlash, and lots of people blaming parents. It's become common to read that ADHD isn't real, that the symptoms are caused by poor parenting and that these same poor parents are using medication as a "quick fix" for their kids' bad behavior. If you had met as many of these parents as I have you would know that this is simply not true.
I'm sure there are cases of misdiagnosis, when the doctors doing the prescribing aren't well-enough informed about ADHD. But the kids who are not getting diagnosed and treated are a much bigger concern of mine.
Instead of people embracing the tremendous upside of early intervention -- the possibility of preventing a lifetime of dysfunction and suffering -- we hear that we should just let kids grow out of their problems. I am well aware of the charge that mental health professionals are pathologizing normal behavior, treating symptoms that all children exhibit -- distraction, hyperactivity, anxiety, impulsiveness, moodiness, disruptive behavior. But the children who need help are those who are way out of the normal range for these symptoms, and they are seriously impaired by them.
No one would tell the parents of a child with diabetes or leukemia that they shouldn't seek treatment, and no one should tell the parents of children with psychiatric or learning disorders that they're overreacting by getting help, whether it's medication or behavioral therapy or both.
Obviously, we need a national conversation about children's mental health, to force out into the open the parent-bashing and misinformation that is being promulgated. We need all our kids to have the opportunity to fulfill their potential, and to get there we need you to help spread the word about early and effective intervention.
This week people all over the country (and the world) will be speaking up for kids who are struggling and the parents who are trying to help them. They will be telling the world that childhood psychiatric disorders are real, common and treatable.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more on important issues in children's mental health, go to childmind.org, which offers a wealth of information on childhood psychiatric and learning disorders.
]]>Overstating the Placebo Effecttag:www.huffingtonpost.com,2012:/theblog//3.13324162012-03-09T15:19:07-05:002012-05-09T05:12:02-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/60 Minutes.
Dr. Kirsch says he got involved in evaluating antidepressant medications by accident during a study researching the placebo effect. To his surprise, he could find no appreciable difference between treating depression with antidepressants and treating it with entirely different drugs, including tranquilizers and barbiturates. Dr. Kirsch then went on to study data from published and unpublished antidepressant drug trials and found that antidepressants performed about as well as placebo in many of the unpublished trials. He concedes that some people did get better while taking antidepressants, but insists the medication wasn't responsible for the change -- the placebo effect was.
The conclusions look damning, but in this case appearances are deceiving. To understand why, we need to talk about placebos -- and depression.
A placebo is by definition pharmacologically inert, but the effect it can have is remarkable, through heightened expectations, suggestion and other less understood effects. This is not limited to depression; placebo can help with pain, digestion, Parkinson's disease and much more. Neuroscientists have taken brain scans of people experiencing the placebo effect and watched as patients' brains mimicked the effects of anti-Parkinson medication. The therapeutic effect is real, although it doesn't last as long as actual medication or surgery.
Two things make depression hard to study: First, people diagnosed with the disorder may get better on their own, making it difficult to determine if a patient is improving because of treatment or for other reasons. Second, not all depressions are alike: People with mild depression and people with severe depression respond differently to medications. There's a subtype called "atypical depression" that teenagers are especially prone to. Those who have it respond best to medications that aren't often used.
To evaluate efficacy as well as safety, the FDA started testing new medications in the 1960s. Unfortunately, there are many problems with how these clinical trials are conducted. Pharmaceutical companies rush to get their product on the market as soon as possible because the patent clock (and their opportunity to profit by marketing exclusivity) starts ticking well before their drug becomes eligible for FDA testing. A primary concern in clinical trials is minimizing potential side effects that could keep the drug off the market. This means giving patient volunteers the smallest dose that could still yield statistically significant benefits -- and when the dosage is kept low to minimize side effects, it will also be less likely to have any real clinical success on someone with a disorder. Rather than taking the time to determine a correct clinical dose, it's cheaper to do lots of studies and throw out the ones that don't get results.
There's also a problem with trial volunteers, who may have varying degrees of depression, ranging from severe to mild to no disorder at all. Doctors running FDA trials are pressured to recruit volunteers as quickly as possible, so they often do a poor job screening volunteers. The doctors may be less discriminating or even outright biased towards volunteers who will be more susceptible to treatment -- both the antidepressant and the placebo form. Some of the recruited patients may be feeling down because of a recent divorce or unemployment or some other life event. These patients are likely to get better on their own, regardless of any medication. Taking a placebo could simply be a morale-booster for them.
What we know from clinical experience -- that antidepressants work best with people who have severe depression -- was actually borne out by the unpublished trials Dr. Kirsch studied. People with more severe depression were helped by antidepressants; it is the people with much milder cases of depression who were less likely to benefit.
The 60 Minutes report seems scandalous, and it is, although not in the way that Dr. Kirsch intended. The argument put forth by Dr. Kirsch and others like him is an ideological one, with no basis in science. Some people are simply opposed to treating psychiatric disorders with medication. Unfortunately, the science behind psychotropic medications is very complicated and what they have to say sounds very simple, so the ideologues can make a big splash.
My colleague Dr. Donald Klein has spent his psychiatric career evaluating medications for their clinical application and helped refine how doctors prescribe medication today. Dr. Klein began studying medicine in the 1950s, a time when psychotropic drugs and indeed diagnoses were still poorly understood. People with severe depression and schizophrenia were contained in massive institutions, and treatment was dominated by psychoanalysis. Dr. Klein tells a powerful story from his residency, when he was in charge of a unit for veterans with psychosis. Dr. Klein began prescribing the vets medication and after six weeks of treatment, one veteran who hadn't spoken in 30 years asked him, "Hey Doc, when am I getting out of here?"
The man's question helped convince Dr. Klein that drugs were not the "chemical straightjacket" that many had assumed them to be. He saw that psychotropic drugs had the power to change lives, and the same is true today. As a child and adolescent psychiatrist, I have also seen the lives of many children turned around by psychotropic medication. I have seen it help kids who were so acutely anxious they were afraid to speak, and I have seen it help teenagers who were so depressed they were ready to take their own lives.
Unfortunately, there are still people who are afraid of medication and choose to ignore the science that supports it. It's true that not everyone should be prescribed a psychotropic medication -- or be included in an FDA trial of one -- but that doesn't mean they don't work for others. Hopefully those who could really benefit from medications won't be scared off by the headlines.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more on psychopharmacology, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.
For more on mental health, click here.
]]>Extremely Loud and the Incredible Courage of Parentstag:www.huffingtonpost.com,2012:/theblog//3.12826052012-02-22T16:23:52-05:002012-04-23T05:12:01-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
In the movie, based on the Jonathan Safran Foer novel, an 11-year-old boy struggles to come to terms with his father's death on 9/11 by constructing an elaborate quest to find the lock that matches an unmarked key found in his father's closet. It's a childish, magical fantasy -- that there will be a message from father to son in whatever safe deposit or lock box it fits. But he pursues it with the ingenious, literal-minded persistence of a very bright child with Asperger's, which the boy, Oskar, appears to have. Like any good quest, it involves traveling far and wide (all over the five boroughs of New York), meeting many characters, and learning from them. But Oskar also has overwhelming fears not unusual in kids on the spectrum; he's terrified of subways and bridges. The sight of him shaking his tambourine to quiet his fears as marches in what he calls "heavy boots" across the Manhattan Bridge will be moving to anyone who knows kids who are afflicted with intense anxiety.
But the thing in "Extremely Loud" that moved me even more than Oskar's nervous pluck was the portrayal of his parents -- their patient and equally ingenious efforts to understand Oskar's complexities and nurture his talents.
Oskar is not an easy child. In a scene that will be familiar to many parents -- whether your kids are on or off the spectrum -- we see Oskar's father, played by a Tom Hanks, trying unsuccessfully to coax Oskar onto the swings at a playground in Central Park by invoking his own boyhood pleasure in it. In that moment he's every parent who's felt the frustration of having a child who just can't do an ordinary thing all the other kids do, or just doesn't share his parents talents or passions.
But Hanks, and the filmmaker, play the scene marvelously: only a tug at the swing as he takes the boy home betrays the father's disappointment. And we are grateful, because Oskar is nearly as afraid of disappointing his father as he is of getting on that swing.
Hanks, who seems wonderfully tuned in to Oskar's strengths and wonderfully non-judgmental about his weaknesses, devises elaborate scavenger hunts to help his son navigate the city and get better at speaking to strangers. For his mother, getting on Oskar's wavelength seems tougher, and her parallel journey is a good deal of what the movie becomes about. She surprises Oskar, and herself, when she says, "You thought only your father could think like you."
But before we see them coming together there's an exchange that's both painful and wonderful in its honesty. In anger and frustration and loneliness, Oskar blurts out, "I wish it was you." That is, that she had been in the World Trade Center that day and not his father. She says simply, "Me, too." Later, feeling badly about hurting her feelings, he says, "I don't mean that." She says, in an awesomely comforting voice, giving him permission to have his feelings, "Yes, you do. "
A lot of critics disliked this film, called Oskar "obnoxious" or other words to that effect, and complained that they were being manipulated into "feeling sorry" for him. I think this is a misreading of the film: we're not being asked to feel sorry for Oskar or his mother and father. We're seeing the world, and the process of figuring out how to live after terrible loss, through their eyes. What I saw was love and courage and great creativity in the face of adversity -- something to admire, not something to feel sorry about.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about parenting kids with special needs and the courage of children, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.
]]>Why "Ritalin Gone Wrong" Is Wrongtag:www.huffingtonpost.com,2012:/theblog//3.12449352012-01-31T15:29:48-05:002012-04-01T05:12:01-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/New York Times fired a shot across the bow of every parent of a child who's taking stimulant medications for ADHD. A piece in the Times' Sunday Review section claimed that there is no evidence that medication helps kids with ADHD after an initial couple of years, and, worse, that ADHD is the result of abusive or even garden-variety bad parenting.
The piece, by L. Alan Sroufe, a psychology professor emeritus at the University of Minnesota, was such a broad assault on what we know about ADHD, and how it is affected by medications like Ritalin and Adderall, that it deserves point-by-point response.
1. Dr. Sroufe claims that studies show that stimulant meds are not effective after the first two years. He refers specifically to a long-term study published in 2009 of 600 children who were treated with medication, or intensive psycho-social interventions, or both. After 14 months the children showed a positive response to medication, and those who had the combined treatment did a somewhat better still. But following up with the kids 8 years later, researches found the benefit had eroded. What he doesn't explain is that after the first 14 months the children were no longer being treated as part of the study. The authors of the study itself call it an "uncontrolled naturalistic follow-up study." In the latter 6 years the children got what the authors call "routine community care. " No surprise that, as they note, "the differential effects of the ADHD treatments, evident when the interventions were delivered, attenuated when the intensity of treatment was relaxed."
The point here is that when we prescribe Ritalin or Adderall for ADHD we don't claim to be curing it. There is no cure for ADHD. We claim that it helps kids while they are taking it by reducing excessive inattention, impulsivity and hyperactivity so they are able to function better in every part of their lives -- at school, with friends, and within their families. There is abundant evidence that it does that, and that kids with ADHD who are treated with medication do have fewer symptoms and function better. As my colleague Dr. Rachel Klein, who has led seminal research on ADHD, explains, "The medications work as long as you give them. That's true of all psychiatric treatments and most medical treatments. Arthritis, diabetes, congestive heart failure. We don't have cures for many chronic illnesses. So, yes, it's too bad, but it doesn't follow that we should not use the treatment."
By the end of adolescence many children no longer need medication, as they have outgrown their ADHD. Others (figures range from 35% to 40%) will continue to experience some symptoms -- and may continue to use medication -- all their lives.
2. Dr. Sroufe suggests that because we don't have randomized studies of the effectiveness of the drug for more than two years, we should conclude that those benefits don't continue. There is no reason to draw this conclusion, especially given overwhelming clinical evidence that it continues to work, in adulthood as well as childhood. There are no randomized long-terms studies that show continued effectiveness of insulin for diabetes either. These kind of studies are extremely difficult and extremely expensive and often unethical: you can't put a child on a placebo for his entire adolescence for the purpose of a study.
3. At the heart of Dr. Sroufe's attack on medication is his observation that many "behavior problems" appear to be generated by a child's environment, including disadvantaged, stressed, chaotic home situations. This is certainly true; the mistake here is to assume that all children who have problems with behavior -- impulsivity, inattention, trouble self-regulating -- have ADHD.
"Yes, there could be some children who show inattention and hyperactivity because their environment hasn't given them the opportunities for appropriate development," notes Dr. Klein. "There are different causes to different presentations. It doesn't mean that one invalidates the other. They can co-occur. And the challenge to the clinician is to distinguish them."
One of Dr. Sroufe's studies, done in the 1970s, was on treating what the authors called "problem children" with stimulant drugs. This vagueness may have been acceptable in the '70s, but it's not now. Many kids with behavior problems don't have ADHD -- or don't only have ADHD. For many kids, stimulant medications are not the right (or the only) needed intervention. But that doesn't mean they don't work for kids who have been accurately diagnosed with ADHD.
4. Dr. Sroufe suggests that since we don't know how these medications work, we should be reluctant to use them. If this standard was applied to all medications, a great many wouldn't pass the test. We didn't understand the mechanism of action of aspirin until the 1970s -- some 70 years after it became widely used. "There are lots of things we do that help people, but we're not sure how they work," says Dr. Klein. "But if they work, we use them. Understanding the mechanism is a goal for science, but it's not a requirement for therapeutic action."
5. Dr. Sroufe notes accurately that these medications have side effects, notably problems with sleep and appetite, which can lead to what he calls "stunted growth." What he doesn't note is that sleep and appetite problems tend to go away after the first month or two, and if they don't we try changing the dose or the kind of medication until we solve the problem. No one said these medications should be used without careful monitoring. The charge of "stunted growth" is an exaggeration; the reality is that kids do fall slightly behind their peers in growth in the first year they take medication, but they also, according to a 2010 study, catch up by the fourth year.
The reality is that the side effects of Ritalin or Adderall are much less problematic than those of many medications considered invaluable. "There are side effects to almost all drugs," Dr. Klein notes. "Aspirin can be lethal. You can have lethal bleeding from aspirin. Does it mean it should never be used? That would be absurd." The fact is that the rate of response (the percentage of cases in which it is effective) is one of the highest in medicine--higher, for instance, than most antibiotics.
6. Dr. Sroufe paints a scary picture of stimulant medications changing a child's brain, that they "develop a tolerance for the drug," and "become adapted to the drug" so that if they stop taking it their symptoms become worse. In fact, there is no evidence at all that kids develop habituation or tolerance to stimulant medications, that they need escalating amounts to get the same effect. And while it is true that there's something called "rebound" that can cause irritation and exacerbated symptoms when the drug wears off, this is a temporary effect, not unlike, as Dr. Sroufe himself points out, if you suddenly cut back on caffeine.
7. In a way the most distressing comment Dr. Sroufe makes in this piece is that ordinary parents who make ordinary mistakes during a child's early development could result in the kind of brain changes we see in children with ADHD. He includes among these potential sources not only "family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves," but also, bizarrely, "especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared. For example, a 6-month-old baby is playing, and the parent picks it up quickly from behind and plunges it in the bath. Or a 3-year-old is becoming frustrated in solving a problem, and a parent taunts or ridicules. Such practices excessively stimulate and also compromise the child's developing capacity for self-regulation."
It's certainly true that parental patterns influence the development of a child's ability to regulate his behavior, and that changing those patterns can help a child learn to rein in his own disruptive behavior -- we see it work spectacularly in parent-child interaction therapy (PCIT). But PCIT doesn't cure the core symptoms of ADHD; in fact kids with severe ADHD usually have to be on medication to be able to focus enough on the training sessions to learn effectively from them.
The sad thing here is that I think what Dr. Sroufe really wanted to argue for in this piece is that knee-jerk use medication isn't the right response to behavioral problems -- or the only necessary response. Kids may get prescribed drugs because it's cheaper and easier than figuring out what's causing the behavior. Many kids who show some of the symptoms of ADHD may have other psychiatric problems that need attention -- they may have anxiety disorders or be on the autism spectrum. Or they may need relief from a chaotic or abusive home situation, consistent support and discipline from their parents, positive role models, and many other things that are harder to muster than a prescription.
We agree with Dr. Sroufe that that is unfortunate. It's too bad that to make that case, he attacked the well-established effectiveness for medications that really do work for kids who have ADHD.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about ADHD, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.
]]>Wimpy Kid: Why 'The Ugly Truth' Is So Appealingtag:www.huffingtonpost.com,2011:/theblog//3.10850352011-11-10T08:14:30-05:002012-01-10T05:12:01-05:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/Diary of a Wimpy Kid: The Ugly Truth.
The Ugly Truth was No. 5 in the series of Wimpy Kid graphic novels by Jeff Kinney about the adventures of a not terribly prepossessing (and not all that admirable, either) middle school student named Greg Heffley. A massive bestseller about a kid with no superpowers in what may be the most awkward and painful of all the stages of life? That's right. And the next book, No. 6 in the series, Diary of a Wimpy Kid: Cabin Fever drops Nov. 15.
I can't tell you what Cabin Fever has in store for readers (the security is both kid- and adult-proof) and Jeff Kinney doesn't need me to sell books (the first printing on Cabin Fever is 6 million). But it's very valuable, I think, to consider what makes this series such a monster hit with our kids.
A lot has been written about the Wimpy Kids graphic novel format, which has appealed to millions of grade and middle-schoolers who were previously unenthusiastic readers -- especially, but not limited to, boys. Kinney sees himself as more a cartoonist than an author, and his drawings are, in themselves, laugh-out-loud funny. But the text is very funny, too. And one of the reasons his dead-pan humor is so tough to resist, at any age, is how darkly honest it is.
You could argue that middle school is a dark comedy waiting to happen. Consider the crazy physical changes kids undergo in these years, on wildly different timetables, resulting in kids like Greg, who look like boys, sitting in math class next to kids who look like men and (perhaps even more challenging to Greg) women. Kids are changing faster in these years of early adolescence than at any time since infancy. They're trying to figure out not only how their bodies work but who they are going to be and where they fit in. That's why they are both desperate to make friends and capable of turning on those friends savagely. That's why they can be merciless to anyone who's different.
"The terrible twelves are a complete analog to the terrible twos," journalist Linda Perlstein, who's written a book on the subject, tells "This American Life" in a recent broadcast about middle school. "They're just not as cute."
A good deal of what Wimpy Kids is about is the brutality of middle school, the baldly hostile and hurtful things kids do to each other at this age. Greg records in his diary his (often unsuccessful) efforts to avoid being trashed by other kids who are cooler or bigger or more sophisticated than he is. Not that he is blameless, either. He complains a lot about bullies -- when he's not bullying (or attempting to bully) others, including his on-again, off-again best friend.
In fact Kinney celebrates Greg's imperfections. "Greg is a deeply flawed protagonist.," he told USA today a couple of years ago. "I think adults who voice complaints about Greg's shortcomings are missing the joke. Kids get that Greg isn't perfect, and I think that's why they like him."
The appeal of Wimpy Kids comes into focus when you hear a 14-year-old named Annie, also on "This American Life", describing her relief at escaping from middle school, and the agonies she went through trying to avoid being a target of other kids while she was there. "No matter who you are or what you do you'll get made fun of for it--anything in the world. It can be hard to do even the smallest thing because someone could tease you or judge you for it."
She confesses that when she got a pair of lace-up moccasins she loved it took her two months to get up the courage to wear them to school. "I didn't want to stand out that much."
And a boy interviewed outside a middle school dance, asked what his hopes were for the event, said with surprising candor: "I'm hoping nothing bad happens -- no humiliation, nothing that will be a story for the next month or two."
Suffice it to say that in the Wimpy Kids books, Greg is often too clueless to avoid those pitfalls, but he lives to tell about them, and if he's not quite laughing about it, the readers are. He turns the humiliations of middle school into a comedy, and that's no mean feat.
A librarian who wrote about the first book in the series on her blog said, "No one in their right mind would ever want to return to the days of Middle School, but if Jeff Kinney keeps churning out books like this one, I'll follow him there any day of the week." For those who have no choice but to be there -- our children -- Kinney's humor offers more balm in this developmentally rich but precarious time than any platitudes we might offer.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about parenting adolescents, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.
]]>How to Help Young Men? Start When They're Childrentag:www.huffingtonpost.com,2011:/theblog//3.9988342011-10-11T12:09:32-04:002011-12-11T05:12:01-05:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
This is a very interesting and well-meaning endeavor that has, not surprisingly, prompted plenty of criticism: that it's hopelessly paternalistic, that the target group, men from 16-24, excludes others that are just as bad off, that it won't work because these young men are beyond saving -- or don't deserve the special treatment.
We know the odds of successfully initiating social and economic change across a population that the Bloomberg administration estimates at 315,000 are daunting. That doesn't mean it's not worth doing, and Bloomberg and Soros are no strangers to spending money to experiment on social change. But we also know that whatever good this program will do for these young men, the best thing that could have been done for them was a concentrated effort, earlier in their lives, to get them the support they needed to flourish in school, and develop the interpersonal skills to be successful adults -- spouses and fathers as well as employees or entrepreneurs.
When we consider the dire problems of undereducated and unemployed young men in our city, we should think about the next generation as well, and how we can help them now, before they find themselves in this predicament.
Early education is the point at which we can most successfully intervene to help children who are not prepared for school or able to function effectively in a classroom. When kids get to preschool or kindergarten and are unable to behave, or participate in learning, they need immediate attention. Some of them need the kind of training and skill building that has been taught effectively in Head Start -- a program perennially targeted for budget cuts.
Some of them have psychiatric and learning disorders, which, undiagnosed and untreated, cause the frustration and misery that leads kids to drop out as soon as possible. Psychiatric and learning disorders can also be the cause of the widespread disruptive behavior that makes so many of our classrooms very poor learning environments for all the children, not just the ones who are acting out. Untreated disorders have also been clearly linked to drug abuse, teenage sex and pregnancy, and incarceration. It's fair to assume that a high percentage of the young men Bloomberg and Soros are targeting have been struggling with issues like ADHD and dyslexia all their lives without getting help.
Unfortunately, black and Latino children who do poorly in school are less likely to be recognized as having a disorder, to be properly diagnosed, or to receive treatment. We need to give our early-education teachers better training in the signs and symptoms of early-onset mental illness. We also need parents to have the resources -- in the form of parent education, information and mental health coverage -- to get kids treatment that will allow them to succeed in school, behave in school, and develop their potential.
For kids who have disruptive behavior, there are excellent tools for both parents (behavioral therapy called parent-child interaction therapy, or PCIT) and teachers (teacher-child interaction training, or TCIT) to more effectively rein in kids who are out of control at home and in school. In many cases, the techniques, using positive reinforcement for desired behaviors and consistent consequences for undesired behaviors, have a transformative effect on young children, who are able to control their own behavior for the first time.
The challenge of getting these kids help is compounded by communities that are sometimes wary of the health care system -- in many cases for historical or cultural reasons. African-Americans live under the specter of experimentation, from slavery to Tuskegee; Latinos often have to reconcile the need to treat these real and possibly debilitating disorders with their religious beliefs. That is why educating the whole community -- and the whole family -- about mental illness, treatable behavioral issues, and neurodevelopmental disorders like ADHD is paramount.
We have every reason to believe, however, that early intervention is the cheapest and the most effective way to ensure that black and Latino boys can take advantage of education opportunities and be prepared for the job market. So as we try to bring disadvantaged young men off of what can be a terrible dead-end track, let's also try to keep the youngest and most vulnerable members of our city and our society on a brighter path from the beginning.
Harold S. Koplewicz, M.D. is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about Dr. Koplewicz, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.]]>Why We Need Psychoactive Medstag:www.huffingtonpost.com,2011:/theblog//3.9738252011-09-26T14:55:56-04:002011-11-26T05:12:02-05:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
Marcia Angell, the distinguished ex-editor of the New England Journal of Medicine, kicked things off with a ferocious two-part attack in The New York Review of Books on antidepressants, antipsychotics and, in general, medications to treat psychiatric disorders. Her argument distills charges often made much more sloppily: that psychiatrists dispense unnecessary and potentially harmful drugs. She impugns both the medications and the motives of the psychiatric profession. Both deserve clarifying responses.
Angell reviews several recent books claiming that careful analyses of studies of psychotropic drugs, done to win FDA approval, reveals that many are no more effective than placebos. Then why are they in such wide use? Angell sees a conspiracy of psychiatrists and drug companies for their mutual benefit, with patient benefit only a distant concern.
In her telling, it started in the late '50s, when psychoactive drugs began to appear. Psychiatrists, competing for patient income with a surging number of psychologists, pushed what Angell calls the "medicalization" of mental illness -- the idea that mental illness is a product of brain chemistry -- so that only they (and not their non-medical doctor brethren) could prescribe the necessary medication. Then, her theory goes, these psychiatrists invented diagnostic criteria -- in the form of the American Psychiatric Association-approved Diagnostic and Statistical Manual (DSM III) -- to match illnesses to available medications. The DSM writers, she charges, were deep in the pocket of the drug companies, who paid them personally and financed their professional organizations.
Like most conspiracy theories, it's breathtaking in its audacity. And, like other conspiracy theories, it becomes difficult to dissect the real from the imaginary.
First, it's preposterous to describe decades of scientific work linking emotional states and disorders to brain chemicals as basically a psychiatric plot to capture more of the mental health market. She writes (as do others) as if psychiatrists were bored by less remunerative talk therapy and wanted to hype their income by quickly dispensing pills. In fact, the drive for medication was fueled by the surprising observation that they were better treatments for mental illness than talk therapy or earlier sedative drugs. With apologies to Angell, more effective and less toxic medications for devastating illnesses such as schizophrenia, major depression, bipolar depression, OCD and panic disorder are as significant, in terms of public health, as finding new cancer medications.
Second, Angell's assertion that the DSM was a thinly-veiled ploy to justify medications ignores its real value, which is promoting reliable clinical communication. Before DSM, diagnosis was basically a labeling free-for-all. A particular diagnosis meant very different things to different people. The drive to make diagnosis less subjective was not an effort to create a market for medications, but to make psychiatric communication effective. Nothing in the DSM, notes my colleague Dr. Donald Klein, former director of research at Columbia's New York State Psychiatric Institute and member of the original DSM III task force, "pushes" medication -- or any other form of treatment.
That some psychiatrists and professional organizations take money from pharmaceutical companies is a fact. It may be true that some allow such money to influence their treatment decisions. This problem plagues all branches of medicine, but psychiatry is particularly affected, as it still lacks diagnostically sufficient laboratory methods. In recognition of the public's current distrust of pharmaceutical companies, the Child Mind Institute does not accept their funding. But we are staunch advocates for more research into mental illness, and the pharmaceutical industry is one of the biggest funders of basic and treatment science. This is simply a fact. A researcher's work cannot be dismissed simply because funding came from a drug company. There's a desperate shortage of funding for research, and not developing new treatments, or not pushing the science forward, in order to avoid the appearance of corporate ties is a far more troubling eventuality.
Which brings us to the issue of the studies Angell says show that antidepressants and other psychoactive medications aren't appreciably better than placebos. Peter Kramer, the author of "Listening to Prozac," responded to this charge in a piece in The New York Times, in which he argued that the studies Angell highlighted were undermined by the biased process by which patients were recruited. Many recruits were not, in fact, clinically depressed, so most get better over time, whether on placebos or real medications. There is a further claim that even the patients who do get psychoactive medications get better because of a sort of "extra strength" placebo effect: The side effects of the medication let them know they're getting the real thing, which undermines double blind precautions and makes them inclined to feel improved. This ridiculous notion must surprise the companies whose side-effect-rich medications never make it through the FDA review for efficacy.
Dr. Klein also explains that there is a real challenge to getting good, clinically useful data out of studies performed after a company gets a patent, in the process of seeking FDA approval for marketing. Because the clock starts ticking as soon as a new medication is patented, a drug company's goal is to move through the testing process as rapidly as possible. So in the first phase of human studies, doses are picked that will not cause FDA rejection because of side effects. The goal is often to use the lowest dose likely to produce statistically significant benefit, however marginal, over the placebo alternative. The result is that the studies' dose is often too small to regularly be clinically useful.
What's the takeaway of all this?
Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.
As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.
Harold S. Koplewicz, M.D. is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about Dr. Koplewicz, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.]]>A Decade Later: Talking to Kids About 9/11tag:www.huffingtonpost.com,2011:/theblog//3.9284432011-09-06T17:24:00-04:002011-11-06T05:12:02-05:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
But there's also the desire to honor the dead, the families who bore the burden of the attack, and the things we stand for as a nation. We celebrate resilience and renewal even as we vow not to forget.
The 10th anniversary, this year, brings those things even more sharply into focus. We're aware of all the ways we've changed and moved on in a decade. And nothing reminds us more viscerally of how much time has passed than our children.
Children who were infants and toddlers the day of the attacks are now middle schoolers. Those who were just old enough to understand what happened are in high school and heading off to college. Kids who were in high school may even have families of their own.
For many younger children, 9/11 isn't something they lived through but a piece of history, something they learn about in school. That's why, when we talk to children about the 9/11 anniversary, it's more important than ever to do it in an age-appropriate way.
As adults, we have our memories and our own relationship to the events of that day; our children probably don't share them. This isn't a bad thing, but it's an opportunity to think about what we want our kids to know, and consider, about this attack on our country, as we each find our way to pay our respects to those who sacrificed the most.
Here are some guidelines for talking to kids about 9/11.
1) Take your cues from your child -- each child, individually, if you have more than one. For those old enough to remember the events of 9/11, let them tell you what the anniversary means to them, what they remember and how they feel about participating in any commemoration. Children, and adolescents in particular, often resent being expected to have appropriate feelings on demand.
2) Share, but don't impose, your feelings. The events and the emotions of that day are still painful to many of us, but you want kids to know that they don't have to feel the same way. Ten years is a long time, especially in the life and mind of a child, and unless they lost people close to them in the attacks, the memories may not be potent. It's helpful to them if they don't feel that you depend on them to perform in a prescribed way.
3) Be age-appropriate. If a child is too young to remember 9/11, consider her age in deciding whether this is a good time for her to learn about it, or learn more about it. Don't force the issue. But if you see that the time is right, you may want to use the event to invite questions, to take an inventory of what she knows or thinks she knows, and provide more details.
4) Don't answer questions that aren't asked. Children as young as first grade are learning about 9/11 in school, as an important part of our history. But there's no reason to volunteer disturbing or frightening details unless a child has heard them and needs a reality check from you. If he does want to talk about things that are deeply upsetting to you, try to do so calmly, without telegraphing your feelings.
5) Turn off the TV when you need to. Try to avoid exposing children to the intrusive, repetitive TV news coverage, especially the pictures of 9/11 we saw for weeks and months after the event. They can make children feel anxious and stimulate unwanted emotions.
6) Help them feel safe. Kids are egocentric. They want to know "are we safe today?" The answer is yes, we are. Because of 9/11, there is tighter security at the airports and important buildings everywhere. And, finally, we are able to tell our children that the mastermind and many other leaders of al-Qaeda, the hate group that sponsored this attack, have been killed or captured.
7) Focus on resilience. If you go to a memorial, talk to kids in advance about why you're going, focusing on honoring those who died, and celebrating the resilience of both the nation and the individual families who lost loved ones. We memorialize things out of respect, to demonstrate that we haven't forgotten their sacrifice, and to stand up for our values and beliefs. We honor those who tried to help those trapped in the towers in the attack and lost their lives as the buildings fell. We honor the many, many people who helped with the search for survivors and the painstaking and painful job of removing the mountain of rubble left by the attacks. Don't talk about the threat of terrorism and the next terrorist attack.
8) Don't focus on hatred. Teenagers have a lot of bravado. They tend to be dramatic and extreme, and some may respond to the renewed focus on 9/11 by wanting to lash out against all Arabs or all Muslims. As a parent, say, "I understand that you are angry. But 9/11 happened because of a select few, not an entire population." Help your child do something positive and active instead. There are a number of great organizations that need support, including Tuesday's Children, the Wounded Warrior Project and the American Red Cross.
9) Don't feel that you have only one chance to talk about this. As parents, you always get a "re-do" to talk about difficult things. It's better to think of tough issues as an ongoing conversation that develops as kids grow and change. If you feel you haven't gotten it right the first time, give yourself a break and try again later.
Harold S. Koplewicz, M.D. is a leading child and adolescent psychiatrist, a member of the advisory board of Tuesday's Children, and the president of the Child Mind Institute. For more parenting tips, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.]]>Mental Illness: When A Therapist 'Comes Out'tag:www.huffingtonpost.com,2011:/theblog//3.8913592011-07-08T08:00:00-04:002011-09-07T05:12:01-04:00Dr. Harold Koplewiczhttp://www.huffingtonpost.com/dr-harold-koplewicz/
"I was in hell," she says many years later. "And I made a vow: when I get out, I'm going to come back and get others out of here."
And she does.
That deeply-troubled teenager, Marsha Linehan, became Dr. Marsha Linehan, a therapist and researcher at the University of Washington who used her own experience to develop a groundbreaking behavioral therapy.
She did that in part because nothing offered at the time she was in agony -- the late 1960s -- helped her get better. Not the Thorazine and Libruim, not the Freudian analysis, not the electric shock treatments. What did begin her journey to recovery was a religious experience, a vision that allowed her to accept who she was. This was a transformative moment for Linehan, then in her 20s, alleviating the despair that drove her self-destructive furor. As The New York Times writer Benedict Carey put it in a story about Linehan, "She had tried to kill herself so many times because the gulf between the person she wanted to be and the person she was left her desperate, hopeless, deeply homesick for a life she would never know."
As therapists we can't offer patients the shining moment in a Chicago chapel that started Linehan on the road out of hell. But we can recognize and embrace the central insight she had, which she later came to call "radical acceptance." It's the basis for the treatment she pioneered -- dialectical behavioral therapy (DBT) -- which enables patients to channel or change the emotions that are driving suicidal urges. But acceptance is also the beginning of many other effective therapies, for everything from substance abuse to obsessive-compulsive disorders.
And acceptance by a broader public of the reality of psychiatric illness is the key to effective treatment for many, many people who are struggling without diagnosis and treatment. That's why it's so important that Dr. Lineman decided, after decades, to go public about her own story, an unusual enough step for a clinician that one of my colleagues at the Child Mind Institute called it "coming out."
Clinicians are trained not to inject their own reality into the therapeutic relationship, but Linehan saw she had an opportunity to give hope to others in the same kind of hell she knew. Hope may not sound like much of a cure-all, but it's absolutely critical to recovery, which is not a passive but an active pursuit.
And as Linehan's struggle with what was eventually diagnosed as borderline personality disorder shows so poignantly, confronting a debilitating mental illness takes enormous personal courage. "So many people have begged me to come forward," she said in the New York Times article, "and I just thought well, I have to do this. I owe it to them. I cannot die a coward."
Of course she was anything but a coward. After getting her Ph.D. in psychology, Linehan chose to work with the most desperate patients, those she calls "supersuicidal," because she felt she understood them.
"I figured these are the most miserable people in the world -- they think they're evil, that they're bad, bad, bad -- and I understood that they weren't," she said to the New York Times. She worked by acknowledging the feelings that drive the suicidal behavior, in a sense accepting the logic of that behavior. Patients can then begin to accept that emotional reality of who they are, that they feel great pain that others just don't feel. That leads to a commitment from the patient to try to change the behavior. As Linehan notes without hyperbole, "Therapy does not work for people who are dead."
Linehan's courage was matched by her compassion and the discipline to translate her personal approach into rigorous protocols to enable it to reach the wider population. Dialectical behavioral therapy continues to be one of the best evidence-based treatments for borderline personality disorder as well as other conditions, including eating disorders and substance abuse.
DBT is one of a host of behavioral therapies that have become extremely powerful tools for defusing psychiatric illnesses, from anxiety disorders to depression to disruptive behavior disorders. Not as well known as the medications in the psychiatrist's arsenal, they are especially important for children and adolescents, whose personalities, and, indeed, brains are still developing. I can't overstate the importance of treating a child with OCD before he becomes a seriously-disabled adult, of treating a teenager who cuts herself before it becomes a lifelong habit. The longer a teenager or young adult has anorexia, the poorer the prognosis.
Dr. Linehan pioneered behavioral tools used in many kinds of psychotherapy, including opposite action -- in which patients experiencing a problematic emotion try to act in the opposite way --and mindfulness -- in which people focus on their breathing and experience their emotions without acting on them. Many of these tools can be customized for children as young as 3 or 4 years old. Accepting the reality of a child or adolescent who is suffering is the first step in giving her the tools to become the person she wants to be.
Harold S. Koplewicz, M.D. is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more on mood disorders and the evidence-based therapies that can help, go to our website, which offers parenting advice and a wealth of information on childhood psychiatric and learning disorders.
]]>