Month: July 2017

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Mental Health

Douglas Berger’s response to ““Doctor, Am I Gay?” A Primer on Sexual Identities” from Psychiatric Times, October 28, 2016, By Jack Drescher, MD

http://www.psychiatrictimes.com/psychotherapy/doctor-am-i-gay-primer-sexual-identities

Dr. Drescher’s model of complex feelings regarding sexual orientation is mainly based on psychological and social factors. His discussion is not wrong, but it seems hard to me to write an article about this topic without noting the basic genetic concepts of genotype vs phenotype and rare type vs wild type.

More and more evidence is pointing to considerable genetic influence on the determinism of sexual orientation. The National Health Interview Survey reported in July 2014 that 1.6 percent of Americans identify as gay or lesbian, and 0.7 percent identify as bisexual, that would be a total of 2.3% of the population. It is hard to imagine this huge number of persons having a psychosocial determinant or just “wishing” to have this strong proclivity to same-sex sexual interest. It seems prudent to assume this is built into them to large degree.

Science is getting closer in this regard. For example this study,

http://www.natureworldnews.com/articles/10443/20141118/homosexuality-genetic-strongest-evidence.htm

details how a study of more than 800 gay participants shared notable patterns in two regions of the human genome – one on the X chromosome and one on chromosome 8.

Because same-sex sexual desire does not lead to reproduction as frequently as opposite-sex desire would, mathematically it must be a smaller percent of the population making it the “rare type” vs the heterosexual “wild type” (reproductive technology may begin to level that difference).Even so, genotype is not everything, and there can be some movement along a phenotypic behavioral spectrum depending on a mix of biological, and psychosocial influences. A genotype will likely set some phenotypic anchor-point from which one can move along to some degree in fantasy or in behavior while they confirm their “set-point” in a biological sense.

For example, some persons are better at concepts and thinking and some are better at making things with their hands-and this is probably genetically determined-but most people can do both to some degree. We do not necessarily need to invoke complex psychological theory to describe how persons find their set-point and proclivity in the phenotype that fits them best.

I’m not saying Dr. Drescher’s ideas are incorrect, but I do think they need to be better integrated to the hardwired background that determines who we are.

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Mental Health

An interesting letter regarding DSM classifications.

http://www.psychiatrictimes.com/anxiety/deconstructing-and-reconstructing-goldwater-rule

Ron,

I like your logic here and I agree with your conclusions. However, you penned this article on the assumption that psychiatric nosology is a validated classification, and that a diagnosis would be known to a psychiatrist if they could directly examine a patient. I think you well aware that the DSM classifications are motivated by a mix of attempting to avoid under or over diagnosing a condition, receiving reimbursement, compromising with special interest groups within psychiatry, and that the names of conditions change, merge, or split over the generations of new DSMs depending on a multitude of factors that have little to do with the validity of a condition. Most crucially, there are no biologically measurable anchor points to objectify the labels we give as diagnoses, there is considerable overlap between many criteria sets, and even the DSMs are clear that they do not purport to classify conditions based on etiology much less objective measures.

The conclusion of all this mess is that, even if a psychiatrist did evaluate a person directly, and even if it was ethical to discuss those findings, any discussion would need the disclaimer that diagnostic labels in psychiatry are for the working purpose of formulating treatment directionality, they are not proven entities that are tied to a clearly definable and objectively measurable parameter as for example leukemia, stroke, MI, etc. are, and thus it is probably unethical to even mention a differential diagnosis much less the name of a condition to anyone not involved in treatment planning, implementation, or support.  

In psychiatry, all labels should be given with this caveat and cautions to patients. The results of treatment challenge and dechallenge and longitudinal course follow-up can help with some level of treatment confidence, but these are by no means validating our classification. It is probably prudent to leave any and all professional opinions out of the public realm on scientific if not ethical grounds. This conclusion has nothing to do with the fact that psychiatrists are also members of society allowed to give like/dislike or agree/disagree opinions about public figures, but not a diagnostic or other psychiatric label, both because of lack of validity as well as on ethical grounds.

Thank you for again writing on a timely topic. 

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Mental Health

RE: “Schizophrenia’s Unyielding Mysteries” By Michael Balter, May 2017, Scientific American

(Unpublished)

By Douglas Berger, Tokyo Psychiatrist

Even if there is no one smoking-gun gene, learning the multiple ways one can develop psychotic symptoms can lead to hints regarding treatments that may benefit many persons. Half of a twin-pair is very strong evidence of genetics, it is not proof that non-genetic factors must be important as random variations in genetic regulation could explain why one twin is normal. There has never been a double-blinded placebo-controlled CBT clinical trial in schizophrenia, and some meta-analyses (1) have concluded that CBT was not better than non-specific controls in treatment or relapse when controlled for blinding.

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(1)             Lynch D, Laws KR, McKenna PJ: Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychol Med. 2010; 40(1): 9–24. PubMed Abstract | Publisher Full Text

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Mental Health

Scientific American Letter to the Editors; “One’s True Nature”, November 2016 Douglas Berger, Tokyo Psychiatrist

In “One’s True Nature”, Stickleback fish were said to “tamp down individual personalities” and “conform” when they were placed under the same cover as opposed to individual cover in pursuit food located at the other end of the tank. Regardless of behavior when separated, it seems to be conjecture that these fish tamped-down their personalities when covered together when they may just as well have been exhibiting imitative behavior.

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A response to: “On Witches and Terrorists, Why torture doesn’t work.” By Michael Shermer. Scientific American May 2017.

(Unpublished)

By Douglas Berger, Tokyo Psychiatrist

Schermer states that accused witches who provide false and unverifiable information are an example of why torture is not effective. Comparing the value and verifiability of various forms of interrogation may give data on the value of torture in a population of interrogees, but doesn’t say whether a specific individual will or will not break and divulge valuable and verifiable information.

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Mental Health

Scientific American Letter to the Editors: “Brain Trust” A Rare Success Against Alzheimer’s, March 2017.

Douglas Berger, Tokyo Psychiatrist

“Brain Trust” in the March issue left me with 2 questions. 1. there is no proof that less cortical surface are resulted from poverty vs. that poverty is the result of smaller cortical surface area in parents that then genetically pass this problem along to their offspring (genetic factors are common most psychiatric disorders); and 2. There is no evidence that food and/or educational/ tutoring vouchers would perform worse than the giving these families cash. Clearly some cash subsidies will be diverted.

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Mental Health

Medical Marijuana and Mental Health: Cannabis Use in Psychiatric Practice

May 31, 2017 | By Christopher G. Fichtner, MD and Howard B. Moss, MD.

Comment by Doug Berger, Psychiatirst in Tokyo, Japan

This article seems quite reasonable, and is in severe contradistinction to other recent articles in the PT on marijuana:

1. Marijuana and the Psychiatric Patient, Psychiatric Times April 10, 2017, By Burns Woodward, MD: http://www.psychiatrictimes.com/blogs/couch-crisis/marijuana-and-psychiatric-patient#comment-53335

2. Cannabis Use in Young Adults: Challenges During the Transition to Adulthood, Psychiatric Times December 30, 2015, By Jodi Gilman, PhD: http://www.psychiatrictimes.com/special-reports/cannabis-use-young-adults-challenges-during-transition-achdulthood

Both of which were horrifically anti-marijuana, probably written by NIDA and signed-off by the authors (see the links to the comments).

However, Fichtner and Moss could probably have added more caveats to using marijuana, clearly not all is actually positive:

1. While the authors did discuss using marijuana ingredients by routes other than inhalation, it is probably not a good idea for one’s lungs to smoke burnt plant substances.

2. They should be clearer that using marijuana based medicinal products is very different from smoking it lest they suggest that pot use may be good for psychiatric disorders (molecular CBD may have quite different effects than marijuana), and the authors were not as clear on that as they should be.

Dr. Moss has $2,900 stock in GW Pharma makers of marijuana derivative drugs, probably more connection to the topic at hand than we would like to see in an academic writer.

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Are We Overdiagnosing and Overtreating ADHD?

May 31, 2017, By Rahil R. Jummani, MD, Emily Hirsch, and Glenn S. Hirsch, MD.

Comment by Douglas Berger, Psychiatrist in Tokyo, Japan

This is a good article, though with some fuzzy parts:

1.    The authors go to great lengths to describe the difference in DSM-5 and ICD-10 diagnostic criteria for ADHD that differ in significant ways on at least 4 important comparison items, then later say that the “Best practices in diagnosing ADHD are well-established”, and that “rating scales lack specificity leading to a high false positive rate…”

What they mean to say, and should say, is that, “because psychiatric disorders are not fully proven by diagnostic criteria or rating scales, clinical suspicion along with response to interventions (usually medication) will help close-in on the likelihood of a specific diagnosis, although a diagnosis in psychiatry is never fully provable because there are no absolute objective physical markers (=biologic findings) that are specific for a diagnosis in an individual patient”.

2.    ADHD is both over- and under- diagnosed, depending on the set of people you look at. The authors title “Are We Overdiagnosing and Overtreating ADHD?”, is somewhat unfair to the cohort of persons who are underdiagnosed:

Release:

https://www.sciencedaily.com/releases/2012/10/121019141124.htm

Original Article:

http://journals.sagepub.com/doi/abs/10.1177/1087054712453169 

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Categories
Mental Health

Douglas Berger Psychiatrist Tokyo, Letter to the Editor in Psychiatric Times re: “Are Placebo Controls Ethical in Antidepressant Clinical Trials?”

Douglas Berger Psychiatrist Tokyo, writes a Letter to the Editor in Psychiatric Times (date unknown)

In their article “Are Placebo Controls Ethical in Antidepressant Clinical Trials?” (Psychiatric Times April 2000) Khan and Khan state that the FDA’s double-blind placebo controlled trial requirement for new antidepressant approval is not necessary in Europe or Asia.

In Japan, while there is no guideline specific for antidepressants, this does not mean it can be omitted. The general guidelines for drug development state that double-blind placebo controlled trials are preferred and it would be unthinkable for the Japan Ministry of Health and Welfare to approve a new antidepressant without data from a double-blind placebo controlled trial, either one done in Japan or using the data from a double-blind placebo controlled trial done overseas (no antidepressant in Japan has yet only to bridge overseas Ph 3 data in their NDA package although fluoxetine may attempt to do so in the near future). The only SSRI on the market, fluvoxamine (since May 1999), had two pivotal double-blind placebo controlled trials. Paroxetine, sertraline, and SNRIs have done or are now doing double-blind placebo controlled phase 3 trials.

The EMEA European regulatory body would also not allow approval of a drug that did not have a double-blind placebo controlled pivotal study.

Proof of maintenance efficacy is also required in Europe for antidepressant drug approval.

Doug Berger, M.D., Ph.D.

US Board Certified Psychiatrist

Tokyo, Japan

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