Douglas Berger, Psychiatrist in Tokyo: Transcranial Direct Current Stimulation and neuroplasticity?6/26/2018
Transcranial Direct Current Stimulation and neuroplasticity? Only 18 subjects open-label no control group or placebo: http://tinyurl.com/y7zexgsw Improved mood not asso w/neuroplasticity so that neuroplasticity has not been shown w/tDCS in depression.
For more information about Douglas Berger Psychiatrist Tokyo visit the following websites:
Douglas Berger, Psychiatrist in Tokyo comments on, "Sex Addiction: Playing Now in Theaters"6/22/2018
Douglas Berger, Psychiatrist in Tokyo comments on, "Sex Addiction: Playing Now in Theaters", By Roberta Zanzonico, MD and Renee M. Sorrentino, MD, Psychiatric Times, January 2018.
Original Article: http://www.psychiatrictimes.com/article/sex-addiction-playing-now-theaters This article seems mired in needless philosophic details about how to care for this 85 year-old man with vascular dementia admitted to a psychiatry ward and who is a danger to other residents at his care facility, refusing oral and effective valproic acid and requiring several emergency antipsychotic injections. His daughter is ok with spiking his food with valproic acid but against antipsychotic treatment. It is clearly much more unethical not to treat this man and let him harm his co-residents, nor to have to force injections on him which is a bit cruel. The treatment team is probably more worried about a legal case than ethics. Assuming we did not live in a society with laws, it is simple enough to spike his food/drink with valproic acid solution and tell his daughter to continue to spike his food/drink at his residence or back home. Hopefully he would agree to blood tests, if he doesn't, the alternative is forcing injections on him that should have blood testing anyway. The answer is a no-brainer. Because we live in a society with laws, his case should be petitioned by the hospital in court as soon as possible. Until the court date, he can be deemed acutely dangerous to others and that spiking his food/drink was better than forcing injections on him. -If the court rules he can just have his food/drink spiked for his condition regardless of acute danger, all is well. -If the court rules his food can't be spiked/drink unless he is acutely dangerous, then the treatment team can note that his condition makes him acutely dangerous daily (regardless of his actual behavior), and the daughter can decide to do what she feels is right for him, i.e., spike his food/drink when he is discharged, at her own legal risk. -If the court rules that he cannot be given medication in his food/drink without his permission, regardless of the daughter having medical decision power and her agreement, the case should be appealed. If the appeals court still agrees with the lower court, then the man can be forcibly injected as needed and the case repeatedly appealed. This situation would be a failure of the legal system not of medical care. Ward staff might be able to refuse to take part in involuntary injections, or quit their job, on ethical grounds, further placing the legal system as the cause of a medical-mess. Doug Berger, MD, PhD U.S. Board-Certified Psychiatrist Tokyo, Japan For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: I was surprised that Brown did not cite this article from “JAMA Psychiatry” May, 2014 that could have helped him understand something about half (or more) of servicemen: Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army. Results From the Army Study to Assess Risk and Resilience in Service members (Army STARRS)
http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1835338 The study found that almost half of soldiers had some mental disorder when they enlisted. The rates of disorders like attention deficit-hyperactivity disorder and intermittent explosive disorder (IED) in the study were similar in the new recruits as well. This finding in line with our practice experience in Japan that includes servicing a total population of 100,000 military personnel, dependents, and civilian workers. Most of these persons seemed to us to have similar problems before they entered the service, some got worse in the service. There is a clear path of employment, training, and for long-termers a pension plan, making the military both a good choice for these persons, and these persons a good choice for the military that recruiting is not likely to give up. However, ADD, ADHD, IED, etc are frequently associated with dysphoric mood states and recurrent brief, persistent, or major depression, in addition to drinking, drug abuse, risk taking behavior, and, along with the stresses of being in a war theater the risk of suicide can increase. The answer to all of this is that, because so many persons enter the military with mental health problems to begin with, any addition of the horror of war to this baseline will continue to make it very challenging to mitigate morbidity and mortality in this population. For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ The open-label GeneSight and unblined Genomind studies are at high-risk for researcher bias and should be suspect to extreme caution. We would never allow anti-depressants to be approved with these kinds of studies (although unblinded/no-blindplacebo psychotherapy studies are unreasonably and widely “accepted” as robust data by our profession all the time).
The issue of whether “adverse effects” are related to anxiety are easily investigated with zero-cost means. Patients’ significant others can manage all the medications, crush up the pills, and blind to the patient put them in patients’ morning small glass of orange juice. Do this a few days on and a few days off, keep a record, and see which days corresponded to the patient’s anxiety. Regardless of a patient being a slow metabolizer, all patients should be started at low doses and can be told to break their starting dose pills in half, crush them, or empty capsules out so that every patient can start low and go slow for a number of days before going up to the low starting dose even. In addition, normal metabolizers may still have adverse effects at usual starting doses due to pharmacodynamics reasons (effects on the receptors etc in the brain) and not pharmacokinetic reasons (ie peripheral metabolism) which is not measured by metabolic genetic testing. Proper clinical instruction and close follow up (which is necessary regardless of metabolic status) makes the use of these costly tests unnecessary in all but the rare patient with treatment resistance and/or those that have extreme reactions-only when drug is put in their OJ. I strongly suggest we never do a genetic test on any patient having “adverse reactions” on OJ with no drug in it and all the pills accounted for. No genetic testing company is likely to be happy with what this advice may do to their market. Doug Berger, MD, PhD U.S. Board-Certified Psychiatrist Tokyo, Japan For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ RE: Deferring to the Mastery of Death: Hippocrates, Judge Gorsuch, and the Autonomy Fallacy12/20/2017
Psychiatric Times, April 03, 2017, By Ronald W. Pies, MD
http://www.psychiatrictimes.com/blogs/deferring-mastery-death-hippocrates-judge-gorsuch-and-autonomy-fallacy We all know about the slippery slope of giving psychiatric patients to right to request suicide from a medical professional. However, terminally ill medical patients who have terrible pain and suffering and are near death (perhaps on a respirator, have multi organ failure, frequent sepsis, oozing blood from skin and other orifices, repeated seizures, etc), are vastly different from psychiatric patients. Pies and Geppert’s argument does not deny that a physician could not induce a comatose state in these persons, perhaps even a permanent coma until death. Coma (without brain death) is not death medically or legally, although it essentially accomplishes the same thing as death does in removing the patient’s awareness and experience from a living state. I would have trouble thinking that physician-assisted coma should be illegal or unethical as a form of medical treatment with specific indications just like any other medical treatment (i.e., it would not be indicated for psychiatric illness), and encourage further debate about it. One could argue that these patients can still be aware of things, but the same could be said of patients on morphine. Coma still racks up medical bills, and it may still be painful for a family to see their loved one in this state. Notwithstanding these caveats, we don’t have to argue about physician-assisted dying if we consider coma is good enough. For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ Referenced article originally published October 26, 2016 in the Psychiatric Times:
http://www.psychiatrictimes.com/career/nonvalidated-pharmacogenetic-tests-part-i-confessions-embarrassed-psychiatry-professor/page/0/3 Dr. de Leon It is refreshing to read about a seasoned clinician backtracking on mistaken prior conclusions. I would opine to go further in limiting the need or utility of these tests. For example, you want to do CYP2D6 and 2C19 before giving a tricyclic. What is the risk of giving someone 10mg BID of nortriptyline and increasing by 10mg BID every 2 weeks up to 40mg BID watching how the patient reacts vs the risk of delaying treatment and cost of the test? Poor metabolizers may easily tolerate titration to 20mg or 30mg BID and have a response after 6-8 weeks stopping the dose there anyway. If a rare patient will have trouble after a few 10mg BID doses they can just stop the medication. EVERY patient regardless of metabolic profile requires careful and slow titration of a tricyclic and should be advised to pause their drug dosing and contact their Dr if they have trouble. I really don’t see the risk-benefit ratio falling on the side of doing a costly test. For CYP2C, Asians have a 3-4x increase number of poor metabolizers. Here in Japan, CYP is not tested, its start low and go slow with most every psychiatric drug. There seems to be little problem with this method as long as there is close follow up. Again, EVERY patient should be followed closely. You also want to do HLA testing before giving CBZ to Asians, I assume to decrease the risk of SJS. The best approach is not to give CBZ to Asians, not do a test. Why not use oxcarbazepine if you need to? There are plenty of other drugs to use, even for seizure disorder treatment, then again your article was on “genetic tests in psychiatry” not neurology. CBZ isn’t used much in psychiatry in Japan nowadays. HLA testing isn’t done here either, though LFT and WBC should be tested a week into CBZ therapy regardless of HLA type. Ok, maybe there is an exceptional case where we want to do a test, but it should be a rare case and tests are no substitute for careful and knowledgeable clinical monitoring. I vote that these tests stay in the research lab for pharmacology research, and in pharmaceutical company labs during drug development, not in clinical psychiatry. For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ Original article published, October 07, 2016 in The Psychiatric Times:
http://www.psychiatrictimes.com/blogs/couch-crisis/deconstructing-and-reconstructing-goldwater-rule#comment-509 Thank you, Ron, for your thorough reply that I largely agree with. First though, let’s be clear, your article was on psychiatric diagnosis in INDIVIDUALS not on the validity of the existence of psychiatric diagnoses in the population. You stated, “On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media.” You are also falling into a logic trap by noting that a SOME medical or neurological problems have no specific marker, i.e., migraine. This is because there are also many like stroke or brain tumor that DO have an objectively measurable parameter such as seeing infarction, hemorrhage, or mass on a brain scan. Unfortunately there is NO psychiatric condition that has an objectively measurable parameter in an INDIVIDUAL in spite of some persons in a POPULATION who fit diagnostic criteria showing various DIFFERENT and subtle brain abnormalities. Brain scans can be said to have near 100% validity in physically proving that the condition specified because scan results match physical findings on direct examination of the brain seen in surgery or autopsy. This is what is meant by “clearly definable and objectively measurable”. The first link you provide below by Aboraya states: “The authors encourage clinicians to use as many validity criteria as possible to improve the validity of their diagnosis.” They do not state or prove anywhere that a psychiatric diagnosis in an INDIVIDUAL is the same as having objective proof as in neurology (I would place Alzheimer’s in neurology not psychiatry for this discussion). The paper by Levy only discusses that pursuit eye movement findings are commonly found in POPLULATIONS of persons who fit criteria for schizophrenia (and in the CLINICALLY UNAFFECTED relatives of these persons). As they show in Fig 5 and in other places in the article, findings are trends in these groups with a standard error but they nowhere state that these tests can be used clinically as proof of diagnosis in an individual. It’s not the same as seeing a mass in one’s head CT which is clearly a mass: there is no trend or standard error, nearly all INDIVIDUAL cases are either yes or no. Coincidentally, I was also the lead author on a published study of eye-movements in schizophrenia: Berger D, Nezu S, Iga T, Hosaka T, Nakamura S: INFORMATION PROCESSING EFFECT ON SACCADIC REACTION TIME IN SCHIZOPHRENIA, Neuropsychiatry, Neuropsychology & Behavioral Neurology, (Journal Name Changed to: Cognitive and Behavioral Neurology) 3:2, 80-97;1990. Full paper here: https://www.japanpsychiatrist.com/Abstracts/Information_processing_effect_on_saccadic_reaction_time_in_schizophrenia.pdf We found a strong trend for differences between normals and those diagnosed with schizophrenia in the small group we studied, but there was overlap and there were outliers. Thus, it is just interesting research data, it is not useful clinically for individual diagnosis, nor does it prove the validity of schizophrenia. Now, evaluating public figures who are more likely to have personality issues, ADHD, mild forms of mood disorder etc. and not schizophrenia is even more problematic because there is less robust evidence of a consistent biologic finding in populations of these persons compared to schizophrenia, especially in personality disorders. So while we would agree on Goldwater, I think you need to take it to the next level of uncertainty when it comes to labeling individuals, examined or not. Psychiatric diagnoses are helpful in clinical treatment, but are unproven constructs and never more than concepts that guide us in what to do, and for mental health workers and institutions to bill medical insurance companies. For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ ‘Why the “You” in an Afterlife Wouldn’t Really Be You’
https://www.scientificamerican.com/article/why-the-ldquo-you-rdquo-in-an-afterlife-wouldnt-really-be-you/ Shermer states that a copy of your memories is no different than your twin but twins never had the same memories to begin with. If one’s genes and connectomes could be exactly copied and functional then there would be two of “you”, both exactly the same at the moment of copy, the next instant on diverging biological life courses. While the engineering hurdle is enormous, it is not physically impossible. For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ http://www.psychiatrictimes.com/bipolar-disorder/lithium-alzheimer-prevention-what-are-we-waiting#comment-49925
The answer to Dr. Phelps’ “what are we waiting for” is a large prospective study of Alzheimer’s patients with a long-term follow up (the studies linked in his comment below are not this kind of study). The study Dr. Phelps is excited about only had 55 persons in each arm with only a 1.5 year follow up (a short follow up for Alzheimer’s), the treatment effect maintained but did not improve further in the final 3 month evaluation term: https://www.researchgate.net/publication/228098677_Microdose_Lithium_Treatment_Stabilized_Cognitive_Impairment_in_Patients_with_Alzheimer's_Disease Looking at the graph of MMSE score changes, assuming these results in this small sample would be valid in a large group, MMSE differences of about 5 points began to seem come out by 12 months and held up to 18 months, but there was no further improvement from month 15 to month 18 in the treatment group, and no deterioration in the control group. Will this modest level of improvement persist in large samples for many months, and how does 5 points on the MMSE translate into meaningful clinical differences over the following few years is a crucial piece of information before we start thumping our prescription pads with lithium prescriptions. I encourage Dr. Phelps to look more carefully at the design and results of this study and change his call from prescribing lithium to promoting a bigger and longer trial. We don’t want people running to lithium if it doesn’t work very much or for too long, perhaps taking larger doses in a fever to treat dementia knowing larger doses are routinely used for mood disorders (no matter what people are told some will still try to take more), and avoiding other treatments, i.e., memantine for which lithium would need a head-to-head comparison. For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ 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.
For more information about Douglas Berger Psychiatrist Tokyo visit the following websites: http://douglasbergerpsychiatristtokyo.com/ http://douglas-berger-psychiatrist-tokyo-reviews.com/ http://about-douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo-info.com/ http://douglas-berger-psychiatrist-tokyo.com/ http://douglas-berger-psychiatrist-tokyo.com/ |
Author - Douglas BurgerBilingual Psychiatrist located in Tokyo. Archives
June 2018
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