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: www.sciencedaily.com/releases/2012/10/121019141124.htm Original Article: http://journals.sagepub.com/doi/abs/10.1177/1087054712453169 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/ 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 For more information about Douglas Berger Psychiatrist Tokyo visit the following website: http://douglasbergerpsychiatristtokyo.com/ Doug Berger*, Douglas Eames, Pablo Prados-Ruano
Meguro Counseling Center, Tokyo, Japan Received 3 April 2008; accepted 9 April 2008 Abstract This paper describes the current state of mental health care for Western expatriates in Tokyo, Japan. Types of therapists, patient demographics, illness breakdown, and psychiatric medications in Japan are discussed and problems in the system and potential remedies are presented. ª 2008 Elsevier Ltd. All rights reserved. Read Entire Article: https://dougbergertokyopsychiatrist.files.wordpress.com/2016/09/travelmed.pdf Psychiatry is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders.
A psychiatrist is a medical doctor (an M.D. or D.O.) who specializes in mental health, including substance use disorders. Psychiatrists are qualified to assess both the mental and physical aspects of psychological problems. People seek psychiatric help for many reasons. The problems can be sudden, such as a panic attack, frightening hallucinations, thoughts of suicide, or hearing “voices.” Or they may be more long-term, such as feelings of sadness, hopelessness, or anxiousness that never seem to lift or problems functioning, causing everyday life to feel distorted or out of control. Read Entire Article: https://www.psychiatry.org/patients-families/what-is-psychiatry Doug Berger, MD, PhD
Dr Berger is in private practice in Japan. Article originally published in May 12, 2009, in Psychiatric Times “An Epidemic of Depression” by Wakefield and Horwitz (Psychiatric Times, November 2008, page 44) raised the issue that DSM does not take into account the context in which symptoms arise for the diagnosis of MDD. The authors opine that the diagnosis should require that symptoms be “excessive” or “unreasonable” relative to the context in which they arise, and that “the efficacy of these medications for the treatment of normal sadness is often overstated.” This is really a discussion of whether first–episode reactive depression should be considered a type of MDD, even if the symptoms are considered “excessive” given the context. (Certainly, persons with recurrent endogenous depression do not need much stress to have a relapse). Some persons react to high stress levels and develop a disorder and some do not (it is now known that holding the short form of the serotonin transporter gene is a risk factor for MDD). While the authors note that a few symptoms of sadness related to “overwhelming” distress may be “too often treated as a mental disorder,” they do not operationally define “a few symptoms of sadness.” If the stress is “overwhelming,” then it makes sense that many persons will succumb to MDD as a result. I think that most psychiatrists would only give an antidepressant to someone with a first episode of reactive depression in which there are concerning cognitive and/or vegetative symptoms that persist despite psychotherapy; in this setting, they may also consider a short course of a soporific or minor tranquilizer. My vote is that each patient needs to be looked at individually and treated based on the clinical judgment of the physician, who should take past and family history into account. Including criteria for excessive reaction to stress in DSM goes against the recent genetic and neuroscience findings that support the clinical experience of MDD seen in a variety of stress contexts and may lead to a delay in medical intervention when needed. Read Original Article: http://www.psychiatrictimes.com/display/article/10168/1413504 The most commonly prescribed psychiatric drugs are antidepressants. They treat depression and anxiety. The first ones, isoniazid and iproniazid, were discovered by accident. They were developed after the Second World War by a Swiss pharmaceutical company (from leftover German V2 rocket fuel!) as tuberculosis treatments. Some tubercular patients taking the drugs became energetic and even rowdy, and so a few curious doctors tested the drugs on psychiatric patients in 1952. Their potential as ‘psychic energisers’ received press attention. Many doctors began prescribing them to treat depressed patients in mental hospitals even though they were not officially approved for psychiatric use.
Pharmaceutical companies quickly became interested in developing drugs targeting depression. They started in the 1950s with the class of drugs called tricyclics. In the mid 1960s brain scientists hypothesised that iproniazid, the anti-tuberculosis drug, improved a patient’s mood by slowing an enzyme that breaks down the neurotransmitter serotonin. The hypothesis led to a second major class of antidepressants called monoamine oxidase inhibitors (MAOIs) which targeted the same enzyme. Despite justifiable concerns about side effects, both types of antidepressant remained drugs of choice among psychiatrists for over two decades. Their use declined after selective serotonin reuptake inhibitors (SSRIs) such as Prozac were introduced. These worked faster with fewer side effects. SSRIs also had a larger market because they treated anxiety (previously the domain of the minor tranquilisers) as well as depression. Read Entire Article: http://www.sciencemuseum.org.uk/broughttolife/techniques/antidepressants Imagine being so overwhelmed with fear and anxiety that you never venture outside of your house and that, being so overcome by social anxiety, you withdraw completely from any social interaction. This is the harsh reality for a growing number of people made completely immobilized by their mental health condition.
It’s difficult to find detailed statistics related to the number of people suffering from this debilitating social anxiety, in part because most reports include those with the issue in the general depression group, which now tops more than 350 million people of all ages and ethnicities around the globe. Hermit, recluse, and lone wolf are only a few of the terms used to describe those with severe social anxiety. Although most people think of North America when social psychological issues are mentioned, the 2013 article, Japan: a haven for the psychologically troubled written by Japan Times reporter, William Bradbury, crowns the Asian country as home to a growing demographic of citizens combatting a variety of social and mental health issues. Read Article: http://www.groundreport.com/doug-berger-tokyo-psychiatrists-must-continue-define-hikikomori/ Psychiatry got its name as a medical specialty in the early 1800s. For the first century of its existence, the field concerned itself with severely disordered individuals confined to asylums or hospitals. These patients were generally psychotic, severely depressed or manic, or suffered conditions we would now recognize as medical: dementia, brain tumors, seizures, hypothyroidism, etc. As was true of much of medicine at the time, treatment was rudimentary, often harsh, and generally ineffective. Psychiatrists did not treat outpatients, i.e., anyone who functioned even minimally in everyday society. Instead, neurologists treated "nervous" conditions, so named for their presumed origin in disordered nerves.
Read Article: https://www.psychologytoday.com/blog/sacramento-street-psychiatry/201410/brief-history-psychiatry Dr. Doug Berger, a psychiatrist in Tokyo, has written before on marriage and divorce in Japan. Here we ask him to elaborate on a few questions.
1. How are children affected by living in a single parent home? This will necessarily depend on a number of factors, the age of the child, the time and quality of the ability of the parent to provide love, affection, and a protective environment, the socioeconomic environment of the family, and the ability of the parent and child to be flexible and reasonable with this situation. Naturally, the more time and quality of the parent’s ability to provide love and security, and the more inherent mental stability both the child and parent have, the better off they will be. The age of the child when the single-parent home was created, and the circumstances around this creation will be of importance, more on that below. 2. Are abandonment issues more prevalent in children from single parent homes? I don’t think it is a valid use of statistics to make a blanket statement and say yes or no. For each home, there is either more or less time alone on the part of the child. One could argue that the chances of having a difficult parent are 50% less than a 2-parent home, and while being alone seems better than being with a difficult parent, we would not advocate single parent homes over 2-parent homes of course. If there is a child that is alone or feels abandoned then we need to engage some kind of social intervention and help this child integrate with some social activities. If the community the family lives in has good infrastructure and a close-knit community with families that participate in many activities where many same-age friendships can be grown then this may be enough in of itself to make a child from a single-parent household feel social and happy. If it is not a community like this, then social services need to have a bigger role to provide some alternative. 3. Are children raised in single parent homes from birth less affected than children whose parents divorced in their teens? It is common to meet children raised in single parent homes from birth who state they did not know any other kind of family structure so that the single parent situation seemed entirely normal to them and they had no problem with it. Divorce of one’s parents in adolescence is usually not a great thing, but might be worse for a child who is between 5 and 12 years-old because they usually more connected to their parents then teenagers. However, this all depends on how bitter the divorce, how many friends the teen has, the inherent mental stability of the child and parents, and the ability of the parents to be reasonable in ensuring that divorce will lead to a smooth transition for the child to continue the same lifestyle and with frequent visits and access to each parent, and this is more important for young teens than older teens. 4. What are some tips for children that may blame themselves for their parents’ separation or divorce? This is not easy to clear up and sometimes takes years to run its course because a course of events has already unfolded once the child has started to think like this. Coaching and psychotherapy may help these children, but probably the best way is to avoid this happening to begin with. Reasonable parents who can continue to work together as parents and a family will help decrease the risk of this outcome. Sometimes, we recommend that the parents move to a partial separation where one of the spouses has a separate living space, but where the family is together often, or at least one parent is visiting the child’s living space regularly. The partial separation may be enough to give the parents space but allow them to continue the family in some way. Then the parents can actually be divorced on paper without telling the children-depending on their age or the parents can go to full divorce in stages as the children get older. It may be easier to acclimate to stressful events unfolding in slow stages. 5. How can parents ease the transition into a single parent household for children? Continuing the ideas presented in question 4, I would say that if for example the father is moving out, he can present the idea to his children that he is getting an “office” to stay in so that he can do work in a quiet place, but he will still spend time at the home and that the children can also visit him. The wife may take the opportunity to have her own social life on days the husband, or ex-husband if they have signed divorce papers, is at the home watching the children. For many couples in conflict, one partner having a separate living space can be enough to decrease the stress in the relationship enough to the point where they can be reasonable with each other. As the children get older, they will not need both parents around so often and the parents can begin to build their lives independently from the ex-spouse both socially and occupationally. Read more on Dr. Doug Berger‘s comments as it relates to single-parent households here: http://www.tokyofamilies.net/2011/06/single-parent-households/. Tests, testing, and tested – we need to critically evaluate the meaning of tests in psychiatry6/29/2017
Douglas M. Berger
Meguro Counseling Center, Tokyo, Japan A recent article entitled, “Perils of Newborn Screening”[1] led me to think of how we in psychiatry and our patients also have some perilous ideas about screening and testing. The article describes testing initiated in 2006 in New York State for Krabbe disease of the nervous system. Krabbe disease is a rare inherited disorder where lack of the enzyme galactocerebrosidase causes the myelin coating on the nerves to break down. Mental and motor development are affected, and muscle weakness, deafness, and blindness may occur.[2] Out of the total one-million babies tested, 24 tested positive and out of 24, 4 developed symptoms. One family refused treatment and subsequently the child died; another child died from complications of the treatment; another’s illness is progressing despite treatment, and one baby who had been treated successfully has recently lost his ability to walk. Parents of babies who test positive, are described to be in a constant state of worry, some pursue risky tests, and the emotional trauma (not to mention the cost) incurred is likely to outweigh the benefits. This example illustrates how one kind of test may have pros and cons. The pros and cons of ‘testing’ can also be seen in one’s daily practice of psychiatry. The following are personal experiences of my practice in Tokyo. CLINICAL EXAMPLES “My 8-year-old child is depressed, should they have psychological (psych) testing to determine if antidepressants are warranted?” A woman I have been treating for a few years for major depression told me about her 8-year-old son who is irritable, has been crying more, and has written some notes contemplating suicide. She first brought her son to a large local counseling center where they recommended in-person counseling with their staff psychologist, school observations, and psych testing (costing about $4,500), and told the mother that they could not recommend starting antidepressants until the psych testing was complete. The son could not finish the testing because he was unable to maintain concentration. The mother eventually decided she couldn’t wait anymore and asked me to evaluate the child who clearly looked depressed. I explained that if the psych testing assessed the son having a depression, this affirms the obvious. If the psych testing assessed the son without a depression, we are still left with a depressed-looking child who is writing suicide notes, and with an anti-depressant responsive depression in his mother. Neither family dynamics nor school issues could explain the child’s depression. We agreed that there was no logic for psych testing in terms of, ‘to treat’ or ‘not to treat’; and in tandem to a medical work-up for depression, we initiated 2.5 mg of escitalopram a day with a good response. Scales and tests for depression may indeed provide some helpful information; however, predictive value, sensitivity, and specificity are still far from perfect,[3] and the National Institute of Mental Health (NIMH) guidance only mentions medical examination and history of symptoms in the evaluation of depression.[4] While no test can fully prove a psychiatric diagnosis, we understood that the medication can be construed to be both a treatment as well as a kind of diagnostic test, i.e., improvement on administration, and relapse on discontinuation would support the diagnosis of a major depression. In addition, while the son was ill with depression, the other aspects of psych testing, i.e., personality or intellectual testing, would not properly reflect these areas of functioning. It would be like asking a person with pneumonia to run around a track, time them, and then make an interpretation of this person’s ability to run (not to mention the cost saving of the psych testing). The next peril is the way the school authorities may use the results of his psychological testing, which may have a negative impact on the child’s education in the future. I opined that the school only needed to know that the son would get help, but did not need to know the diagnostic or treatment details. “My 4-year-old has been tested and diagnosed with Asperger’s Disorder, can you counsel him?” This has been a more frequent inquiry in recent years. Some parents or adult patients almost seem to be proud to have this diagnosis, thinking that it portends high intelligence, but it may actually be a way to avoid a more uncomfortable mental illness diagnosis. Most of these parents do not realize that there is no test to prove that someone has Asperger’s, (the criteria for Asperger’s includes: Marked impairment in social relations, often with stereotyped motor movements, and a vast knowledge of some topic of esoteric or impractical value),[5] and that the incidence of Asperger’s is thought to be extremely low (about three in 10,000)[6] when compared with other disorders whose symptoms overlap with Asperger’s (i.e., attention deficit disorder/ attention deficit hyperactivity disorder (ADD/ADHD), which may affect up to 10% of children.[7]) Few of the patients who come in with a supposed diagnosis of Asperger’s actually fulfill the criteria for Asperger’s. On examination, most of these children have symptoms suggesting ADD or ADHD; some have depression or anxiety, and others a shyness or awkwardness that may be normal or may evolve into social anxiety disorder later in life. On rare occasion some do look like high-functioning autistic children, although it seems parsimonious and logical to assume that these children have the far more common diagnosis rather than a rare diagnosis if the symptoms overlap significantly. The peril here is when the parents or an adult patient does not accept having a diagnosis or treatment other than that for Asperger’s. If a child also seems to have a comorbid ADD or ADHD, it needs to be treated first; to ascertain what Asperger’s symptoms may be left. Otherwise, it would be like making a diagnosis of asthma in a child with pneumonia (i.e., it is impossible to see if Asperger’s is there while the person is clearly impaired with ADD or ADHD). In addition, once a child gets a diagnosis in their educational record, it tends to have a life of its own as definitive, and neither parents, educators, nor even psychologists or psychiatrists, endeavor to change the record. “Cognitive behavioral therapy has been tested and proven to be effective for depression; can you give it to me?” This is another situation where the use of the word ‘tested’ comes in and is an inquiry that can be a challenge for the psychiatrist to handle when the patient has vegetative symptoms, a strong family history, and a chronic course of depression because these patients usually require antidepressant medication in addition to any therapy. Cognitive behavioral therapy (CBT) aims at repairing negative thoughts that are thought to cause depression.[8] Clinically, it is easy to observe; however, that negative cognitions improve when depressed mood improves, be it with antidepressants or the natural cycling course out of depression.[9] This is analogous to delusions improving, when one is given an antipsychotic, so that negative thoughts are more likely the result of depression rather than the cause, just like a runny nose and a cough are the result of a cold. If negative thoughts were the cause of depression, then this would be the only Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I condition where the symptoms are also construed to be the cause. However, it can often be seen that CBT may help persons with depression function better. Degree of depression is usually evaluated by a rating scale that assesses both neuro-vegetative symptoms as well as misery (i.e., cognitive symptoms such as despair and helplessness). Giving persons hope and support can alleviate some of the misery symptoms decreasing depression scores. Allowing some time to pass where the persons improve by themselves or cycle out of depression can also decrease scores. In either case, the person functions better and their depression scores decrease over time. Even a few points lower on a depression test can result in a call of a “statistically significant difference” compared to a supportive therapy control group, but that does not mean the illness is really treated. For example, I broke my arm by falling on the ice. I had real pain and also misery because I couldn’t do things I normally liked to do. When my orthopedist told me, “I see many fractures like this, you will be fine in a few months,” all my misery disappeared, but the fracture did not change. Patients in misery can respond well to an authority figure which gives them hope. A more important problem with using the word ‘tested’ is that it is not easy to study psychotherapy as a modality of treatment because the studies cannot be double blinded like a drug study that has a placebo arm—an extremely crucial point. A study on bias in treatment outcome studies concluded that the results of unblinded randomized clinical trials (RCTs) tended to be biased toward beneficial effects if the RCTs’ outcomes were subjective (as they are in psychotherapy studies) contrary to being objective.[10] Patients and even professionals assume that the words “randomized and controlled” mean that the studies looking at a therapeutic modality are fully evidence based, even if they are not double blind. They may be single blinded, i.e., the rater may not know the treatment the patient received, but the patient themselves cannot be blinded to the type of therapy, thus potentially biasing the results. Depression studies notoriously have large random errors due to the wide variety of subjects many of which have mild forms of low mood, investigator and patient preference and economic incentive, or non perfect rating instruments, etc. Bias can lead to a result very far from the true value.[11] A recent meta analysis[12] examined how effective CBT is when placebo control and blindedness are factored in. Pooled data from published trials of CBT in schizophrenia, major depression, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of major depression, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. This does not mean that CBT has no value, it only means that we need to consider CBT as an adjunctive modality to help functional impairment and suffering vs. an illness course-changing intervention. It is imperative that our field does not allow studies that are unblinded to be called “evidence based tests.” They need to be in a different category, i.e., “uncontrolled clinical data”, or “clinical impressions” (of CBT practitioners and/or their patients). CONCLUSION To the lay-person, the word “test” implies some absolute truth. The value of a test or a diagnosis given by an authority is very hard to evaluate by the average lay-person, and when it comes to testing of a therapeutic intervention, even most mental health professionals do not understand why it is crucial to control bias by double-blinding in a clinical trial of an intervention, whether psychotherapy or drug. The words “controlled” or “randomized” seem to carry more weight than they are worth if there is no placebo or double blind to back them up. We must also not avoid a critical discussion of the economic incentive to do a test or to “prove” the evidence base of a certain therapy. {Ed.: Dr. Berger is in private practice in Japan and consultant on pharmaceutical clinical trials. Web page is at: www. japanpsychiatrist. com. This article is intended as a personal opinion piece and not a scientific analysis.} REFERENCES 1. Bleicher A. Perils of newborn screening: Doctors may be testing infants for too many diseases. Sci Am 2012;307:16-7. 2. Pastores GM. Krabbe disease: An overview. Int J Clin Pharmacol Ther 2009;47(Suppl 1):S75-81. 3. Rivera CL, Bernal G, Rossello J. The Children’s Depression Inventory (CDI) and The Beck Depression Inventory (BDI): Their validity as screening measures for major depression in a group of Puerto Rican adolescents. Int J Clin Health Psychol 2005;5:485-98. 4. Available from: http://www.nimh.nih.gov/health/publications/men-anddepression/diagnostic-evaluation-and-treatment.shtml. [Last Accessed on 2013 Mar 30]. 5. F84. Pervasive developmental disorder. International Statistical &ODVVL¿FDWLRQRI’LVHDVHVDQG5HODWHG+HDOWK3UREOHPVth (ICD-10) ed. World Health Organization (2006). 6. Fombonne E. Epidemiological surveys of pervasive developmental disorders. In: Volkmar FR, editor. Autism and Pervasive Developmental Disorders. 2nd ed. Cambridge: Cambridge University Press; 2007. p. 33-68. 7. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Children. National Health Interview Survey, 2002. March 2004, Series 10, No. 221. 8. Burns, David. Feeling Good, The New Mood Therapy. Avon Books; 1980. 9. Fava M, Davidson K, Alpert JE, Nierenberg AA, Worthington J, O’Sullivan R, et al. Hostility changes following antidepressant treatment: Relationship to stress and negative thinking. J Psychiatr Res 1996;30:459-67. 10. Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: Meta-epidemiological study. BMJ 2008;336:601-5. 11. Steven Piantadosi. Clinical Trials: A Methodologic Perspective. 2nd ed. Hoboken: Wiley-Interscience; 2005. 12. 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. Psychological Medicine 2010;40:9-24. |
Author - Douglas BurgerBilingual Psychiatrist located in Tokyo. Archives
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