A Common Struggle: A Personal Journey through the Past and Future Mental Illness and Addiction By: Patrick J. Kennedy and Stephen Fried ( Book Review by Dr. Blumenfield)

Screen Shot 2015-11-18 at 6.27.58 PMA Common Struggle: A Personal Journey through the Past and Future Mental Illness and Addiction   By: Patrick J. Kennedy and Stephen Fried

This is a story, told in the first person of Patrick J. Kennedy. It is really two stories presented to us simultaneously. It is about Patrick Kennedy, son of Edward Kennedy and nephew of JFK and Bobby Kennedy. He has been a US congressman from Rhode Island for eight terms and was one of the staunch advocates for parity legislation, for mental illness, and addiction. Yet at the same time that he was leading the fight in the United States Congress to bring about these major changes in our healthcare system, he himself was secretly battling mental illness and addiction.

An important part of his personal story was a discussion of alcoholism in his family. Not only was the author an alcoholic but his brother, mother, and father, Ted Kennedy also struggled with this condition. It is significant that all of them except his father ultimately recognized their problem and entered various programs to help themselves. His mother battled alcoholism for a prolonged period of time and yet her condition was not recognized by family members despite the fact that they knew about several hospitalizations and treatment programs that she had undergone.

One of the most revealing insights about his father that he revealed in this book is how Ted Kennedy was traumatized by the tragic death of his three brothers, JFK, Bobby Kennedy, and his oldest brother, Joe Jr., who was killed in World War II. An additional major trauma for Ted Kennedy was the death of the young woman in Chappaquiddick, an incident well covered by the press.

It was not a simple pathway for the author to recognize his own problems. Even after a period of therapy with Psychiatrist Peter Kramer, author of the well known book (Listening to Prozac). Kennedy felt this treatment was helpful but did not eliminate his addiction problem or allow full acceptance of his bipolar condition. He vividly described how he would convince himself that he didn’t have any problems if he didn’t drink in public or take “illegal” drugs.

Patrick Kennedy served in the Rhode Island legislature and was elected as the youngest member of the US Congress in 2004 during a period that his addiction and mental illness was hidden from the public. It was also pretty much hidden from himself.

His colleagues in the US Congress ultimately became aware of his attempts to hide his drinking problem. Kennedy describes an important event for him when in 1996, Minority Leader, Dick Gephardt, offered him the prestigious chairmanship of the Congressional Campaign Committee on the condition that he stop drinking. This made him realize how he was denying that he had a problem that was known to others.

It wasn’t until 2005 that he publicly admitted that he was suffering from a mood disorder that was being treated by a psychiatrist. While his own struggle continued, he became more effective in his advocacy in the US Congress. One misconception he believed had to be clarified concerned Nancy Reagan’s “Just Say No” campaign against drugs. He felt that this missed the main point that addiction is not something you can simply say no to, just as you can’t say no to cancer. It is a disease and by implying you can just say no stigmatized people who have the genetic propensity to have this disease.

As much as the story of Kennedy’s recognition of his own illness of addiction and mental disease and how he battled it is quite enlightening, the battle for a definitive bill in the US Congress is just as revealing.

The events leading up to the 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act are quite interesting and complicated. They are also quite personal to Patrick Kennedy. It took place at the time that he was relapsing to alcohol and painkillers and also was having an exacerbation of his bipolar condition. While Patrick Kennedy was one of the leading champions in the House of Representatives for this legislation, his father, Ted Kennedy, was a major supporter of this bill in the US Senate. This was also at a time that the senior Kennedy was dying of a brain tumor. Compromises had to be made in the bill and the Senate was reluctant for the legislation to be as comprehensive in various aspects and details of the bill as was wanted by the House of Representatives. There also was a question how the legislation would deal with the new surge of mental health problems occurring in soldiers returning from the war. There was a concern that it should cover PTSD as well as addiction in the returning servicemen. Patrick Kennedy described the dramatic moment that his dying father came to the senate floor to vote for the final version of the bill to the applause of the US Senate.

Even with the passage of this extraordinary legislation, the battle for adequate parity for healthcare support was far from over. The proof and the success of this landmark bill would depend on the implementation by the federal and state governments and certain local rulings are expected to eventually reach the Supreme Court. The 2016 presidential race can certainly also be expected to impact the success of implementation of this legislation. As of this writing, it appears that the Republican candidates may be reluctant to support the implementation of this legislation and provide funding for new programs.

Patrick Kennedy decided to leave the United States Congress in 2010. Since departing from Congress, he has continued to be a leading advocate to bring about implementation of the 2008 legislation for mental illness and addiction. In this regard, among many other things, he has worked with two important organizations in which he plays very active roles. The Kennedy Forum (kennedyforum.org) gathers experts in mental health and addiction and holds important conferences that they hope will ensure implementation of the 2008 legislation. They are also committed to promoting a translation of neuroscience into the preventative and treatment interventions for mental health and addiction. The second organization in which Patrick Kennedy is involved is One Mind (onemind.org), which is dedicated to the promotion and support of “brain health” and creating a fast track for treatment. Their current focus is on new approaches to treat and cure PTSD but they look forward to applying solutions for all brain disease including depression, Parkinsons, ALS, dementia, Alzheimer’s disease, and addictions.

Patrick Kennedy does not bemoan problems. He is clearly a man not only with a vision but with plans and solutions. He concluded his book with a scorecard of how we should rate our public officials who have the opportunity to pass legislation and make changes. Also at the end of the book, he had a section for people who are dealing with their own mental illness and addiction. He tells them not to be alone in this struggle and how important it is to get treatment. Finally, sandwiched in this book was a series of photographs of many well known members of his family. It brought back many memories to this reader of the great accomplishments of many members of the Kennedy family and of the tragic events that they experienced.

It should be noted that at the time that Patrick Kennedy wrote this book, he was three and a half years sober. He has shown that he is a very accomplished and insightful man. I believe we are going to hear a great deal about him in his advocacy. He has provided in this book a valuable historical account of the reasons to fight for the proper care of mental illness and addiction. I am sure he has a bright future and many people will benefit by his skills and his passion.

 

Depiction of Bipolar Illness in Silver Linings Playbook

Movie review of film SIlver Linings Playbook which is about a guy with Bipolar Disorder.

There is a new movie out that is getting very good reviews. Bradley Cooper plays a guy with a condition labeled Bipolar  Robert DiNero plays his father who seems to be an obsessive compulsive gambler. The following is a movie review of the film which I wrote for  FilmRap.net.  I would be interested in any comments by the readers of PsychiatryTalk.com who may have seen this movie.

**** Silver Linings Playbook-

We are always sensitive when there is humor presented at the expense of people with mental illness. This is what seemed to be the case when at the beginning of the film we meet Pat (Bradley Cooper ) who is about to be released from a mental hospital. He is being picked up by his mom (Jacki Weaver) and we see that he has Bipolar Disorder, flies off the handle very easily and fools the nurse into thinking that takes his medication when he really cheeks it and throws it away. The humor continues as we meet his father, Pat Sr. (Robert DiNiro) who has an obsessive disorder and is a superstitious gambler who always bets on the  Philadelphia Eagles. From finding ourselves unhappy that we are laughing at these dysfunctional characters, we then become aware of the great pain that they are suffering which early on shows in the sensitive performances of Weaver and DeNiro. The storyline then reveals the circumstances of Pat Jr’s hospitalization and his trauma in regard to his wife’s behavior. Bradley ‘s performance is tremendous as he plays mentally disturbed , determined and very smart. However the real stand out and maybe even Oscar performance is by Jennifer Lawrence who plays Tiffany a beautiful. dysfunctional , quirky , vulnerable and very intense woman. She is  recently widowed, who becomes entwined with Pat as he is trying find a way to recapture his wife. The photography, mostly single camera  fast moving as is the directing by David O. Russell, the editing by Jay Cassidy and the music by Danny Elfman which includes Frank Sinatra and Johnny Mathis at the appropriate times with a little “ dancing with the stars”  thrown in. In the end what makes this movie a winner is that it  is a real love story, complete with sentimentality all around. Think Frank Capra and It’s a Wonderful Life, Christmas lights and all. (2012)

Let’s Talk About Suicide

Suicide is the 11th leading cause of death among persons over age 10. Patients with Major Depression or Bipolar Depression have a 20-60 fold increase of mortality rate over the general population. The role of medication and psychotherapy is can be important in preventing suicides. This topic will be discussed in future blogs and is the theme of the annual meeting of the
American Academy of Psychoanalysis and Dynamic Psychiatry which will be held in San Francisco Aug 16-18 2012.

Both attempted and completed suicides represent a major clinical and public health challenge. The CDC has ranked suicide as the 11th leading cause of death among persons over age 10 (33,289 suicide deaths were reported in the United States in 2009.

In a recent article in Psychiatric Times Dr. Tondo and Baldessarini  noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with Major Depression or Bipolar Depression have a 20-26 fold increase of mortality rate over the general population. It was also stated in this article the fact than fewer than 1/3 of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further state that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several recent studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity—all of which are particularly prevalent in Bipolar Disorder and may contribute to the unusually high suicide risk in persons with this disorder. In patients with such conditions (especially young patients), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict and other psychological issues can all contribute to self destructive behavior which can result in suicidal behavior. Suicidal gestures which may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyber bulling has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue not only for mental health professionals but for leaders in the military, teachers, parents and for us all. We also need to recognize that there are many mental health issues that have to be faced in the aftermath of a suicide.

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16-18 meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (of which I am the current President) which will be held in San Francisco (just prior to the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can contact me  if you have any questions at this time

The Genome and Psychiatric Care

This blog discusses how the understanding of the human genome and the construction of the human chromosome may be able to influence psychiatric care. Psychiatrists have previously relied on history ( including family history ) with a mental status evaluation to make a diagnosis and develop a treatment plan. Unless the patient had an identical twin with similar symptoms, family history only has a limited value in providing assistance in making the diagnosis or in predicting response to medication. The author originally hoped that this would radically change with the breaking of the genetic code and the human genome project. However thus far the research has limited value in the application to current psychiatric care. There is some promising research in regard to schizophrenia and genetics as well as some recent work concerning bipolar disorder and post partum depression, which is reviewed. The use of biomarkers particularly in brain imaging and the use of the EEG for the prediction of effectiveness for antidepressants are discussed. Several ethical considerations related to this type of research are also raised.

How Understanding the Human Genome Can Influence the

Practice of Psychiatry

The Human Genetic Sequencing Project

In April 2003 the human genetic sequencing project was completed.  This meant that the 25,000 genes  (which are made up of 3 billion chemical bases) in the human DNA were defined and stored in computers. dna_530I am far from being a biochemist and am in no way an expert in this area. In fact I didn’t even understand that it would take another three years until we understood the  construction of the first  human chromosome. However that did not stop me from imagining what the future of psychiatry and all medicine would be like after this great accomplishment.

The Decision Process Before The Genetic Code Was Broken

When a patient comes to me I take a detailed history and do a mental status examination (the psychiatrist equivalent of the physical examination except it is by talking). I inquire about the patient’s family history including medications used by the patient and any medications  used by close family members who have the same illness. I make a diagnosis of the patient’s condition and then I  may suggest psychotherapy or medication or a combination of both.

Let us say that the patient has a major depression and required an antidepressant medication. I would have many choices from which to choice. I would base my decision on the latest research. Job+InterviewI may be influenced in my choice of which medication to use if the patient were highly anxious or had insomnia since some medications are more activating than others and some are more sedating.  I would inquire about the patient’s sexual functioning since many of these medications can have sexual side effects. Some medications might help various types of pain or obsessive symptoms which could  influence my first choice of a medication. I may have to take into account the patient’s financial status in regard to a choice of a less expensive generic medication or if there were a list of medications, which are less expensive in regard to their insurance coverage. All these factors need to be considered  not only with the first choice of medication but very often a medication may be changed or a second one is added and these factors would all be reconsidered.

Very rarely would genetic factors be taken into account in deciding on which medication should be used. (Family history would be helpful in making the diagnosis.) If the patient should be an identical twin with the exact same genetic make up than I would pay exquisite attention in considering a similar diagnosis and choosing the same medication. This occurs only once in every 250 births. If such a person needed a medication I could be pretty sure that their side effects and efficacy probably would be identical or nearly the same as their twin. Of course even identical twins  can have different life experiences  and therefore their total psychological make up and environmental exposure would not be the same. If a sibling, parent or child  had a good or a bad experience with a particular medication that might influence my decision but it would have no where near the significance to me as the situation where  the patient would be an identical twin.

How I Imagined the Decision Process Would Be  After the Genetic Code was Broken

I had this vision which I told my residents and students  how, in the future,  patients would come to doctors and would have a card in their wallet with their entire human genetic makeup encoded . Elecom-Magnetic-Card-ReaderThe physician would put the card  into a device on his or her desk, which would  read it and provide information as to any illnesses for which  the individual had a clear genetic propensity. It would also tell us the exact medications, which would target and cure these illnesses. In fact it would be possible to construct viruses ( which are DNA particles ), which could alter genetic structure and eliminate the diseases or even the propensity for them. Not only would cancer be cured or prevented but also so would the major mental illnesses  I had read about these possibilities in he past and now that the secret of the human genome had been unlocked , I thought that it was just a matter of time before this became a reality.

How Things Now Stand

I am sorry to report that my fantasy has not yet become a reality.  The journals and scientific meetings are filled with various pieces of research that might contribute to the puzzle . There are new companies, which offer saliva or blood tests, which will examine DNA. However,  there are no genetic research  tests, which have substantially changed clinical practice in the past several years.

I would like to give you a sample of some the latest genetic research so you can get a glimpse of where we might be heading with the expansion of our understanding of the genome.

Schizophrenia

Even before the genome was completely mapped there were many connections to various regions of the  chromosomal structure that suggested linkage to schizophrenia.chromsome

More recently the International Schizophrenia Consortium pooled genomic data from various data bases and analyzed 8000 schizophrenic patients and 19,000 healthy controls. They found differences in a region on Chromosome 6 between schizophrenics and the controls. This chromosome area is related to the immune system response to infections and autoimmune diseases.

Bipolar

Research by the same group demonstrated that  there were genetic similarities in the genome of schizophrenic and bipolar patients that were not shared by nonpsychiatric diseases such as coronary artery disease and rheumatoid arthritis which suggests that these genetic variations are specific to psychiatric disturbances.

Post Partum Symptoms

In still another  study, published in the  American Journal of Psychiatry November, 2009,  showed that genetic variation on specific chromosomes may increase the susceptibility to post partum mood symptoms.

The researchers were able to show some  polymorphisms or  variations of Chromosome 1, 2, 9 and 14 which could indicate susceptibility to postpartum  symptoms . There is a wide range of postpartum symptoms as I outlined in a previous blog. It is essential that evaluation of such symptoms  be a part of the pre and post natal care of all women. It may be that the these findings will be helpful in the future for diagnosing and treatment of this condition.

Effectiveness of Antidepressant Medication

There  has been some preliminary research to suggest that people with certain alleles related to the serotonin transport system had positive or negative responses to SSRI antidepressant medication . However  the latest research which I could find in regard to whether genes and chromosomes will allow us to predict the effectiveness of particular antidepressant therapy was far from conclusive and suggested that there would most probably be multiple interacting genetic factors.

As promising as all this research seems to be, it has not yet changed the way psychiatric diagnosis is made or how treatment is plans are developed. I hope that this will happen in the next few years. Down the road  researchers may also be able to design drugs to correct the chromosomal variations that are  due to dysfunctional protein arrangements.

Biomarkers May Have to Do if We Don’t Have Complete knowledge of Genetic Makeup

Research has also been moving forward ( perhaps even faster than genetic research)  in the area of biomarkers.  We have known for a long time that an elevated serum  cortisol level, could indicateEEG an emotional state such as anxiety and/or depression . This is not specific enough to be of great help in making a diagnosis which we could make without these tests. However more specific biochemical tests might be helpful in making the diagnosis even though we don’t have the specific genetic markers.

Similarly, if we can use brain imaging to see changes in the brain structure with various psychiatric conditions such as schizophrenia, this may help make the diagnosis.

We may be able to  even use various tracing devices to follow the uptake distribution and utilization of various medications in the brain, which should be able to help us in our decision making processes. Even a non evasive procedure such as an EEG may tell us if an antidepressant is working.

The research described above is just a small sample of the explosion of work that is being done .

Ethical Considerations in Utilization of Genetic Research

Even before the sequencing of the human genome , questions have been raised about  the ethical considerations that sophisticated knowledge of genetics as well as advanced biomarkers  will bring up.

For example with genetic engineering, not only might physical and mental illnesses be avoided but also so might psychological traits where genetic links were discovered. Could this create adverse impact on future generations?

There are also important questions as to how genetic information will be acquired and used. Will individuals be giving full informed consent for this testing and use of their genetic material ?  Will there be mandatory genetic testing? Will all newborns have to undergo genetic testing for various conditions?

Also will the knowledge that one has an illness which hasn’t shown it self yet  or the propensity to have an illness create problems for people? This may be especially true if there is not an adequate treatment for an illness. For example, not everyone would choose to be tested to determine if they are likely to get Alzheimer’s Disease especially if there were nothing to do to prevent it.

What will happen if the insurance industry gets hold of  genetic testing results?

Fortunately the new healthcare legislation is supposed to prevent any discrimination on the basis of preexisting conditions . I assume this will also apply to preexisting genetic variations, which are expected to  create various physical and mental conditions.

It looks as if we have a long road to go before physicians will have  a genetic code reader on their desk  and there may be some important ethical questions along the way.

I welcome your comments of this topic.