Science and Research News - 2006 Archive

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Eight-year-olds 'can use Prozac'

Prozac can be prescribed for children as young as eight, the European Medicines Agency has said.
It decided the benefits outweighed the risks in children with moderate to severe depression who failed to respond to psychological therapy.

However, it ruled the drug should only be used in combination with on-going therapy.

Mental health campaigners said it was vital that any use of the drug in children was closely monitored.

Prozac, or fluoxetine, was developed by Eli Lilly and Co but is now widely available in generic versions.

It is one of a class of drugs known as Selective Serotonin Reuptake Inhibitors (SSRIs).

There is evidence suggesting that some SSRIs are associated with an increased risk of suicidal behaviour and thoughts.

Following a review the UK regulator, the Medicines and Healthcare products Regulatory Agency, ruled that most SSRIs were not suitable for use in adolescents.

However, it decided that the benefits of Prozac alone outweighed the risks, and so ruled that the drug could be given to under-18s.

In its latest ruling, the EMEA's Committee for Medicinal Products for Human Use (CHMP) said children should be started on a 10mg daily dose of Prozac.

This could be increased to 20mg per day after one to weeks.

But if no clinical benefit is seen within nine weeks, treatment should be reconsidered.

A system will be put in place to obtain safety data on use of the drug in children, in particular whether there is any impact on sexual development.

CHMP also stressed that doctors and parents should carefully monitor children and adolescents for suicidal behaviour, particularly at the beginning of treatment.

Paul Farmer, chief executive of the mental health charity Mind, highlighted problems concerning another SSRI, Seroxat.

The drug was Britain's best-selling anti-depressant, but has been found to induce aggressive and suicidal feelings in children and adults.

He said: "It's vital that the lessons from Seroxat are learned.

"Clinicians must exercise extreme caution in administering this treatment to children and adolescents, including very careful monitoring of reactions in this group.

"We would encourage doctors, patients and carers to make full use of the Yellow Card reporting scheme to ensure data on adverse drug reactions is adequately captured by the drugs regulation agencies."

The charity YoungMinds welcomed the EMEA decision.

Avis Johns, the charity's development director, said: "The impact of severe depression on the child, their family and wider community can be devastating.

"Though quite rare, the ability to combine a range of therapies with appropriate medication can provide significant benefits and should therefore be welcomed."

It is estimated that one in ten children are affected by mental illness.

 

OCD in Egyptian Adolescents: The Effect of Culture and Religion

Obsessive-compulsive disorder was once believed to be a rare condition. The prevalence rate of OCD in three catchment areas in a U.S. study ranged between 1.9% and 3.3% (Robins et al., 1984). In comparison, a study conducted in Cairo, Egypt, of 1,000 psychiatric patients attending a university clinic showed an incidence of OCD of 2.5% (Okasha et al., 1968). A replication of this study showed an incidence of 2.3%, indicating the stability of the prevalence of the disorder over time (Okasha and Raafat, 1991).

Previous Egyptian studies on psychiatric phenomenology have shown a prevalence of culturally determined symptomatology, where religion and prevailing traditions seemed to color not only the clinical picture of the condition, but also patients' attitudes about their disorder (Okasha, 1966).

In one of our studies, 90 patients suffering from OCD (diagnosed according to the ICD-10) attending our outpatient clinic were followed from 1991 to 1992 (Okasha et al., 1994). The patients were assessed by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) for symptomatology and severity of symptoms. Sixty-nine percent of the patients were males and 32% were females. The mean age was 23.7, with a mean duration of OCD of 3.2 years. Twenty percent of patients had positive family histories for OCD. Forty percent of patients presented with a mixture of obsessions and compulsions, whereas 29% presented with only obsessions and 31% with only compulsions. Religious and contamination obsessions (60%) and somatic obsessions (49%) were the most common. The most common compulsions were repeating rituals (68%), cleaning and washing (63%), and checking (58%), mostly related to religious beliefs. Seventy-one percent of patients were rated as severe on the Y-BOCS. While all patients showed some lack of insight into their disorder, 9% had no insight whatsoever. One-third of patients had a comorbid depressive disorder. Regarding premorbid personality disorders, 14% had obsessive personality disorder, 34% had paranoid, anxious or emotionally labile personality disorders, and 52% had no specific premorbid personality disorder.

The role of religious upbringing has been evident in the phenomenology of OCD in Egypt. The psychosociocultural factors are so varied that they can affect the onset, phenomenology and outcome of OCD. They can even affect response to treatment. The emphasis on religious rituals and the warding-off of blasphemous thoughts through repeated religious phrases could explain the high prevalence of religious obsessions and repeating compulsions among our Egyptian sample. This is true even if the participants in the study were not practicing their religious duties.

To elaborate further, Moslems, who constitute almost 90% of the Egyptian population, are required to pray five times a day. Each prayer is preceded with a ritualistic cleansing process (Wudu or ablution), which involves washing several parts of the body in a specific order, each three times. This ablution is invalidated by any form of excretion or ejaculation and, for some radical Moslems, by any contact with the opposite sex. Women are not allowed to pray or touch the Koran during their menstruation, after which they should clean their bodies through a ritualistic bath. The prayers themselves vary in length and consist of certain phrases and suras from the Holy Koran that have to be read in a certain sequence.

The emphasis on cleanliness or ritual purity is the cornerstone of most of the compulsive rituals. The number of prayers and their verbal content can be the subject of scrupulousness, checking and repetition. The ritualistic cleansing procedures can also be a source of obsessions and compulsions about religious purity. Other evidence of the religious connotation inherent in OCD in Moslem culture lies in the term weswas. This term is used in reference to the devil and, at the same time, is used as a name for obsessions. It is also characteristic of a conservative society like Egypt to expect sexual obsessions to be among the most frequent in female patients. Although it is accepted socially (but prohibited religiously) for Egyptian males to have a wide range of sexual freedom in all stages of their lives, sexual matters remain an issue of prohibition, sin, impurity and shame for Egyptian women. The female gender is surrounded by so many religious and sexual taboos that the issue becomes a rich pool for worries, ruminations and cleansing compulsions in women susceptible to developing OCD.

Christians represent approximately 10% of the population in Egypt, which was equivalent to the percentage in our study sample population. The presenting symptoms for these patients were almost similar in terms of obsessions, where religious and sexual thoughts were predominant. However, there was a marked difference in rituals, which were more frequent in Moslems. This emphasizes the roleof ritualistic Islamic upbringing, as compared with a Christian upbringing, in our community.

A comparison was also drawn between the most prevalent symptoms in our sample and those of other studies performed in India, England and Jerusalem. Contamination obsessions were the most frequent in all studies. However, the similarities of the contents of obsessions between Moslems and Jews, as compared with Hindus and Christians, signify the role played by cultural and religious factors in the presentation of OCD. The obsessional contents of the samples from Egypt and Jerusalem were similar, dealing mainly with matters of religion, cleanliness and dirt. Common themes between the Indian and British samples, on the other hand, were mostly related to orderliness and aggressive issues (Akhtar et al., 1975; Greenberg, 1984; Khanna and Channabasavanna, 1988; Pollitt, 1957).

Another cultural characteristic of Egyptian psychiatric patients is reflected in the Y-BOCS rating of the severity of OCD in our sample. The majority of patients rated between moderate and severe, and the total Y-BOCS score was severe in most of the cases, indicating high tolerance for psychiatric morbidity before seeking help. Native healers, religious people, friends and family elders are the primary caregivers for psychologically disordered individuals. When those interventions fail, seeking out the general practitioner, and then the psychiatrist, are the next resorts.

A surprising finding in our study was the fact that none of the patients had excellent insight into their disorder. Insight was mildly affected in 26% of cases, moderately affected in 50% and severely affected in 14.4%. This contrasts with the historically accepted characteristics of OCD--that patients recognize the absurdity of their obsessions and compulsions. However, our findings echo those of Lelliott et al. (1988), who found that one-third of their 49 ritualizers perceived their obsessive thoughts as rational and believed that rituals warded off some unwanted or feared event. The more bizarre the obsessive belief, the more strongly it was defended, and 12% made no attempt at all to resist the obsession.

Regarding the comorbidity of OCD with other psychiatric disorders, our results showed that one-third of patients had an associated depressive disorder and another third had various other diagnoses. The remaining one-third of patients did not show any psychiatric comorbidities (Okasha et al., 1994). These results can be compared to those obtained by Rasmussen and Eisen (1992), who found that two-thirds of their sample also had major depressive disorder.

Another study was conducted to determine the prevalence of obsessive-compulsive symptoms (OCS) among Egyptian students (Okasha et al., 2001). The multistage, stratified, random sample of students came from the El Abasseya educational area in Cairo. The tools used in this study included the General Health Questionnaire for screening of psychiatric morbidity and the Arabic Obsessive Scale for obsessive traits. The Y-BOCS was used to determine the profile of OCS and the ICD-10 was used for diagnosis of OCD. Prevalence rates for psychiatric morbidity, obsessive traits and OCS were 51.7%, 26.2% and 43.1%, respectively. Obsessive-compulsive symptoms were more prevalent among younger students, females and first-born participants. Aggressive, contamination and religious obsessions and cleaning compulsions were the most common. Nineteen percent of participants with OCS fulfilled ICD-10 criteria for OCD. This work presented data from a field study among adolescents in secondary schools and university students between the ages of 15 and 24. The prevalence of probable minor psychiatric morbidity was 51.7%. This high prevalence rate could be explained by the many biological and social factors that are associated with adolescence and early adulthood. This is especially true in a country such as Egypt, where the socioeconomic situation prolongs the duration of dependence on family and where attempts at independent living are met with major challenges (mostly economic). Furthermore, the last two years of school in the Egyptian educational system determine the student's future career, mainly whether or not they can have a university education. This is a crucial indicator of social status, even in the absence of economic resources.

In another study, we looked at the prevalence of OCS in a sample of Egyptian psychiatric patients (Okasha et al., 2000). Obsessions can occur in many psychiatric disorders, or they may constitute the entire illness. This is referred to as an obsessional state. The relationship of OCS to different psychiatric disorders still remains controversial. This work was undertaken to study the co-occurrence and phenomenology of OCS with other psychiatric disorders.

We examined a sample of 372 psychiatric outpatients and 308 controls using the Arabic version of the Y-BOCS checklist. Participants were additionally assessed by the obsession symptom section of the Present State Examination, the Eysenck rigidity scale and the religious orientation scale. Obsessive-compulsive symptoms were found to be significantly higher in psychiatric patients than in the non-psychiatric controls. Eighty-three percent of patients with neurotic, stress-related and somatoform disorders; 51% of patients with mood disorders; and 47% of patients with schizophrenia, schizotypal and delusional disorders were found to have OCS in their symptomatology. Furthermore, the data suggest that OCS in psychiatric patients has a distinct phenomenology from that in controls. The results did not, however, reveal a relationship between OCS and either rigidity or religious orientation.

The higher prevalence of OCS in the clinical psychiatric population (62.4%) tends to confirm the validity of the subsyndromal forms of OCD. All the symptoms in the Y-BOCS checklist were significantly more prevalent in the clinical population than in the general population, except for hoarding-saving obsessions. This suggests that OCS in the clinical population differs from that in the general population. It remains an issue for future exploration whether those subgroups would require treatment. However, the 62.4% prevalence of OCS in our clinical population could be compared to the study done by Hantouche and Bourgeois (1995), who found OCS in 17% of their clinical population.

There is still controversy about whether lack of insight should be regarded as the hallmark of a delusional or psychotic subtype of OCD or as a dimension that is present with different degrees of severity. It seems that the categorical diagnosis of OCD is not very satisfactory. The dimensional approach may better account for the variability in degree of insight and resistance and for the relationship between OCD and OCD spectrum disorders.

There is still incomplete evidence that OCD spectrum disorders are a separate cluster, as the similarity between them is greater than their similarity with OCD if we use proper diagnostic criteria. The fact that these patients may respond to selective serotonin reuptake inhibitors is not a valid criterion for similarity (Okasha, 2000).

Further research is also required to explore the biological and psychosocial correlates of OCD associated with depression, anxiety, psychosis, basal ganglia disorders and streptococcal infection. Should they be considered as different diagnostic subtypes?

Finally, we should have reliable tools to differentiate between OCS, traits that are prevalent in many traditional societies where religious rituals play a major role in people's lives, obsessive-compulsive personality disorder and OCD. The Y-BOCS scale has a cutoff point to differentiate between obsessive-compulsive personality disorder and OCD, but none for obsessive symptoms or traits (Okasha, 2000).

Dr. Okasha is chairperson of the department of neuropsychiatry at Ain Shams University in Cairo, Egypt. He is also director of a World Health Organization collaborating center.

References
Akhtar S, Wig NN, Varma VK et al. (1975), A phenomenological analysis of symptoms in obsessive-compulsive neurosis. Br J Psychiatry 127:342-348.

Greenberg D (1984), Are religious compulsions religious or compulsive: a phenomenological study. Am J Psychother 38(4):524-532.

Hantouche EG, Bourgeois M (1995), [Obsessive-compulsive disorders versus obsessive-compulsive syndromes. Comparative study of two surveys of the general population and of psychiatric consultants.] Ann Med Psychol (Paris) 153(5):314-325.

Khanna S, Channabasavanna SM (1988), Phenomenology of obsessions in obsessive-compulsive neurosis. Psychopathology 21(1):12-18.

Lelliott PT, Noshirvani HF, Basoglu M et al. (1988), Obsessive-compulsive beliefs and treatment outcome. Psychol Med 18(3):697-702.

Okasha A (1966), A cultural psychiatric study of El-Zar cult in U.A.R. Br J Psychiatry 112(493):1217-1221.

Okasha A (2000), Diagnosis of obsessive-compulsive disorder: a review. In: Obsessive-Compulsive Disorder, Evidence and Experience in Psychiatry, vol. 4. Maj M, Sartorius N, Okasha A, Zohar J, eds. New York: Wiley & Sons.

Okasha A, Kamel M, Hassan AH (1968), Preliminary psychiatric observations in Egypt. Br J Psychiatry 114(513):949-955.

Okasha A, Lotaief F, Ashour AM et al. (2000), The prevalence of obsessive compulsive symptoms in a sample of Egyptian psychiatric patients. Encephale 26(4):1-10.

Okasha A, Raafat M (1991), The biology of obsessive compulsive disorder, an evidence from topographic EEG. Arab Journal of Psychiatry 2(2):106-117.

Okasha A, Ragheb K, Attia AH et al. (2001), Prevalence of obsessive compulsive symptoms (OCS) in a sample of Egyptian adolescents. Encephale 27(1):8-14.

Okasha A, Saad A, Khalil AH et al. (1994), Phenomenology of obsessive-compulsive disorder: a transcultural study. Compr Psychiatry 35(3):191-197.

Pollitt J (1957), Natural history of obsessional states. Br Med J 26:194-198.

Rasmussen SA, Eisen JL (1992), The epidemiology and clinical features of obsessive compulsive disorder. Psychiatr Clin North Am 15(4):743-758.

Robins LN, Helzer JE, Weissman MM et al. (1984), Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 41(10):949-958.

 

Less Anxiety But More Violence?

How is it that anti-anxiety drugs can cause anxiety and insomnia, sometimes within the first day or two of treatment? This effect is repeatedly noted in the Physicians' Desk Reference for most selective serotonin reuptake inhibitors such as fluoxetine (Prozac) and sertraline (Zoloft). Anxiety reactions occurred in 14% of patients given fluoxetine for obsessive-compulsive disorder versus 7% on placebo (PDR, 2003a). Similarly, insomnia occurred in 33% of patients with bulimia treated with fluoxetine versus 13% on placebo (PDR, 2003a). Fluoxetine and sertraline induced tremor in about 10% to 11% of patients with major depression compared to 3% for placebo (PDR, 2003a, 2003b); these are not the soothing qualities we expect for anti-anxiety medications.

Different Types of Anxiety

A simple explanation is that there are two (or more) separate types of anxiety, and a drug can affect them differently. Specifically, SSRIs reliably decrease psychological anxiety but not somatic anxiety. Somatic anxiety is primarily a tension phenomenon, with restlessness, agitation, impatience, hyperreactivity and irritability. It is largely but not entirely observable. Tension is associated with high epinephrine or norepinephrine activity and activation of the sympathetic nervous system. Drug-induced akathisia is usually described as a tension phenomenon.

In contrast, psychological anxiety is largely comprised of worry, repetitive thoughts and dissatisfaction. Because it is subjective, understanding its presence and severity requires description by the patient. Psychological anxiety is apparently related to low serotonergic activity. The separation between somatic anxiety and psychological anxiety has been observed in symptom cluster analysis (Watson et al., 1995) and suggested by pharmaceutical response (Fogari et al., 1992). This separation implies that the evaluation of anxiety involves specific assessments of somatic anxiety and psychological anxiety. Because pain, dizziness and disassociation can respond to hypnosis therapy, they might be considered additional types of anxiety.

Different types of anxiety can provoke each other in a circular loop, but this does not make them inseparable. Although pain causes anxiety, when pain remits, anxiety can persist if an anxiety disorder has developed. Similarly, worry can induce somatic anxiety, but restless tension can persist after worry has faded. Tension can begin with worry, yet it can eventually be autonomous from worry. This concept resembles phantom pain that persists after the physical cause of the pain is removed.

Somatic anxiety is sometimes mislabeled as psychological disinhibition. Inappropriate conduct that appears when irritability or hyperreactivity overcome self-control does not illustrate psychological disinhibition. Analogously, pain can cause patients to scream; this is bodily discomfort, not psychological disinhibition. The discomfort is the same, with or without the scream. Tension is also a bodily discomfort. Another inconsistency between tension and disinhibition is shown by the effect of benzodiazepines--they diminish tension but actually increase disinhibition.

Mythology in DSM Anxiety

The DSM formulation of anxiety disorders contains the belief that the mind controls bodily tension. This is done by combining tension and psychological anxiety together in the diagnostic criteria. Surely psychotherapy can relieve psychological anxiety. The problem is that after successful psychotherapy relieves the psychological anxiety, the patient may no longer meet anxiety disorder diagnostic criteria but might still suffer from somatic anxiety. This inconsistency is resolved only by believing that psychotherapy also reliably treats somatic anxiety.

However, besides muscle movement, body control by the mind is indirect, incomplete, highly variable and largely speculative. It is not right to base our professional diagnosis and treatment on the assumption that psychotherapy can control bodily function. The alternative to this belief is once tension has become persistent and intrusive, it no longer depends on worry in order to continue. Worry provokes bodily tension, and it also predisposes to infections, injuries and substance abuse. The bodily consequences of these problems are not reasonably curable by psychotherapy alone, but require medical treatment of the body.

Psychiatrists might be able to occasionally decrease persistent tension or other somatic conditions with psychotherapy. Still, it is not appropriate for DSM to require the belief that psychotherapy (or pharmacotherapy) reliably relieves somatic anxiety as it diminishes psychological anxiety. The myth that psychological anxiety and somatic anxiety are the same condition probably pervades DSM because it is a widely accepted belief. This belief may predispose to violent consequences from not treating somatic anxiety in patients on SSRIs.

In 1991, several news reports mentioned individuals in whom suicidality became problematic after starting an SSRI (e.g., Masand and Dewan, 1991). However, that same year, an ad hoc U.S. Food and Drug Administration panel found no connection between SSRIs and suicide (Harris, 2003). Nevertheless, in 2003 the United Kingdom Committee on Safety of Medicines recommended that physicians avoid most SSRIs for treating major depression in patients under age 18 (Duff, 2003). Similarly, the U.K. Medicines and Healthcare products Regulatory Agency warned doctors against prescribing paroxetine (Paxil) for children (Vedantam, 2003). This year a "healthy" participant given duloxetine (Cymbalta) committed suicide four days after discontinuation and was the fifth suicide in premarket trials of duloxetine (Harris, 2004). Both sides of the suicide/violence issue are represented by a variety of publications.

Healy (2003) claimed an excess of suicides and suicide attempts in participants taking SSRIs compared to a placebo group. A National Institute of Mental Health-sponsored analysis found no significant difference between fluoxetine and placebo for suicide attempts and completions (Leon et al., 1999). However, violence should theoretically be less prevalent in the treatment group because it is a symptom of the illness that is being treated. The lack of a decline in suicidality with drug treatment implies that the therapeutic effect is incomplete, at least for a group whose symptoms include suicidality.

Significant versus Reliable

On one side of the debate are reports of suicide in patients given SSRIs (The Guardian, 2003). On the other side are reports about patient groups for whom average instances of violence and suicide are not increased with SSRIs (Leon et al., 1999). If SSRI-induced violence is genuine but rare, a study of patient group averages will not reflect it. Rather, it will be hidden by patients who respond to SSRIs.

To illustrate, suppose that 30% of patients show decreased irritability with treatment, 65% hardly change and 5% show increased irritability, while average irritability falls significantly. If the consequences of increased irritability are clinically unacceptable, the statistical significance is irrelevant. A more effective treatment might add a drug that reliably decreases irritability.

Rather than group averages of violence-related behaviors, the incidence of violent acts must be described. Indeed, the reported decrease in suicides since SSRIs were first introduced suggested that these drugs diminish more violence than they might provoke (Walsh and Dinan, 2001). On the other hand, violent methods of completed suicides in patients with detectable fluoxetine levels were about three times the incidence of violent suicides of patients with tricyclic antidepressant levels (65% versus 23%) (Frankenfield et al., 1994).

Incidence of Violence

The fact that patients on SSRIs may commit more violent acts does not mean that the SSRIs caused them. A simpler explanation is that violence becomes worse by leaving somatic tension unrelieved. Tension does provoke violent acts such as suicide (Busch et al., 2003), and symptoms left untreated can make themselves worse. However, the sedative properties of some TCAs (e.g., amitriptyline [Elavil, Endep]) can actually decrease tension. That is, there may be more frequent violent suicides of patients on SSRIs such as fluoxetine than on TCAs, because TCAs may offer greater tension relief. Another explanation is that physicians are more reluctant to give TCAs to patients who appear suicidal because of the toxic overdose potential (Warshaw and Keller, 1996). Both explanations presumably contribute to the finding that more violent suicides may be seen with SSRIs than with TCAs.

Studies that do not reflect positively on SSRIs are unlikely to be published, and this undermines the proper understanding of these drugs. GlaxoSmithKline acknowledged that eight of its nine studies of paroxetine in children and adolescents were not published, and the FDA assessed the overall result to be that paroxetine was not effective for depression in patients under age 18 (Harris, 2003). This nonpublication is a deliberate bias in favor of SSRIs. It obstructs us from making an impartial assessment of positive and negative effects of SSRIs by considering collections of published results, including meta-analyses. The professional ethics of withholding publication are questionable. We are left to make only impressionistic judgments. We psychiatrists seem to be overly comfortable doing so, to such an extreme that DSM expects us to overlook evidence and apply subjective impressions instead (see Psychiatric Times April 2003, p30; and June PT 2003, p23).

On the opposite side, biases against SSRIs are notorious, specifically those propagated by antipsychiatry organizations. When we dismiss these groups for their wrongful predation of the mentally ill or for posing as a religion, it is easy to also dismiss the issues they raise. This is not logically correct.

Not Just Akathisia

It is clear that SSRIs induce somatic tension in the form of akathisia (Hamilton and Opler, 1992). From what I have seen, patients who already have observable tension have the most problematic SSRI-induced akathisia. Figuratively, adding the SSRI was salting an open wound. These patients ended up discontinuing the SSRI on their own within days. Patients who can tolerate an SSRI for months seem unlikely to have problematic akathisia from it. So, it is implausible to attribute substantial violence or suicidality to akathisia, because these patients will not tolerate the drug long enough to commit violence or suicide. Nevertheless, the possibility of SSRI-induced akathisia is an additional reason to monitor for and treat somatic anxiety symptoms. As with antipsychotic-induced akathisia, patients with akathisia from SSRIs should tolerate medication better when the akathisia is relieved.

Of note, patients who do not achieve remission on fluoxetine have substantially more somatic anxiety than patients who remit (Fava, 2003). This meshes with my experience that patients referred by primary care physicians after inadequate SSRI responses show prominent restlessness. That buspirone (BuSpar) does not decrease tension as benzodiazepines do probably explains why patients do not accept it (Rickels et al., 2000) or SSRIs as substitutes. Similarly, the sedative action of clomipramine (Anafranil) presumably explains its superiority over SSRIs for tension relief in OCD (e.g., Geller et al., 2003). In addition, tension mitigation surely underlies the mushrooming use of antipsychotics for nonpsychotic patients, and their recent concurrent use with SSRIs (Corya et al., 2003).

Mood or Anxiety

This discussion focuses on disorders that are treated by SSRIs: primarily anxiety disorders, atypical major depression and bipolar II disorder. Differences among them are unclear because they are subjective (see PT December 2003, p75), and there is close overlap in symptoms, co-occurrence and treatment approaches (see PT April 2003, p30). All are dominated by hyperreactivity, assertive dissatisfaction and tension. Their psychological anxiety tends to decrease with SSRIs but their tension does not.

Suicidal behavior varies across these disorders. Attributing suicidality or violence to undertreated major depression is not supported by the literature. Undertreated tension is just as plausible a cause. Dishonor-related tension apparently underlies hara-kiri, stock market crash jumping and post office revenge. Adding SSRIs to the association between tension and violent behavior (i.e., suicide) produces an explanation for suicidal behavior in patients on SSRIs. The problem is resolved by adding treatment of somatic anxiety to treatment with SSRIs or buspirone.

Treatment for Somatic Anxiety

Tension, as hyperarousal of the sympathetic nervous system, is diminished by calming drugs (see PT March 2003, p48). The fine details are everyday topics in my clinical teaching of psychiatry residents. Calming drugs are generally ß-blockers, a-blockers, anticonvulsants, sedating TCAs, low-potency antipsychotics or benzodiazepines; thus, we need to know when other doctors give these medications to our patients. Drugs with consistent efficacy and only rare side effects have a smooth, gradual action without rebound, tolerance, rapid elimination (short half-life) or psychological impairment. This excludes benzodiazepines, some sympatholytics (e.g., propranolol [Inderal]) and more than minimal doses of antipsychotics (see PT January 2003, p12; PT February 2003, p44; PT March 2003, p48; and PT November 2003, p8).

In summary, suicidal and violent acts occur in patients with anxiety because somatic anxiety is undertreated. There is a mistaken impression that SSRIs or buspirone reliably treat somatic anxiety.

The Controversies
SSRIs treat anxiety but also induce anxiety--why does this happen?
Does anxiety always involve worry?
Worry causes tension, so why doesn't relieving worry always relieve tension?
Is chronic hyperarousal a thought problem or a physical problem?

Acknowledgment
Matthew Parvin, M.D., assisted in the literature search for this article.

Dr. Swartz is chief of the division of psychiatric research at Southern Illinois University School of Medicine in Springfield. Much of his research has concerned the application of physical science methods to common clinical problems in psychiatry and medicine.

 

Mental health shake-up announced

Mental health campaigners have welcomed a shake-up of mental health nursing announced by the government.
Mental health nurses will be urged to spend less time doing paper work and more time with patients.

More psychological therapies will be provided as alternatives to drug treatments, and there will be efforts to improve care on mentally ill wards.

A spokeswoman for the charity Mind, said patients had often said they felt "alone and abandoned" on wards.

The government has said it efforts will be made to improve recruitment and retention of mental health nurses, through better career structures and new kinds of nursing roles developed.

There will also be moves to improve the image of working in the mental health field by presenting positive messages about the mentally ill to the media.

Health minister Rosie Winterton said: "The time is right to provide mental health nurses with a new direction and clear future role in order to deliver government reforms such as the Mental Health Bill, personalised care and choice."

The shake-up comes in a report following a six month consultation with mental health professionals, providers and action groups.

Mental health charity Mind said there had been a real issue about lack of training of mental health nurses on in-patient wards which had often been used as a "holding bay" for patients.

Sophie Corlett, director of policy at Mind, said she was delighted nurses would be encouraged to engage more with service users and take a more active approach to their recovery.

"Too often do we hear of a lack of interaction between the two, particularly on wards where patients may feel alone and abandoned," she said.

Marjorie Wallace, chief executive of mental health charity Sane, said: "In our experience, the lives of mentally ill people and their families can be transformed where they have regular contact with a skilled and compassionate nurse.

"However, callers to our helpline report bleak days on wards, with minimal contact with nurses and therapists and little to do.

"We therefore welcome the proposal that nurses should be freed from administrative work to spend more time in direct contact with patients, looking to their physical and psychological wellbeing."

 

Oh, no! That's the bit of your brain announcing a cockup

WE’VE all done it — the cheeky e-mail about the boss that you send him by accident; toiling over an examination question only to realise you’ve got the wrong end of the stick; the go-for-broke call on red as the roulette ball lands on black.

That “cold sweat” moment — the split second when someone realises they have made a potentially costly mistake — has been found to set off mechanisms in the brain that could help scientists to understand mental health problems. According to neurologists from the University of Michigan, a part of the brain suddenly becomes more active when we realise that ill-judged actions carry serious consequences. The discovery could assist the understanding of conditions such as obsessive compulsive disorder (OCD) and depression.

The rostral anterior cingulate cortex, or rACC, has been found to go into overdrive when such an error is made. When the mistake does not carry a penalty, or when a correct action carries a reward, the same area of the brain is far less active.

Using brain imaging, the scientists have traced rACC activity for the first time and compared it with brain patterns in people with obsessive behavioural problems. They found that in the brains of OCD patients the rACC area, which is also associated with emotion, became much more active in response to an error that carried no serious consequences than it did in those people without the condition — suggesting it is linked to increased anxiety.

The research, published in the Journal of Neuroscience, involved 12 healthy adults having their brains scanned as they responded to a series of tests. Some of the tests carried a monetary reward, others carried penalties of the same size and some carried neither.

The participants had quickly to press a button to answer each test, which involved determining an odd letter among other letters. They were immediately told if they were wrong or too late in responding.

Stephan Taylor, lead author and associate professor in the Department of Psychiatry at the University of Michigan Medical School, said: “In general, the response to a mistake that cost them money was greater than the response to other mistakes, and the involvement of the rACC suggests the importance of emotions in decision processes,” he said. “It is very interesting that the same part of the brain that responded in our OCD study on regular errors [that carried no consequences] also responded in healthy individuals when we made the error count more.”

The researchers hope to study the impact of cognitive behavioural therapy — a form of “talking” therapy — on how OCD patients respond to their errors. “OCD patients may have a hyperactive response to making errors, with increased worry about having done something wrong,” Dr Taylor said.

“We hope this kind of research will help us get a handle on this condition.” The finding does not have immediate implications for OCD patients, he cautioned. But it could help in the development of new treatments.

Obsessive compulsive disorder is often characterised by untoward anxiety. Obsessions include unwanted thoughts that can trigger repetitive behaviour such as handwashing, counting and checking — rituals performed with the hope of preventing or dispelling obsessive thoughts.

OCD is listed by the World Health Organisation among the most debilitating illnesses and may affect 3 per cent of Britain’s population.

The full research document from this article is available for download.

 

Dr Raj Persaud in Plagiarism Row

He is Britain's most famous psychiatrist, as at home before a TV or radio audience as he is treating a patient. But now he has been caught up in a row over plagiarism, and is standing down from the Radio 4 programme, 'All In The Mind'.

He is used to shining the psychological spotlight upon the problems of others. But now the nation's best-known psychiatrist, Raj Persaud, is finding it turned upon him and his own inner motivations. And it is proving an uncomfortable experience.

Professor Persaud is a consultant at one of the country's leading teaching hospitals, the Maudsley in London, though he is better known as Britain's number one pyscho pundit - at home everywhere from the sofa of Richard and Judy and the pages of women's magazines like Cosmopolitan to the greyer columns of the serious newspapers and the studio of Radio 4's leading programme on mental health, All in the Mind.

At least he was until yesterday when the BBC announced he would be standing down from the programme following allegations that he plagiarised the work of an American professor of psychology on three occasions last year. Dr Persaud might have hoped the affair had gone away, but it shows no sign of doing so. Yesterday his personal website was in meltdown.

The problem first arose in February last year when Dr Persaud's column in the Times Educational Supplement was found to have a substantial percentage of its words on the social psychologist Stanley Milgram copied directly from the website of Professor Thomas Blass of the University of Maryland. The American academic - whom Dr Persaud had interviewed on Radio 4 in November 2004 - complained to the good doctor direct and was told that he had intended to acknowledge the article from which he quoted but the attribution had been omitted in error. The TES website then added suitable alterations to the text.

The trouble was he did the same thing again in two other articles on the same subject; Milgram's notorious experiments in which students administered electric shocks to other students, and carried on doing so even when their victims (who were really actors) seemed to pass out or even die.

The first article, a book review of Blass's book on Milgram, was written for the February edition of the journal Progress in Neurology and Psychiatry. Professor Blass saw it and contacted the editor, who in September - wheels turn exceeding slowly in academic publishing - issued a formal retraction of the article.

Then a third piece on the same subject appeared in the British Medical Journal in its August edition. This too had large chunks of Thomas Blass's text reproduced without attribution. "He had taken paragraphs from my work, word for word," he told The Guardian last year. "Over 50 per cent of his piece was my work, which I have spent more than 10 years researching. I felt outrage, disbelief and incredulity this could happen, that a person who is himself a writer could do this. It's very disconcerting." The BMJ also issued a formal retraction, which appeared in its December edition. The Institute of Psychiatry and Maudsley NHS Trust have set up a panel to review the matter. It has yet to report.

All of which was, to say the least, rather embarrassing for the man described by The Spectator as "the most eminent psychiatrist of the age". Raj Persaud is certainly one of the best-known psychiatrists of the age, in this country at any rate. As well as appearing as the sofa shrink on daytime television, he frequently pops up in the Daily Mail, Telegraph, Times, Independent and Guardian. As well as Radio 4 he does a programme for the BBC World Service.

There have always been psychiatric professionals who sought to popularise their trade. Dr Persaud's predecessor, Dr Anthony Clare, was celebrated for his In the Psychiatrist's Chair interviews. "The trouble is that Anthony Clare was very scrupulous about the kind of things he did," said a fellow psychiatrist yesterday, "but Raj has never been terribly discriminating. He's gone for maximum exposure, with articles on a huge range of subjects, and with very short deadlines." But even his critics - and Dr Persaud has colleagues who think all the media hoo-ha diverts him too much from his post as a senior NHS consultant - concede he is a man worthy of respect.

The Reading-born psychiatrist has eight degrees and diplomas to his name, including, in addition to his medical qualifications, an MPhil, a master's in statistics and - unusually for a psychiatrist - a degree (first class) in psychology. A former pupil of Haberdashers' Aske's private school, in Elstree, Rajendra Persaud went to University College London where, thinking a medical degree too limiting, he also attended sociology and art classes. As a result, he failed his first-year anatomy exams, but was so traumatised by the failure that "I more or less moved into the library for the remaining years of the clinical course", becoming such a fixture that at one point the Dean begged him to take a holiday.

From that point, hard work characterised the career of one of Britain's youngest consultant psychiatrists. He won numerous awards, including the prestigious Royal College of Psychiatrists' Research Medal. In 2002 he was voted one of the top ten UK psychiatrists by his peers at the Institute of Psychiatry and the Royal College of Psychiatrists. He was the youngest on the list. In 2004 he was appointed Gresham Professor for Public Understanding of Psychiatry. "He is very highly rated within the Institute of Psychiatry," said another psychiatrist. "He has done a lot to reduce the stigma of mental illness and help the public take a more favourable view of psychiatry."

Given all that why did he resort to copying someone else's work? Dr Persaud said it was all down to an error "whereby when I cut and pasted the original copy, the references at the end were inadvertently omitted". Three times? The doctor's fellow psychiatrists are, perhaps surprisingly, sanguine about the whole business. "All three pieces were clearly written around the same time," said one, "and it looks like he has been sloppy rather than wilfully deceptive."

The Institute of Psychiatry review panel is not a disciplinary process, noted another. "In academic circles plagiarism - passing someone else's data off as your own - is the worst sin you can commit," said a third. "But this is not that kind of plagiarism. It's journalistic rather than scientific, which is much less serious. It's a 'failure to attribute' rather than 'intention to deceive'. Raj doesn't need to do that. His ability is not in question." And it all occurred within reviews of Blass's book on Milgram "which," said another shrink, " is an implicit context of attribution - it's not as though Blass wasn't mentioned in the pieces - they were all plugs for his bloody book."

What it does suggest, said another psychiatrist who also writes regularly in the media, but under a pseudonym, is that "Persaud, despite all his denials, does spread himself too thin. You can't really do a high volume of stuff at a very high level. The danger when you write a lot is that you can't remember whether this is something you've done before."

It also reveals the perils of computer technology which allows writers to cannibalise their own work through cut-and-paste techniques, making the odd change here and there to avoid total repetition, he says. "If something has been saved on the computer without care it would easily be possible for a prolific writer to come across a few paragraphs and think, 'That's quite good - I'll use it again' without realising they hadn't written it in the first place. It's the pressure of short cuts."

"Raj is an incredibly hard worker," said another psychiatrist and friend of Dr Persaud. "But that means he's inevitably taking tremendous risks. Even so, most of his articles reveal he's done some research or reading when he's on a subject outside his own expertise. And he uses his general training to put forward an article that's usually more than adequate for public consumption."

But what drives him to push himself forward in a way which requires such risk-taking?

Raj Persaud, who lists poker as his first recreation in Who's Who, has in the past said he turns down 90 per cent of the requests he gets from "editors unsympathetic to the fact that the evidence or research clashes with their opinion".

Not all his colleagues are convinced. Why, queries one, did he feel obliged to write a third review for Progress in Neurology and Psychiatry? "It's a crap freebie journal that most people put straight in the bin," said one psychiatrist friend. "So why did he do it? Because he was paid? He can't need the money. Because it keeps his profile up? He certainly has a huge ego. Or because his success is based on saying yes to everything?"

Yet another colleague remarks: "The wonder is that he hasn't come a cropper earlier." Dr Persaud knows he has come one now. "Another friend got an email from him saying that the day all this broke was the worst day of his life," said a psychiatrist friend. "He's been very foolish and he knows it. He's mortified."

Perhaps the writings of one Raj Persaud offer an answer. One of humanity's greatest incentives, the prolific psycho has written, is "social rewards such as flattery, esteem, attraction, and praise". Writing of the fatal flaws in the characters of politicians like David Blunkett and Bill Clinton which lead them into extraordinary acts of hubris, Dr Persaud also comments: "There is another ingredient to add in to this toxic and psychologically explosive cocktail.

"Psychologically embedded in the relationships of the powerful are the seeds of their eventual destruction and [many] politicians remain in deep denial about that. People with elevated power become disposed to elevated levels of risk-taking. They are more mentally oriented to potential rewards and oblivious to pitfalls."

A psychiatrist writes. And he should know.

 

SSRI Pregnancy and Nursing Concerns

Use of a type of anti-depressant medication during pregnancy may increase the risk of a stillborn baby, research suggests.
A Canadian study of almost 5,000 mothers found those who used SSRIs were also more likely to have premature and low birth weight babies.

However experts said women should not stop taking medication without expert advice.

The study is published in the American Journal of Obstetrics and Gynaecology.

The researchers, from the University of Ottawa, compared the health of babies born to 972 women taking SSRI anti-depressants with that of babies born to mothers who did not use anti-depressants.

SSRIs, or selective serotonin reuptake inhibitors work by increasing levels of the mood chemical serotonin in the brain. They include Prozac.

The researchers found women using the drugs were twice as likely to have a stillbirth. They were also almost twice as likely to have a low birth weight baby.

Almost 20% of women who used SSRIs gave birth prematurely, compared to 12% of those who did not use the drugs.

Babies born to women using SSRIs were also more likely to have seizures.

The researchers said women should be fully briefed about the potential risk of SSRIs before taking a decision about whether or not to use them.

Charlotte Davies, of Tommy's, the baby charity said pregnant women could opt for other types of anti-depressant medication.

She said: "Whilst this study has found a correlation between SSRIs and pregnancy complications, it has in no way confirmed a clear causal effect between the two, so pregnant women should continue taking their medication as normal.

"Left untreated, the physical and psychological effects of depression can lead to problems during pregnancy.

"Sufferers of depression are far more likely to smoke, as well as lose their appetites and in extreme cases are more likely to attempt suicide, which can all have devastating effects on mother and baby."

Previous research has also raised doubts about the safety of using SSRIs while pregnant.

Last year Danish and US scientists found use of the drugs in the first three months of pregnancy was linked to a 40% increased risk of birth defects such as cleft palate.

That research also suggested that use of SSRIs in pregnancy raised the risk of a premature birth.

In a separate study, Spanish research found that babies whose mothers used SSRIs are at risk of being born with withdrawal symptoms.

The Medicines and Healthcare products Regulatory Agency has warned doctors not to prescribe most SSRI drugs, apart from Prozac, to children.

This followed evidence that use of the drugs in young people might increase the risk of suicidal behaviour.

A spokesman for Eli Lilly, which manufactures, Prozac said the company had never promoted the use of the drug for pregnant or nursing mothers.

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