Should your Doctor be your Friend?

By Jeffrey Borenstein, M.D.

Last Friday, October 14th, I was asked to be a guest on the Dr. Drew show to address the important issue of the doctor-patient relationship. Our discussion centered on the friendship between Dr. Conrad Murray and Michael Jackson and the inappropriate crossing of boundaries.

First and foremost, the doctor-patient relationship is special, centered on trust, caring, and helping. But it is not a friendship – friendships are two way streets. The therapeutic alliance in the doctor-patient relationship is a one-way street – the doctor’s role is to help the patient. 

Another issue we discussed was “doctor shopping." When a person who has a diagnosis of chemical dependency gets prescriptions from various doctors in order to misuse medications, typically pain meds or anti-anxiety meds (benzodiazepines), it's called "doctor shopping." When a physician is aware of this behavior or even suspects "doctor shopping," it's the doctor's duty to take action and stop filling prescriptions rather than enable such destructive behavior.

If you have a friend or family member misusing medication in this way, don’t sit by quietly. Taking appropriate action could save a life. Encourage your loved one to seek appropriate treatment. On the Healthy Minds Public Television series, we have two episodes which focus on chemical dependency, episodes #111 and #112 which can be seen at www.wliw.org/healthyminds. 

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Mental Illness or Muse? Amy Winehouse and Historic Artists with Bipolar Disorder

By Mohammad Alsuwaidan, MD 



We have no doubt lost a profound musical talent in the tragic death of Amy Winehouse this week.  Her public struggle with substance abuse and bipolar disorder (commonly known as manic depression) has reignited curiosity about possible links between creativity and mental illness. In such unfortunate circumstances, it serves well to draw upon the lessons of history in making meaning out of sorrow.



A little more than 120 years ago, a misfortune befell another budding talent. A young painter entered a psychiatric hospital in Saint-Rémy-de-Provence, Southern France. Known by his neighbors in town as “fou roux" (the crazy redhead), he had been troubled with mental illness throughout his life. A few months prior, he had reached a crisis point and during his breakdown, he rushed to a brothel to see his friend - a prostitute named Rachel. He handed her a small wrapping of newspaper - telling her to “keep this object carefully” and ran off. Unwrapping it, she was shocked to find the freshly cut and still bloody lower portion of his left ear!

Vincent van Gogh holds legendary status in Art and his influence has crossed cultures and eras. To gaze onto the vivid colors and hypnotic swirls in his work is to be transported into another world - a morphed view of reality that can only be seen through his eyes. There is a tendency to romanticize van Gogh’s mental illness – which most respected psycho-biographers believe to have been bipolar disorder.



The notion that there is a fine line between creative genius and “craziness” is not new and has existed since ancient times. Most of this interest has focused on bipolar disorder; many famous figures have been speculated to have suffered from this mental illness: Beethoven, Edgar Allan Poe, Emily Dickinson, Victor Hugo, Charles Dickens, Edvard Munch, and many more. We continue to see this pattern in the modern day among celebrated actors, poets, painters, and musicians like Ms. Winehouse. Yet, despite our modern methods, illuminating the “line” or “link” between mental illness and creativity remains elusive.  Studies show that a certain level of melancholy or mixed emotions may be needed to access the creative spring. Unfortunately this negative emotion may also underlie some of the symptoms seen in bipolar disorder. 



Herein lies the eternal dilemma in the field of medicine – balancing benefits of treatments against their risks. Could some bipolar treatments dampen the creative drive? The evidence, both anecdotal and empirical, says yes.



Yet research also reveals that when individuals with bipolar disorder receive treatment, their overall productivity, focus, and organization improve. We know that the poet Robert Lowell produced the largest portion of his work after receiving lithium treatment for his bipolar disorder. And though some critics argue that his “pre-lithium” work is more striking in its poetic beauty, they admit that had it not been for the stabilizing effects of his treatment leading to many more – still beautiful – poems, we may have never known Lowell and his artistic mastery at all.



The message to mental health professionals is clear in my mind; we should attempt to treat highly-creative individuals with mood disorders with all the latest advancements including medications. BUT we should listen carefully and work with our patients to understand what effect treatment is having on their creative drive. Perhaps some individuals need some degree of discontent to “kindle the creative fire,” and we should step up to the challenge of helping them achieve a tolerable and productive balance.



At the young age of 37, after a manic episode of creating many paintings, Vincent van Gogh walked into an empty field outside his home, aimed a loaded revolver into his chest, and pulled the trigger. His famous last words, as he lay dying in his brother Theo’s arms, were "La tristesse durera toujours" (the sadness will last forever).



Perhaps had he not suffered some degree of sadness, you and I would have never heard of van Gogh. Perhaps had he lived longer, his influence would have been even greater. Perhaps the next van Gogh or Poe or Winehouse will walk into a mental health clinic next week suffocated by their sadness, yet possessed by creative inspiration. The questions are complex scientifically, ethically, and philosophically. But I believe that a balance can and should be reached (or at least approached) and that tragic endings can be re-written. 



Dr. Mohammad Alsuwaidan is a psychiatrist with expertise in Mood Disorders at the University of Toronto and a Master of Public Health candidate at Johns Hopkins University. Learn more: http://www.mohammadalsuwaidan.com/





References:

KR Jamison, Touched with Fire: Manic Depressive Illness and the Artistic Temparment, Free Press Paperbacks (New York 1993). p.85

AW Flaherty, Frontotemporal and Dopaminergic Control of Idea Generation and Creative Drive. Journal of Comp. Neurology 493:147-153 (2005).

Santosa C.M. et al. Enhanced creativity in bipolar disorder patients: A controlled study. J. Affect. Disord. (2006), doi:10.1016/j.jad.2006.10.013

Flaherty, A. (2011). Brain illness and creativity: mechanisms and treatment risks. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 56(3), 132.





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Caring for the Mental Health of Your College Student

By Roberto A. Blanco, M.D.

A recently released national survey on the state of mental health for entering college students revealed that this year's freshmen class has the highest stress levels in the history of the 25 year survey.  There are several reasons.  According to study authors, students face increased competitiveness and demands in high school as well as more financial challenges due to today's economy.

Although it's an exciting time, your child's transition to college can be a difficult one - especially if he or she suffers from a mental illness.  Here are some things that you and your prospective college student should be thinking about prior to choosing a university and heading off to school:

1.    What can I do to ease the college transition? 

Some schools offer an orientation program over the summer to help students become comfortable with the campus and surroundings, learn organizational and study skills and socialize with fellow freshmen.  

Apart from these organized programs, it is important that, as a parent, you work on transition issues and independence.  Make sure that your child has all materials needed for school including an organizer and a computer.  If your child is getting psychiatric treatment, teach your son or daughter the importance of their medicines, therapy and attending their appointments regularly.  If they haven’t yet been self-administering their medications, before going to college, it is important that they learn and start taking their medicines without supervision.

If you have serious concerns about how your child will do with the college transition, you may want to consider schools close to home.  Depending on the amount of concern, it may be best to choose a school which would allow your child to drive home for the weekend if needed.

2.   What’s the quality of the college's mental health program?

Some colleges and universities do not have mental health services available through the school.  If they don’t, you need to understand how a student can go about getting help.  If the school is not in a major city, you need to make sure that there are enough providers close by so that your child can get the services that he or she needs in a timely manner.

Some universities have therapists but no psychiatric providers on staff.  Others offer both counseling and psychiatric services but put a cap on the number of appointments at the university mental health center prior to referring students out to the community.  All of this information should be provided by each individual school.  And you should know all of this information prior to committing to a particular school, especially if your child is likely to use mental health services.

3.    What is the educational environment of the university?

Some universities are known to be high-pressure, unforgiving environments.  This could be due to the rigor, expectations or challenges of courses.  Sometimes, this can be eased by a strong academic support team or advising system.  Often, peers can make the university culture overly competitive in unhealthy ways.  Some places are notorious for students stealing other students’ lecture materials and notes or not helping out when needed.  If your child is particularly sensitive to stress, it may be best to go to a school where the environment is more collegial and supportive.

Other schools are notorious for having easy access to drugs or alcohol on campus.  While drugs and alcohol are available at most schools, they are easier to get at some schools which are located in major cities or areas of high accessibility.  If your child has a history of drug or alcohol abuse, you should be extra considerate of these location factors.

4.    Will the financing of this school put my child in overwhelming debt?

While a good college education is one of the most important investments, your child should not mortgage his or her future by creating large amounts of unnecessary debt.  In addition, universities with higher tuition may necessitate your child working during school to avoid excessive debt.  This can also add stress.  If schools are relatively equivalent in meeting your child’s long-term career goals, choose the college which will put your child in a better financial position after he or she graduates.

Of course, after your children go to college, you will want to monitor how they are doing intermittently.  Particularly stressful times are usually at the beginning of school, around exam time (midterms and finals) and anytime a romantic relationship ends.  Checking in around these times may be the most beneficial.  If it turns out that they need more help than some parental TLC, make sure that they see a professional.

I hope that these suggestions have been helpful.  Feel free to leave comments or questions for further discussion.

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Won’t they do other drugs?

By R. Scott Benson, M.D.



This is a question I get every time I talk with a family about medication treatment for their child with attention deficit hyperactivity disorder (ADHD). And the best answer has been “some will, some won’t”.



But at the APA meeting in New Orleans there was a report from the research group at the Mass General in Boston. They have been able to suggest answers to a lot of question about the outcome of children with ADHD. There is a higher rate of substance use problems in adolescents and adults who have a diagnosis of ADHD. But in this 10 year follow-up of children they asked “What are the predictors?”



Their data confirmed that a diagnosis of ADHD was associated with an increased incidence of drug and alcohol problems. But the finding of severe conduct problems in these children was even more highly associated with future substance use problems.



The take home message for me is that medication alone will not be sufficient to address the severe problems that many children with ADHD present. Parent training, especially for those with severely disruptive behaviors, is a necessary, integral part of their treatment.