Crazy Talk

Do you need treatment?

Every once in a while a curious friend will ask me about the patients that I treat in my practice wanting to know why they need to come see me.  The question always stumps me because the concept of "need" is not as black and white as we would like to believe.  Who needs to see a psychiatrist?  The extreme cases are pretty easy to categorize.  Individuals with severe symptoms of depression, psychosis, anxiety, insomnia, whatever, can probably described as needing to see a psychiatrist.  Of course, you then have to define "severe" but let's say that without treatment, these individuals would frequently end up in the hospital and when outside be unable to function.  On the other end are individuals with no mood, anxiety, sleep, or relationship issues...do you know anyone like that? 

In the end, unless we fall in the extreme category, we each need to decide for ourselves, but I wouldn't make the question about whether we need treatment but whether the cost in time and money of treatment makes sense.  With this shift, the stigma of being in treatment would diminish and more of the people who could really use some help would be freer to get it.

Who's physically healthier, the person who gets his annual physical or the person who hasn't seen a doctor in years?  Who has better teeth, the person who sees their dentist or the one who doesn't?  Who's healthier, the person who makes the decision to see a mental health professional or the person who decides that they don't need to?

The Science of Positive Thinking

As the economy suffers and my patients follow suit, I find myself talking more and more about the role of positive thinking in helping my patients feel better.  And I find that I am encountering a lot of skepticism and resistance.  The resistance comes down to a general belief that the positive thinking doesn't work; that it's not scientific.

Not scientific?  Ever hear of the placebo effect?  This phenomenon is so widely accepted that it is taken for granted.  Every new treatment has to prove itself better than placebo to be approved.  But what is the placebo effect if not positive thinking?  The idea behind placebo controlled trials is to determine whether a medication works because it is making some physiological change or just because the patient (and doctor) think it's going to work.  The placebo effect can be as high as 30 or 40% if not higher.  That's an effect based on positive thinking.

In these difficult times, maybe we should pay attention to what science has long accepted.  Believing that positive change is possible can make all the difference.

The Stealth Winter

The first official day of spring is just a few days away and the weatherman described tomorrow's weather as a return of winter.  It's not going to snow but may dip down into the upper 30s.  Certainly not what we want the temperature to be as we gear up for spring, but not exactly the worst the NY winter sends our way.

My focus today is on the importance of our expectations on how we react to certain situations.  Looking back at data on the average temperature historically on March 19 in Central Park in NY shows that the average high is about 46F and the average low about 33F.  These are averages.  The temperature right now at about 1:30 in the afternoon is 43F, toward the upper part of the range so on the warmer side for what is usual this time of year.  Yet for some reason, we expect it to be warmer, maybe related to an association with the official first day of spring.  This is a set up for disappointment.  It's usually colder than it is this year this week and the forecaster still describes the weather as a return of winter.

If we didn't expect it to be spring-like, the weather wouldn't bother us so much.  Maybe what we need to do is move the first day of spring into April.  That's not going to happen but hopefully we can apply this lesson to other expectations we have to avoid setting ourselves up for disappointment.  There is nothing wrong with being optimistic and in fact I've advocated that general attitude in previous posts.  The distinction is holding unrealistic expectations in the face of evidence to the contrary.  It's good to be open to the possibility of how we'd like things to be but better to prepare for what seems most likely given the information we have available.

Choosing in Reality

Among many other things, the election of President Obama combined with the current financial crisis has brought the debate about the health care system back to the forefront.  We are quickly reaching the point where we cannot ignore the fact that the system has been broken for long time because, basically, we no longer have the money to throw into a largely corrupt and inefficient system. 

This Thursday, the President is holding a summit in Washington to gather information on how to fix the problem.  Unfortunately, thus far he has not included anyone who supports a single payer system.  He has invited representatives of the insurance industry and many politicians who support the status quo.  It is not clear that single payer is the solution but it certainly deserves due consideration. Opponents of single payer immediately invoke the idea of "socialized medicine".  They then point to all of the drawbacks of socialized medicine as it has been implemented in other countries, the main one being healthcare rationing.

I am by no means a health policy expert, but what I can say is that a single payer system is not what would trigger health care rationing.  Reality is what would.  We have been living in a fantasy world in which we pretend that there is no price on health.  Certainly, the value of life and good health is priceless in its importance, but the fact is that there are costs associated with providing health care services.  Not only do I think we should be willing pay this price but I think that it is feasible to do so while providing care to everyone, but it would entail making decisions not to pursue costly low yield treatments.

Whatever the solution ends up being, part of it is going to have to entail accepting that we have to confront the reality of death.  And all of us have to accept that health care, including paying for it, is a priority.  We can't simply demand good insurance without accepting that it has to be paid for.

Sleep Hygiene

Happy New Year!  I still haven't quite got the hang of posting regularly and I admit that I did consider shutting down, but then what sort of role model would I be?  So I demonstrate my belief that persistence pays off ultimately by forging on.

For this first post of 2009, I have decided to share an information sheet I have put together for my patients to summarize the concept of sleep hygiene.  In other words, what to do when you have trouble sleeping before turning to medication.  It can also be applied as one tries to come off of sleep medication or really for anyone to use to address difficulty sleeping.  So here it is:

1. Lie down intending to go to sleep only when you are sleepy.

2. Do not use the bed for anything except sleep; that is, do not read, watch television, do not eat, and do not worry while in bed.  Sexual activity is the only exception to this rule.  After sexual activity, the rules once again apply.

3. If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish until you feel sleepy and then return to bed.  Although you should not stare at the clock, you should get out of bed if you do not fall asleep within a few minutes.

4. Repeat step 3 as necessary throughout the night until you fall asleep

5. Set an alarm and get up at the same time every morning regardless of how much sleep you got during the night.  There may be a few tired days but since you need to sleep your body will gradually acquire a consistent sleep pattern.

6. Do not nap during the day

(I do not take credit for these instructions.  They were put together from general behavioral guidelines and were not taken from a particular source)

Tougher times, same strategies

People have been asking me if I'm busier these days given the stress caused by the tough economic climate.  Certainly my patients are struggling with the disheartening reports in the news that seem to get worse daily.  But in the important ways, things are business as usual.  What I mean is that I try to have my patients focus on the things that they have control over, mostly their own choices and behavior.  There is no point to obsessing over what is happening with the economy because the macro issues are out of our control as individuals.  Now, this does not mean that we should ignore outside realities.  The things going on in the world should inform our decisions, but the key is to expend most of your energy on the things, the choices, the actions, that you actually control.  Secondly, in tough times like these, it makes sense to temper our expectations.  This does not mean that we cannot expect things for ourselves to improve; it just means that we need to understand that changes for the better are likely to take more time than they might otherwise.  But the usual strategies for success and positive change still apply.  Incremental improvements toward our goals will still get us where we want to be.  And history has shown that things will get better again.

Now do what I suggest AND do

A quick post just to show why you shouldn't give up.  I stayed away for over a month out of frustration, but came back this morning and now again after just a few hours, and the problem is solved. I can again adjust the font size.

(this post refers back to the previous blog entry)

Do what I suggest, not what I did

Contrary to what the lack of a post in August implies, I am actually working this August.

I was doing well with posts for a few months and have fallen off recently. I was thinking about why this is and I was vaguely aware that it is related to my frustration over not being able to fix the technical problem I have been having with not being able to increase the size of the font. As I mentioned in a recent post, I am stuck in this microscopic font. I have had an exchange with the tech support on this site, but after a few emails that were not helpful, I started avoiding the issue.

This is exactly what NOT to do and the kind of thing that derails many of the best intentioned plans. Eventually this technical problem will be dealt with. Either they will figure out why I am stuck in this font, or I will find a way to get around it, or I can even move my blog to a different site. There are many other possible solutions that aren't coming to me now but will if I continue to work on this problem.

The point is that giving up on a problem guarantees that your progress is halted. Even if they had fixed the problem, I have been avoiding the site for a month and would not have known. Now that I am back, the problem is not fixed (yet) but at least I am back to posting to my blog. This font is not ideal, but it should not stop me from posting altogether.

So please, when you encounter an obstacle that frustrates you, do not give up and decide that you are defeated. Instead, take a deep breath, regroup, and approach it again the best that you can. Every attempt that you make is different than the ones before because it has the experience of the previous attempts behind it. What does this mean? Keep trying because you might surprise yourself by succeeding the next time without necessarily knowing what you did differently

Freedom of information more than just interesting reading

I read an article today related to New York City's new law that requires restaurants to list nutrition information, including calories, on their menus. The article indicated that the posting of the calorie information has impacted the way that New Yorkers are ordering. It suggested that people are making healthier choices simply by being presented the calorie information.

This observation supports my idea that people often allow themselves to deny some pretty obvious facts, whether related to calories, or health, or most things.

Another area that this could be relevant is pricing for prescription drugs. For many years, pharmaceutical companies have successfully defeated legislation that would require drug prices to be listed on medication bottles. They have invested heavily in lobbying Congress each time the issue has come up. The reason for this is that they know that people would be less apt to be wasteful and irresponsible with their medications if they knew how much they cost. I think this is true even if they are not necessarily the ones paying the full cost. People have a sense of what is a fair price; this is why the market is a useful way to balance cost through supply and demand.

I commend NY legislators for applying their understanding of human nature to give New Yorkers more information about the food they eat and I hope that the Federal government will fulfill their responsibility to the American people by ignoring the drug companies' lobbyists and making the simple requirement that drug costs be transparent.

Staying Sharp by...babysitting?

I just read an interesting tidbit and since, as usual, I'm overdue for a post, I thought I'd share it. Recent research has demonstrated that one important factor in maintaining a healthy brain as we age is socialization. Specifically, it seems that caretaking in particular is linked to longevity and avoiding cognitive decline.

Most people know that human females have a longer life expectancy than males. Related to the observation that caretaking extends lifespan and helps maintain cognition was the observation that in species in which the males take the primary roles as caregivers, it is the males that have longer lifespans!

One take away message is that for people deciding what to do to try to maintain clear thinking as they get older, it makes sense to opt for time with other people, especially in a caregiving role rather than say, doing crossword puzzles alone.

The power of caregiving is also buttressed by the observation that pet owners tend to have lower rates of depression and suicide.