I think it is most unfortunate that so many people suffering from acute mental health symptoms are treated with medication only. Often, there is the time and the resources to provide psychotherapy first. Some problems, are best treated with psychotherapy, and in some situations, such as anxiety disorders, psychotherapy has been identified as the treatment of choice in many cases. Medication actually interferes with the effectiveness of psychotherapy of some anxiety disorders. If the problem is more emergent, certainly medication and psychotherapy could be an effective intervention in most situations.

These principles are even more important when dealing with children, particularly children suspected to be suffering from bipolar disorder. Diagnosing children is a particularly thorny task. Symptoms are often not at all like adults or even like other children. The temptation to contain the child's behavior with medication may just exacerbate the condition, at least in the long run. A mis-diagnosed and vigorously treated child may become a particularly maladjusted adolescent or adult.

Psychiatric News: Letter to the Editor by Victor Schwartz, M.D.

"I read with interest the report of Blader and Carlson's study in the June 15 issue on the dramatic increase in the rates of children hospitalized with discharge diagnoses of bipolar disorder. They reported that since 1996 the rate of children discharged with the diagnosis of bipolar disorder has increased fivefold. The cause of this seems obscure. They suggested that upcoding (reporting a more pathological diagnosis to insurance companies to justify admission) might be at least partly to blame. In any case, I think most clinicians would agree that the diagnosis of bipolar disorder is currently being made significantly more frequently in children than in past years. This has occurred in spite of no change in DSM criteria for bipolar disorder. The implications of this in relation to our supposedly scientific diagnostic criteria are worth pondering.

It may be that we have only recently become adept at diagnosing bipolar disorder in children. David Axelson, M.D., is also quoted in this review (although he is not a co-author of the paper) as suggesting that the increased rate of bipolar discharge diagnoses may reflect frequent need for readmission among these children. If they are in and out of the hospital more often (because of chronic instability or difficulty in managing them), the number of discharged children carrying the bipolar diagnosis would go up.

If this claim is accurate, it may raise another concerning thought. In the September 1996 American Journal of Psychiatry, Drs. Sara Bolton and John Gunderson published a clinical case conference in which they presented a young woman who was diagnosed as bipolar. They claimed she was actually a borderline personality. They also suggested that the bipolar diagnosis resulted in the thrust of her treatment being primarily medication based, which in turn resulted in deterioration in her condition. They argued that this diagnosis resulted in a sense of the patient's being out of control of her life and emotions and that this in turn resulted in significant regression.[...]Just to be clear, I am not suggesting that bipolar disorder does not occur in children. What I am suggesting is that when bipolar disorder becomes the default diagnosis for any child who is moody, difficult to manage, or stubborn, and when the primary mode of treatment becomes mood stabilizers, we might be missing, admittedly in some ways, harder-to-treat and manage family, environmental, and personality issues, and we also may be serving our patients poorly. The bipolar diagnosis needs to be made cautiously and after careful examination. If a "bipolar" child is not responding robustly to "treatment," it is imperative to reconsider the diagnosis."

I applaud Dr. Schwartz for his leadership in what has become a runaway freight train of diagnosing children with bipolar disorder. Indeed, if a child doesn't respond robustly to medication for bipolar disorder, the diagnosis is in question.

In the case of children, there is no prevailing justification to treat children solely with medication. If an acute episode of out of control behavior requires hospitalization, certainly medication should be consider, but so should family counseling, behavior modification and parent training. I can't imagine an adequate differential diagnosis without and assessment of the family and a trial of behavior modification. While the family is assessed, I don't believe the time involved in a hospitalization necessarily provides an adequate trial of behavior modification, nor am I sure the milieu of the hospital unit is a sufficient environmental intervention.

Today, I tripped over an interesting article on assessing suicide potential.

Psychiatric Weekly

America bears witness to 30,000 deaths by suicide per year. Although clinicians have a fairly good grasp of long-term risk factors, possible short term indicators of risk have been largely overlooked. Dr. Jan Fawcett believes that, to make real headway in combating suicide, doctors need to identify patients at acute, not just chronic, risk of suicide and treat their symptoms aggressively.

[...]“We have plenty of clinical associations, and even quite a few social and epidemiological associations, for suicide risk,” Dr. Fawcett says. “However, when it comes to a clinician evaluating an individual patient, things can get difficult. Most of the associations we have predict long-term risk for suicide, but clinicians needs to know what’s going to happen tomorrow. When it comes to predicting acute risk, we’re very deficient.”

Dr. Fawcett’s work has suggested that the standard risk factors taught at medical school—prior suicide attempts, suicidal ideation, hopelessness—while strong predictors of ultimate risk, aren’t of much predictive use in the short term. “What I’ve found,” he says, “is that you often see increased anxiety and agitation and severe insomnia immediately preceding serious suicide attempts.”

Dr. Fawcett’s data suggest that increased anxiety and severe insomnia are effective predictors of short-term suicide risk in 70%–80% of hospitalized patients, although he believes the number is somewhat lower in outpatients.

“Patients at high risk are experiencing, through their anxiety and agitation, what I call ‘psychic pain’,” Dr. Fawcett says. “It’s a type of pain I don’t think anyone understands who hasn’t experienced it, but when that’s paired with hopelessness suicide can be the result.” Screening for this type of anxiety is no simple task, Dr. Fawcett explains. “Anxiety is not uncommon in depression— ≥60% of depressed patients have moderate anxiety. The real warning sign is an increase in symptoms of anxiety, but assessing the severity of anxiety goes against the current habit of classifying symptoms as either present or absent. Clinicians need to ask probing questions regarding the severity of the symptoms, and, also, find out how much of the day is spent experiencing the symptoms.” MORE

Dr. Fawcett is correct. I have found the "psychic pain" he's talking about is an existential stress where one's sense of competence and/or value as a human being has been challenged beyond what the person's self-esteem can tolerate. Thus, a imminently suicidal person believes she is no longer worth the air she breaths, the space she takes on earth, nor can her value to others be seen as no less than an annoyance, and as bad as an intolerable burden. A recent grievous loss, such as an close relationship or a job, combined with a number of other stressors, often triggers the crisis.

I've often wondered about those who are suicidal and treated by SSRI anti-depressants. A few have experienced suicidal crises apparently aggravated by the medication. This has created considerable debate about treating children and adults with SSRIs when suicidal.

As I've said before, anti-depressants AND therapy are often helpful in these crises. However, a suicide watch by family and friends may still be necessary during the crises because of the time it takes for the treatment to work.

Complicating the picture is that SSRIs cause significant side effects when first started. The symptoms are similar, but not necessarily the same as what has been called "SSRI Discontinuation Syndrome". Psychiatric Weekly has another article about this issue.

The antidepressant discontinuation syndrome is manifested by a wide array of symptoms. Onset of symptoms occurs shortly after stopping drug or reducing the dose. Common symptoms include dizziness, anxiety, irritability, panic attacks, mood lability, decreased concentration, and insomnia. Nausea, occasionally associated with vomiting, and other gastrointestinal symptoms are frequent.

[...]By rapidly decreasing the efficiency of the primary inactivating system (serotonin reuptake), SRIs initially can cause nausea, which may be blocked with agents that inhibit serotonin (5-HT)3 receptors.15,16 Adaptation to this SRI side effect occurs during initial weeks of treatment along with other changes in neuronal function. Gradual desensitization of autoreceptors during SRI treatment allows serotonin neurons to recover normal firing rates and to progressively increase 5-HT neuronal transmission, perhaps accounting for the delay in onset of their therapeutic effects.

[...]In prospective controlled trials, paroxetine has been found to have the highest incidence of post-treatment AEs compared with other SRIs. Fluoxetine, by contrast, has the lowest reported incidence of discontinuation symptoms, presumably due to the long elimination half-lives of parent drug and its active metabolite.

My experience has indicated that a few people experience very uncomfortable side effects when starting SSRIs. If they are also suicidal, then the experience of the side effects, sometimes extreme "skin crawling" agitation perhaps similar to the clinical syndrome called "akathesia" may well trigger a suicide attempt.

Suicidal clients who are starting SSRIs need close monitoring.

Nikhil Rao in his blog OK so I’m not really a cowboy has an interesting article about the perils of taking diagnosis too seriously. He makes his point by noting that his tendancies to show schizoid and schizotypal traits is more a function of his chronic pain than a reflection of his personality.

He argues that diagnosis should not be about social acceptability or conformity but should reflect an more meaningful underlying process. In other words, diagnosis should be in part based on widely accepted constructs about internal psychological processes that reflect on etiology and cognitive and neurological function as well as behavior and symptoms.

The problem with schizoid and schizotypal PD I think is shared with anti-social PD. The concepts originated in psycho-dynamic theory representing internal states. The first two have been thought by some to be traits related to schizophrenia. Schizoid PD relates to a preferance for social isolation. Schizotypal PD relates to systematic errors in thought process like ideas of reference and magical thinking that appear to be a simple more common pattern similar to a thought disorder. Anti-social PD is most closely related to criminal attitudes and behavior.

When looking at a group of people in prison, most would have a number of traits suggesting anti-social traits. However, there are many reasons for a person to behave anti-social. Some grow up in families or subcultures that accept criminal behavior. Traditionally, the concept of anti-social comes from the psychopathy. Psychopaths are thought to have no or at least an unconventional conscience. Neurological studies suggest these people have underdeveloped or "immature" brains. The concept of anti-social PD adds so many people to the catagory that it deflects attention away from the causes of criminality towards the behavior itself. The value of concepts is largely rooted in their contribution to understanding. I see anti-social PD as muddying the waters.

The American Psychiatric Association adopted the Diagnostic and Statistical Manual (DSM) as it's diagnositic standard. It has steadily moved diagnosis towards a set of measurable criteria that is necessarily behavioral. Cognitions are not measurable in the traditional scientific sense. By taking us to “measurable”, the DSM de-emphasized the causes and internal processes that created the diagnostic construct. At the same time, the DSM effectively added a significant number of people who would not fit the constructs internal process and etiology. I would argue that many now fit a particular diagnosis that do not belong there.

The risk here is that we forget we are also working with internal states rather than just behavior and symptoms. Diagnosis should have some relationship to theory and methods of treatment. Based on DSM, we treat symptoms and change behavior which may not be addressing the underlying problem that caused the behavior. If diagnostics is taught solely within DSM nosology, we turn out diagnosticians who know little more about how to help someone, not qualified mental health professional who have an in depth understanding of psychology and the art of treatment.

Diagnoses don't reflect real phenomena, they represent conceptual models that are by and large still, in a way, experimental. Theoretically, diagnosis should lead us to treatment methods. While an experienced clinician sees some guidance in the diagnosis, it's still more about art than science. The DSM tries to make diagnosis more scientiific but in the end guts important content and understanding.

Clients often see diagnosis as some sort of magical rite of passage into the mysterious world of mental health treatment. Actually, diagnosis is largely overrated. Many clinicians wouldn't use it routinely in any formal way if insurance companies didn't require a diagnosis for payment.

Diagnosis is helpful for communicating about treatment between professionals. But as a guide that carries any stable meaning over time, it's value is limited. People are much more complex and not amenable to fitting into catagories. And the diagnostic catagories are far from accurate and reliable across different episodes of illness or even between professionals seeing the same client at the same time.

The structure of the DSM IV is based on how a group symptoms suggest a particular diagnosis from research and clinical experience of the participating professionals. Some clinicians have thought of the DSM IV as a recipe for diagnosis that removes much meaning from the practice. Diagnosis reduced to it's most simple terms becomes simplistic, lacking any meaningful information about the development and treatment of the disorder.

But now there is a new Diagnostic Manual available. In the spirit of Sigmund Freud, the American Psychoanalytic Association has written it's own version. This manual is based less on phenomenology and more on theory based on clinical experience dating from current times back to the time of Freud. Will it prove better? Only time will tell.

New York Times

Now, in an effort to provide more of this context, a coalition of organizations representing psychoanalytically oriented therapists has produced a diagnostic manual of its own. Unlike most psychiatrists, psychoanalysts focus their efforts on understanding the meaning and the psychological roots of mental suffering, rather than on diagnosing mental disorders and treating them with drugs or less intensive methods of talk therapy.

The new guidebook, unveiled Saturday at the annual meeting of the American Psychoanalytic Association, is modeled on the standard diagnostic manual in its format and its title, the Psychodynamic Diagnostic Manual. But it emphasizes the importance of individual personality patterns, like masochistic, dependent or depressive types, which are found in many people but which qualify as full-blown disorders only at the extremes.