President Obama - An education on Marijuana

Dear President Obama,

As a mother who regrets not attending Woodstock and lived in a day and age where pot was considered cool and chilled out more people than those living in Valley of the Dolls, I am proud to say that I never tried the stuff.  Why?  Though I was a nerd and had my nose in a chemistry book all of the time, the true effects of marijuana on the brain were not extensively researched.  The real reason is that my mother would have killed me and despite my being away from home,  she was sitting on my shoulder, I swear.

Despite pursuing a medical career and using short nose clamps to stop bleeders, I was surprised to see that they actually had another "off hospital grounds" use - to clip to the end of a  joint to assure that the user and sharer would not burn their fingers but, more importantly, get, as Maxwell House would say, enjoy the last drop.  I know this as I had to pass it around a friend's dinner party in the '70's and made sure in reached the end of the row at a Fleetwood Mac rock concert in the '90's.  Mom would have been proud - I passed it along and held my breath.

But now, having a background in radiology, medicine, and psychiatry, I have been exposed to all of the  growing literature that is exposing the dangers of marijuana.  Ever try to talk to a teen about the dangers in smoking marijuana?  Probably the most difficult task facing parents today.  Why?  They will quickly spout off that no one has died of an overdose of marijuana.  And, now, they have you, Mr. Obama, the leader of our country and a role model to many children, teens, and young adults, stating that you do not feel that it is any more harmful than alcohol.  Really?

Now, you are to be well informed on all topics and thank God that you have staff to keep you informed of the political issues affecting us all.  But guess what?  All you have to do is use your fatherly instincts to discuss drugs and alcohol.  Protecting our borders?  How about protecting our nation's youth.  I do not have a committee, a cabinet, an advisor.  I have the heart of a mother that fears another unnecessary death will result in the complacency by parents and adults towards alcohol and drugs.

A search of the literature shows other country's publishing the harms of marijuana.  Hopefully the United States will soon have legitimate candidates to study now that it is becoming legalized.  Let me list a few findings.  I will address the medical benefits of marijuana that are often used as the first line of defense when fighting for legalization of this drug.

MEDICAL BENEFITS OF MARIJUANA:

1)  Anti-emetic or anti-nausea effects:  Early on, THC, the active drug found in marijuana, had been shown to be effective for some patients who suffered nausea from cancer chemotherapy treatment.  However, the narrow window between the anti-nausea dose and that which caused unwanted psychic effects made THC difficult to use.  In some studies negative side effects occurred in 81% of patients.  In another study, 22% reported no effect of nausea symptoms.  The advent of serotonin 5-HT3 receptor antagonists (told you I was a nerd) demonstrated a more powerful anti-emetic effect.  For this reason, physicians virtually NEVER prescribe THC for use by chemotherapy patients as the new drugs are more powerful and have no psychic side effects. 

2) Multiple Sclerosis:  Although some studies have shown that cannabis can relieve muscle pain and spasticity in patients and also relieve tremors in animal studies, in can also further impair posture  and balance.  Please understand that THC receptors are found in those areas of the brain that control posture and balance and memory.  In addition, MS patients who use marijuana had a greater number of psychiatric diagnoses and a slower mean performance time on standard neurological tests.  And in some trials, an increase in aggressive behavior and paranoid tendencies were demonstrated in standard psychological tests.  Overall, without boring the reader any further with studies and trials, a minority of MS patients can receive some symptom relief through the use of marijuana extracts or THC, but a significant percentage of patients suffer unwanted adverse effects.

3) Glaucoma:  THC has been shown to reduce the intraocular pressure in humans who have glaucoma.  But the pressure was reduced only when the patient stayed under the effects of THC almost continually.  More effective medications such as prostaglandins have been developed to control the intro ocular pressure.  Now if one wants to be continuously high and suffer unwanted side effects, it is their choice.  but there are better and more effective treatment options.

4) Appetite control:  We are all aware of the "munchies" affecting marijuana use.  And laboratory studies do support the fact that THC does increase the appetite which may not be a good thing for most of us as poor food choices are made under the influence.  With the First Lady munching on an apple with NBA stars, the negative effects that marijuana has on our youth and teens is certainly something the couple should be on the same page with. However, those individuals suffering from debilitating diseases  such as AIDS-related wasting syndrome do benefit from the use of marijuana as THC has been able to maintain their weight.

5) Brain Effects:

Because I started my career with a residency in Radiology I will show this MRI coronal view of the brain.  The loss of brain matter is highlighted in the cannabis user with increased cerebral spinal fluid and loss of brain matter..  After all, pressure has to be maintained and when the brain loses neurons it is replaced with spinal fluid, thus the decreased gray matter and increased fluid showing as black.  The pink is our precious amygdala, responsible for important functions such as memory and emotions.  To me a picture speaks a thousand words.  Enough said.

6) Psychiatric illness:  A recent study found that marijuana use significantly increased the risk of developing mental health problems among those young people who possessed a genetic high risk for schizophrenia.  And if there is a family history of substance abuse, a young person is much more likely to develop an addiction to any substance.  There is also a strong correlation between development of depression and bipolar disorder.  Remember the picture above?  You can destroy your amygdala all by your lonesome without a family history.  You know the sad thing, so many mask symptoms of depression, bipolar, paranoia, voices, increased stressors, and the will to escape and chill out with marijuana.  And my attempts to teach these teens in school auditoriums have been met with laughter and disrespect.  Where will this culture that has developed with marijuana use begin to detach itself from the "utopia" they have associated with this drug?  One student had approached me after a lecture - one in which I threw out students in the class laughing and rolling their eyes at me.  She stated that she was 4 days clean and didn't miss the drug so much as she did the way of life it offered her.  This is not a chill out pill, folks, but strong ties develop and makes this particular drug with its "no one has died boasts" a major battle for parents such as myself.   Gee, thanks, Mr. Obama.

And now for the most important reason why parents should fight the battle!!

7) Gateway Hypothesis:  I saved the most difficult topic for last.  My son, Andy, who died at the age of 19 on 1/16/2004, would argue with me that it was not a gateway drug.  He also had no respect for me.  Although I had taught Drug and Alcohol Abuse and Dependence to med students rotating in Psychiatry at Case Western Reserve Med School, he saw me as a mother who never used and ignored the facts, claiming that it was "safe" and that maybe I needed a joint to "chill out".  But there is a tendency for marijuana users to go on to use other addictive drugs.  Whether it is a predisposition or just more easily available when traveling in a circle of drug using friends is not completely known.  However, studies have shown that 311 pairs of same sex twins with earlier marijuana use (before the age of 17 years) were 2-5 more likely to use illicit drugs.  Unfortunately, these young, beautiful individuals have no idea whether it will be their gateway drug.  It was my Andy's.

So Mr. Obama.  I wanted to inform you that I am angry with you.  You may send your Secret Service to my door, you may decided to audit me, some people will accuse me of taking issue with you because I am a "racist", or, the sad conclusion, I am a person who is uncool and should learn to keep her mouth shut and reach for my surgical clamp.

As a mother who has lost a son and knows that marijuana AND alcohol are dangerous, I will fight you tooth and nail on this topic until I am convinced that you have decided to reconsider your position, not as a previous marijuana smoker and using your own experience, but as a father who wants to protect his daughters and set a better example, not only to them but to the youth of our nation.

To the presidential assistant previewing this notice:  Please consider passing it along to your boss.

Sincerely,  Dr. Elaine Campbell

Mental Health Awareness Week - Suicide

Life has it's ups and downs and I, for one, have had plenty of roller coaster rides. I confessed that I had suffered from depression in the past. I will also be honest about today's topic. I am one of the 24% of individuals who have considered it as a means of ending some extreme emotional pain. And as you are aware from my previous posts, Baby Boomers are more successful than any other generation at attempts and completion. So, let's discuss suicide.

I can throw out all sorts of statistics to you. Over 34,000 people die of suicide a year - translating to one person dying every 15 minutes. Although women are more likely to try, men are more successful because of the more violent means they choose - firearms or hanging. 90% of adults and 60% of adolescents who commit suicide have a diagnosed mental illness, especially depression or substance abuse. And, sadly, 70% of older individuals visited their PCP within the month of their suicide.

The above statistics are important as it underscores this very important consideration - that suicide might be preventable.

Again, I always consider the Biopsychosocial characteristics of an individual when considering signs of suicide as well as risks of suicide. And why? Because there is no poster person that represents the face of suicide. Although statistics are an important consideration, it is the individual we are truly analyzing.

The following are WARNING SIGNS listed by a Suicide Prevention Program called Yellow Ribbon. Please visit them at www.yellowribbon.org:

WARNING SIGNS

Abrupt changes in personality
Giving away possessions
Previous suicide attempt
Use of drugs and/or alcohol
Change in eating pattern - significant weight change
Change in sleeping pattern - insomnia/oversleeping
Unwillingness or inability to communicate
Depression
Extreme or extended boredom
Accident prone (carelessness)
Unusual sadness, discouragement and loneliness.
Talk of wanting to die
Neglect of academic work and/or personal appearance
Family disruptions - divorce, trauma, losing loved one.
Running away from home or truancy from school.
Rebelliousness - reckless behavior.
Withdrawal from people/activities they love.
Confusion - Inability to concentrate
Chronic Pain, Panic or Anxiety
Perfectionism
Restlessness

Many of the above warning signs refer to the biological and psychological factors I discussed in previous posts. Yellow Ribbon also emphasizes the need to consider the RISK FACTORS. Many of those listed here refer to the sociological factors. Coupling the two gives a clearer suicidal risk. I agree completely.

RISK FACTORS

Problems with school or the law
Breakup of a romance
Unexpected pregnancy
A stressful family life. (having parents
who are depressed or are substance
abusers, or a family history of suicide
Loss of security...fear of authority, peers,
group or gang members
Stress due to new situations; college
or relocating to a new community
Failing in school or failing to pass
an important test
A serious illness or injury to oneself
Seriously injuring another person or
causing another person's death
(example: automobile accident)
Major loss...of a loved one,
a home, divorce in the family,
a trauma, a relationship

Yellow Ribbon stresses the following:
Suicide victims are not trying to end their life - they are trying to end the pain!

How can we help?
First of all, don't be afraid to be direct. Talk openly and matter-of-factly about suicide.
You have to be willing to listen. Allow the person to express their feelings.
Do not be judgmental. Don't debate whether suicide is right or wrong, or feelings are good or bad. Don't lecture on the value of life.
Don't be afraid to get involved, to be available, to show interest and support
Don't act shocked. You want to maintain their trust in you,
Don't be sworn to secrecy.
Offer hope that alternatives are available but do not offer glib reassurance.
Ask if they have a plan. Take action. Remove any means, such as guns or stockpiled pills.
Get help from persons or agencies specializing in crisis intervention and suicide prevention.

If you are experiencing thoughts of suicide, or have even developed a plan or have the intent, please contact someone you know, visit the closest ER or call the number listed below.

If you are worried about someone and see some warning signs and/or identify risks, please consider getting involved.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week.

When I lost my son, Andy, at age 19, to an accidental drug overdose, I started a foundation modeled after Jason's Foundation which is dedicated to the silent epidemic of teen suicide. Please visit www.jasonfoundation.com if you are concerned about our younger generation.

I wish you all brighter days and good mental health. Peace, Dr. Elaine

Mental Health Awareness Week - Depression Treatment and Options

HEALTH AND WELLNESS -Depression - Part 2 - Treatment options

As I promised, I wanted to devote four of my postings to depression. Today's topic is dedicated to treatment options.

I suspect that the growing percentage of suicide attempts in baby boomers may be influenced by the increasing amount of stressors facing our generation and the reluctance to seek treatment for depressive symptoms. Of course medication cannot magically remove the threat of foreclosure or stop a partner from their emotional or physical abuse. But there is hope for those suffering from the symptoms of depression and we will discuss a number of possible treatments in today's article.

Have you ever heard of the term BIOPSYCHOSOCIAL? It is a combination of the words biological, psychological and sociological. And it is these important aspects of our lives that should be taken into consideration when treating depression.

Biological concerns address not only family history of mental illness, medical illnesses that could contribute to depression, but also to substance abuse problems. This information can contribute to treatment recommendations that might include follow up for current medical symptoms and referrals to substance abuse programs.

Psychological considerations are paramount in considering treatment options. How do you cope with sadness, with stressors, with unexpected changes in your workplace or daily routine? Are you one to "cry over spilled milk" or do you pride yourself in making "lemonade from lemons"? Our defense mechanisms come to play when things go wrong emotionally. I have clients who claim that "this too shall pass" and never need any significant interventions. Others may collapse on my desk with the same mild symptoms, demanding that I find immediate relief. No two individuals experience similar episodes in exactly the same way. Some turn to substances to self-medicate or stop taking medication the minute they experience a side effect that might be transitory or if relief of symptoms does not come within a short period of time. They can perceive their situation quite differently which effects the way they feel and, ultimately, the way they behave.

Social concerns have more recently been at the core of my clients depression. Job losses and financial concerns, foreclosures, broken marriages that occur after years of celebrating anniversaries are just a few of my client's stressors. In addition, a strong support system is an essential element of the care plan. Are family members invested in the welfare of this person? Does the client live alone? Are there caring neighbors? Do they have a spiritual base and is a church family present?

All of the above considerations need to be a part of the initial assessment. Will the client need medication only? If a family member has a history of depression as well, did they respond to a certain medication? Are other medical problems under control or contributing to the situation? Are the client's defense mechanisms inadequate to deal with their current situation? Would a referral to a counselor such as a social worker or psychologist be necessary at this time? Is a case manager needed to address the financial situation, living arrangements or unexplored entitlements that the clients may desperately require?

Without team management, my task is made more difficult because medication alone may not solve the problem. However, I am a psychiatrist and it is my function to treat the symptoms with medication and to refer to the wonderful social workers, psychologists and case managers if needed. God Bless them all. I feel that these important individuals are so overworked and underpaid. They are truly devoted caretakers. And I am proud to claim that my daughter, Molly, is one of those dedicated LISW's.

Now about medication. For client's presenting with mild symptoms, medication may not be necessary. If the symptoms are more moderate or severe, and I am referring to the number of symptoms that they are experiencing, then medication is advised. If the patient has physiological complications, with poor sleep, loss of weight, dramatic change in functioning, or suicidal thoughts, plan or intent, then hospitalization is usually recommended at that time.

The selection of medication depends on the symptoms that are described by the client. And certain neurotransmitters in our brain are utilized to help target and relieve symptoms. I am referring to serotonin, norepinephrine, and dopamine.

If anxiety, obsessive compulsive traits, or ruminations are present(those thoughts that show up at bedtime or tend to act like a broken record), then my first choice is a serotonin agent. They are classified as SSRI's or Selected Serotonin Reuptake Inhibitors (lexapro, zoloft, celexa, paxil, prozac, luvox) and can be very efficacious in targeting symptoms that include anxiety, ruminations, guilty conscious, and obsessive compulsive traits that predominate one's depression. Concerns that often leads to non-compliance are side effects - transient stomach or abdominal discomfort, headache, or more importantly, sexual dysfunction, specifically the inability to experience an orgasm. This needs to be discussed with patients prior to treatment.

Medications that include both serotonin and norepinephine also supply benefit for concentration and anxiety. If focus is a problem, often times a combined drug can offer benefits. SNRI's (Serotonin Norepinephrine Reuptake Inhibitors) include effexor, pristiq, cymbalta, and remeron. Remeron is benefical if the client is unable to sleep as it has sedative properties and causes no sexual side effects. Cymbalta is used in clients that have some of the physiological symptoms of depression. Effexor and pristiq provide not only serotonin and norepinephrine, but some affinity for dopamine which is addressed below.

Dopamine, to me, is the "feel better" neurotransmitter, providing energy, motivation and concentration. If the symptoms are more consistent with a "couch potato", or a withdrawn nature, than a dopamine agent like wellbutrin may be indicated. Although it also has no sexual side effects, it is limited in client's who have no history of seizure disorder or eating disorders.

Education is an important aspect of the initial assessment. Medication needs to be taken consistently and the client needs to be aware that responses to medication may require at least 2 to 3 weeks. Any concerns regarding side effects or thoughts of discontinuation of the medication need to be discussed with the doctor. Follow-up appointments are critical in determining the response to the medication, whether dosage needs to be adjusted or whether other agents need to be considered for adjunctive benefits.

There it is - my philosophy of medication management in a nutshell (actually "blogshell").

In summary, discuss your full spectrum of symptoms with your doctor so that the right medication can be prescribed. Do not leave the office without a full understanding of the side effects and benefits of the medication. Do not change your dosage or stop treatment unless discussing this with your physician first Should suicidal thoughts develop during the inital part of the treatment (often seen in children, adolescents, and young adults), notify your doctor immediately or present to the Emergency Room for a risk assessment.

Tomorrow I will discuss the topic of suicide.

Mental Health Awareness Week

Did you know that it was Mental Health Awareness Week?  I am embarrassed to say that I was more observant of Reverend Martin Luther King and focusing on his dream - Judging one for the content of their character and not the color of their skin.

However, people who suffer from depression, anxiety, mood swings, substance abuse and other mental health issues are indeed judged quite harshly.  The stigma remains and those people standing in judgement are unaware that this is not a character flaw.

I received a very touching Facebook feed from a friend.  Here is what she wrote:
"Depression, anxiety and panic attacks are not a sign of weakness.  They are signs of trying to stay strong for too long.  Did you know that 1 in 3 of us go through this in our lifetime?  It's Mental Health Awareness Week.  Share the support.  Let those who struggle know that they are not alone….."

As a tribute to my dear friend I am resurrecting some information on some mental health issues.  This long, cold winter and lonely holidays can increase the likelihood of depression.  Here is part 1 of a 4 part series I published in 2010 regarding depression.  You can pull-up all 4 parts as well as read other important topics related to mental health issues on the blogsite.

Please be kind to those that suffer.  Carry an extra blanket in your car for the Homeless.

HEALTH AND WELLNESS -Depression - Part 1

What is depression? If you were to ask your friends or family, or be brave enough to conduct a survey of passing strangers on a street corner, I guarantee you would get a variety of different responses. That is because depression has become an umbrella term used by many individuals to describe a number of different moods ranging from "the blues" to a severe, debilitating state where nothing but suicide could end their pain. There is quite a gap between these two ends of the spectrum. So, let's begin by defining depression more clearly.

First of all, I am very grateful to have a person who is feeling "depressed" actually sitting in my office. Most of my patients who are depressed may be referred by their primary care provider (and may not follow through). Some are brought by a family member or friend, not necessarily willing to provide details to a complete stranger. Very few individuals come on their on volition. So, when I am given this opportunity, I better be able to diagnose my client correctly.

As a psychiatrist, I rely on specific criteria to diagnosis an individual with a major depressive episode. The interview is critical in gathering the objective data. I rely on an acronym to obtain the necessary information - SIGECAPSS. This represents the following symptoms: (S) Sadness or depression; (I) lack of interest or anhedonia; (G) guilt, poor self-esteem, worthlessness; (E) loss of energy; (C) poor concentration; (A) changes in appetite, either increased or decreased; (P) psychomotor retardation or agitation - most likely observed by others ("All you do is sit around" or "You seem more edgy than usual"); (S) changes in sleep pattern, either increased or decreased; and, most importantly, (S) suicidal thoughts, plans, or intent. The DSM-IV manual (the psychiatrist's bible for establishing diagnoses) requires that at least five (or more) of the above symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) (S) depressed mood or (2) (I) loss of interest or pleasure. If the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning such as family relationships then it becomes a major depressive disorder. I have also been required to rule out any medical condition that could contribute to depression (e.g. hypothyroidism), any concurrent use of alcohol or drugs that can influence or mimic some of the above symptoms, or bereavement symptoms that have not become more debilitating after a two month interval. I am not at all dismissing the depression that can be attributed to other general medical conditions, substance abuse, or pathological bereavement. These individuals are just diagnosed under a different terminologies. In addition, individuals with other mental illness, including bipolar disorder, schizoaffective disorder, or adjustment disorder with depressed mood can also experience the same symptoms. It is beyond the intention of this posting to address these other conditions but will be discussed at another time.

When I wrote above that I am "grateful" to be able to assess a person face to face, I truly meant this. Depression is treatable. Statistics claim that women are twice as likely to develop depression than are men. Based on the gender of my clients, I suspect that this statistic is true. However, men are also less likely to admit that they might be suffering from depression. Considering the other statistic that woman are more likely to attempt suicide but that men are more successful, I am concerned that this younger segment of my generation (the 46 to 54 year olds) are experiencing more stressors.

PLEASE!!!!! Even if you are feeling "a little blue", or if a friend, a colleague, a family member gives you some feedback about a change in your behavior, promise me that you will at least talk to your primary care physician. If you do not have one, turn your insurance card over and call the number for behavior health services for a referral. If you do not have insurance, there are community mental health services in your county that can offer you services. MOST IMPORTANT - if you have thoughts of suicide, please go to the nearest Emergency Room for an evaluation. Please promise me that. I may not know you or the extent of your grief or your stressors. But I do know that everyone on this earth is precious. Life is precious. Please have faith and know that you are loved.

With Blessing and Peace to all, Dr. Elaine