This month’s Lancet discusses the effectiveness of internet based CBT with a live/real-time therapist showing benefits which last 8 months.

Though unconventional, I am very supportive of this modality of treatment, particularly considering that younger generations are increasingly reliant on the internet to communicate with one another.

“computerised CBT programs, although effective, are inflexible, can be difficult to tailor to individual patient needs, and are associated with low rates of adherence. However, individual CBT can be offered by a therapist online, with instant messaging in which client and therapist communicate in real time with typewritten responses. Possible benefits from this approach include flexibility and optimum use of patient and therapist time, reaching client groups for whom travel to treatment centres is difficult for reasons of geography or disability, and access to foreign language therapists. Some evidence suggests that writing about traumatic events can lead to improvements in health. This approach is acceptable to patients with depression, and therapy without face-to-face contact could encourage greater disclosure.”

This takes ones ED skills of making quick assessments to a new height. Here people receive a few minutes with a psychiatrist or therapist with little or no follow up for a small fee and get their needs met.

I am amazed that it helps some people, but hey who am I to comment on what works for some. I suppose one can look at this as a kind of psychiatric outreach….

I’ve been trying to make sense out of the health care options available to Americans.  Click on this link to watch Dan Roam’s awesome slideshow which breaks the whole mess down into extremely simple digestible parts or view it from here:   Health care slide show

my 2 cents:

-the private insurance industry must either be tightly regulated or have non-profit (cooperative, government) competition, they’re a huge siphon of health care cost (in dollars and MD’s time) and have a conflicting interest in the health of a patient.

-insurance fraud on medicare and medicaid should be investigated and entirely dismantled. the racketeering rings which embezzle millions of American HC dollars yearly would better serve the poor, elderly or disabled whom they originally intend to treat

-tort reform instituted: in my not-yet-2 years of residency I cannot recall the numerous times I heard physicians say… ‘and we have to order xyz’ (to protect ourselves), sad but true…

-electronic medical records which are HIPAA protected and HIGHLY secure.  these records should provide limited information (meds, D/C plan, tests, imaging) to the highest level of health care providers (MD, PA, DNP/DnRP, etc…) FORGET pharmaceutical and insurance companies who will mine info for their profit oriented goals.  this system should trace every single person who logs into the system, what they look at, and hold them accountable (liable) for breaking HIPAA laws.  its ridiculous that medicine is decades behind the technology of the banking and legal professions.  a system like this would benefit larger metropolitan areas where pts may hospital jump, or recieve most of their care at one place but for various reasons receive emergent care at another hospital.  in the case of psychiatry, this can be an invaluable tool:  when pts come into the CPEP they often are not able to provide an accurate history.  Thus to know where a patient gets their care, what kind and their standing meds would be an asset in the goal of creating consistency in care and helping them get back on track.

-control pharmaceutical costs: stop direct to consumer advertising to start, make new medications AFFORDABLE

this whole argument is exhausting to listen to. i have a feeling that it drastic changes are not made we will only be ready as a society to make them when the system hits a critical stage.

Unless you’re that technologically saavy, have your finger on the pulse of subcultre  and happen to be a profound nerd for all things medical…. here are a few videos to entertain your spirit… advice for those not in medicine: dont take this seriously!

Diagnosis Wenkeback

and from the skilled residents across the Park at Mt Sinai: Mo Pages Mo Problems

UAB ER Rap

And if you’re an older nerd: Waking up is Hard to Do

laughter can sometimes be the best medicine

Been away from writing on the blog for a bit, without going into a lot of detail it can be explained with one word: residency

Instead of trying to play catch up with all the changes that have occurred in the past several months, I’ll just jump right into the present. Stay tuned…

Sometime last year I was suprised to learn of the abuse of ‘neuro-enhancing’ drugs in college students via a friend of mine whos daughter is a college freshman.  A recent article in The New Yorker cites that up to 25-35% of  college students used off label prescription stimulants once (in the previous year to the survey).

This 10 page well written article covers many topics, of which safety and ethics interest me the most, but here are a few thoughts I have as a result….

-the article appears positively weighted regarding how stimulants improve cognitive functioning, however why are healthy academically average or above average individuals so troubled by an imperfect memory, is it such a terrible human quality to live with?

-the long term effects of using these medications in this manner is undetermined at this time, people reading this article or considering such a practice must not overlook its tremendous ease in becoming habit forming= a MAJOR problem

-this article bring attention to some people’s concerns (fear?) around characteristics associated with aging, focusing on the ‘negative’ aspects (memory loss) and apparrent attraction to an instant solution (a pill).  Do advocates of youthful charactistics incorporate life style changes (clean diet, gentle exercise, stress management, etc) to support this way of life?

-off label use of medication, particularly if its addictive, seems like something medical experts would be very conservative about. Is the support of stimulant use by some scientists and medical professionals financially influenced?

-I am very curious of the emerging field ‘cosmetic neurology’ mentioned int he article, which utilized medications to ‘enhance’ human functioning

-another curious segment of humanity has emerged:  the subscribers of the “ImmInst”, aka  Immortality Institute forums, where people aggregate to discuss methods for life-extension and the benefits of cognitive enhancers using technology and science.  The ancient quest for immortality is alive.

-people in this article appear more interested in increasing their competitive edge over others (in their class, profession, or in another country) and making deadlines they normally would not be able to achieve without the drug, to what end do we wish to push ourselves? Whats wrong with not being able to do it all?

-one psychiatrist reframed the family’s request for their son’s school performance to be assisted…. and examined their motivations: do they want their son to fit into the world, or do we all want to make this world a better place for everyone live in?

What would you do if your child was in college or preparing for a standardized exam, and 30% of his/her classmates were using neuro-enhancing drugs to improve their scores?

As one person said, “It’s fundamentally a choice you’re making about how you want to experience consciousness”. If one would like to expand or ‘advance’ their consciousness, might I suggest meditation? It has many fewer side effects….

I’ve disappeared for a while due to the demands of my rotations but am back to write some more commentaries on integrative medicine, health and wellness. Its good to be back!

I like to follow NY State Attorney General Andrew Cuomo’s work busting criminal activity, because the stories associated with the crima are at times truly unbelievable.  Lately, hes had a lot of mess to clean up in our Empire State and if you endorse the reduction of white collar crime, hes your guy.  

This week hes all over the 700 member Millionaries club at Merrill Lynch, which reflects a small number of the 39,000 employees who recieved over a Million dollars each in bonuses before they were bought by Bank of America. Merrill distributed $3.9 BILLION in bonuses, even though they were getting 50 Billion in bailout money. 

WFT!

PLEASE, Mr Cuomo, stop the insanity!

 

other great cases of his:

making Aetna repays students…

The Bernie Madoff disaster…

the MTA retirement directly into disability scam…

the list in endless, keep p the good work Mr Attorney General.

This month Psychosomatic Medicine published a very small cross sectional study examining pain perception and the potential analgesic effect of mindful Zen meditation.   Although the study size was small (n=13), the subjects had greater than 1,000 hrs of meditation and discovered some positive effects of Zen meditation.

Results indicated: meditators required nigher temperatures to elicit pain  and reported decreased pain intensity compared to control (reported no change). In meditators, pain modulation corresponded to a slowed respiratory rate.  The article thought the mindfulness-related results may be in part explained by changes in respiratory rates.

The study concluded:

Zen meditators have lower pain sensitivity and experience analgesic effects during mindful states. Results may reflect cognitive/self-regulatory skills related to the concept of mindfulness and/or altered respiratory patterns.

Its a preliminary study which suggests further investigation regarding the application of mindfulness meditation in pain management.

Here’s a nice little article from the NIH on meditating for health purposes with a bibliography.

I would love to see a unified digital health record system, however I’m against the current on line medical record proposal because it doesnt abide by  HIPAA laws (a brief explanation here)   In the mean time to digitize records, i plan on using a scanner, store my docs on my home computer, stick it on a thumb drive and bring it to my doc’s office until we develop a safe national system!

Google apparently is feverishly denying rumors that its interested in selling its (your) medical record info.

Every time I revisit the topic of parasitology since medical school, my stomach turns…. In the UK, they’re exploring the use of ‘bugs’ with various inflammatory conditions like; hay fever, asthma, IBD, Alzheimer’s, atherosclerosis, some forms of depression and cancer… and other conditions like diabetes.

I thought you’d never ask!

Bikram Yoga, commonly called ‘hot yoga’, involves practicing  a routine set of asanas in a 104* F heat.  According to this article, it has risen in popularity and endorses competitions in the UK (and LA next month) with aspirations to enter the Olympics.  I am surprised to read that yoga has a competitive history in India, and wonder what that looks like; who meditates better? has more devotion? selflessness?  or peace?  I am trying to make a point that competitive yoga may detract the student from the essence of its practice.

I understand from this article that the competition primarily judges asana practice (poses), one dimension of yoga’s complex form.  Maybe this would benefit a few, however Americans are so competitive by nature, it might be more fruitful to explore yoga’s softer side which encourages a less ego driven way of life.

Heres a creative approach (explained many times before) about how parents can help their kids build stronger immune systems by exposing them to dirt and then some (or essentially letting them be kids)…  Though it makes sense, its still not popular with the urban parents faithfully armed with antibacterial handwash 24/7. 

It makes you wonder why kids who grow up in farms are less likely to develop allergies and autoimmune diseases…

Integrative Medicine is a ‘relatively’ new movement, research is helping credit/discredit various therapies’ effectiveness.  Andrew Weil is quite popular.  I dont consider him a snake oil sales man though, he has made meaningful contributions developing integrative medicine within the medical community, and has popularized it in the public arena without too much ‘woo’ (with his Aveda line, supplements and home care products).

The ‘alarming trend’ of physicians heading towards integrative medicine (I’ll include all involved, see last bullet) can be interpreted to reflect any one of the following (however not limited to this list):

• CAM is effective in some areas where medicine falls short or as an alternative to allopathic treatment
• CAM improves quality of life
• Patients feel better using CAM it even though it may not change the course of disease (even if its via a placebo effect)
• The medically trained (MD/RN/PA’s), non-medically trained (L.Ac./LMT/MSW) or those with no training (just hung out a shingle) are out to make a buck

I think the latter option is where people tend to jump first without further examination, and subsequently lump practitioners with training and extensive experience, with those who don’t (ie: Weil or Chopra = Trudeau?).

Acupuncture and herbal therapies have existed for thousands of  years  as the primary form of treatment for civilizations.  Why would we ignore them if they can offer us something? And evidence supports it? While I dont believe ‘if its ancient and x peoples used it, so should we’ or think we should treat medical problems based on ‘beliefs’ (see my post when faith healing kills) I think its realistic to look at all therapies as potential resources, and critically ask; what is the best thing to use/do for x health situation? which causes least harm? most benefit? was it studied? what are the results?

Kevin Trudeau should have known better than to tout his product as a cure for cancer after being warned (with a court order no less).  There was no evidence behind it.   He SHOULD have been hammered to the ground.  It looks like hes been on a long road of poor judgment and insight…. his wiki page describes him as “pocket billiards promoter and alternative medicine advocate” (nice combo!), indicates he first got involved in a CAM (nutritional) pyramid scheme while in prison, and outlines briefly his criminal record for the past 18 years!  I dont think its reasonable to lump Trudeau with Weil or Chopra regarding “sham CAM”.

Out of curiosity I did a quick pubmed search on arthritis/inflammatory disease and the use of omega 3 FA.  I came up with a few articles, some of which help shed some light on the MOA behind omega-3’s…  (Its a slow day at the hospital….pardon the type-o’s)

Thanks for the post Shadowfax!