Computer problems

I am having computer problems again. I will be back posting on this blog as soon as I can.

Cottonwood Staff Family Program

We not only have a great clinical staff at Cottonwood but a very great support staff as well. I would like to introduce you to Lindey Alaestante, our Family Program Coordinator

Hello, I’m Lindsey Alaestante and I have been working at Cottonwood just a little over two years now. I began working here as a Mental Health Technician on the Adolescent Unit and in time moved on to our Marketing Department and am now Cottonwood’s Family Program Coordinator. One of the things I have really valued is that even in my short time here I have had the opportunity to experience so many different aspects of the treatment Cottonwood provides. I have had opportunities that range from working with patients at Cottonwood to professionals out in the community and now with the family members of our patients here. Each experience has been exciting and rewarding. I have valued each opportunity for different reasons and have learned so much in this short time.

Some of my most memorable times here have been spent with the girls of the Sweetwater unit. I have seen so many patients come in and be transformed in their short time here and it was so amazing to be a part of this. On the unit I accompanied many of the girls through their family week and I would see the changes occur in the family and the healing begin to take place. I miss working with our patients on a daily basis but after experiencing the family program and seeing firsthand the impact it can make on the entire family I am so thankful to be a small part of this process. Many of the families I encounter are anxious about coming for the program and don’t know what to expect and I have the opportunity to get to know them a little bit and make them more comfortable with coming out for our family week. I can assure family members with great confidence what an amazing experience they will have here because I have faith in the staff who are always hard working and extremely dedicated. Being a part of this team is by far the most rewarding part of working at Cottonwood.

Trauma Neglect Abuse Corticotrophin Releasing Factor

Mental health care providers have long known that there is a relationship between early life abuse or neglect and the later development of adult psychiatric problems. We have known it is related to the stress response system but the the mechanisms of how this happens had not previously been shown. A presentation given at the annual meeting of the American Psychiatric Association sheds a bit more light on this issue.

Early life trauma and/or neglect is associated with higher levels of corticotrophin releasing factor (CRF) which sets the stage for sensitizing the nervous system. CRF is secreted both by the amygdala as well as the hypothalamus. The amygdala is a structure that exists in each temporal lobe and is the main center in our brain where fear responses are organized. Stress induces hyperexitability in the amygdala and leads to greater release of CRF. The hypothalamus is a structure in the middle of the brain that regulates hormone activity as well as basic functions such as the sleep -wake cycle, heart rate and temperature. Secretion of CRF causes the pituitary gland to increase secretion of aderenocorticotropic hormone (ACTH) which in turn causes the adrenal glands to secrete more cortisol which is the main stress hormone in our body. Normally cortisol will then enter the brain causing inhibition of CRF which leads to the ending of the stress response. This is called a negative feedback cycle. In people who have been exposed to early life trauma and neglect however this feedback inhibition fails to work leading to persistent high levels of CRF secretion and the continuation on an ongoing basis of the stress response. Because of the high levels of CRF the CRF receptors downregulate causing the brain to secrete even more CRF.

The knowledge of the central role of corticotrophin releasing factor leads to exciting possibilities of not only treatment but possible ways to reduce the potential of adult psychiatric problems in individuals who have been exposed to early life trauma and neglect.

Thought for the day

An act of kindness causes a ripple effect of which we can never be fully aware.

Prostate Cancer PSA Screening American Urological Association Guidelines

New guidelines for screening for prostate cancer are being presented today at the annual meeting of the American Urological Association. The guidelines have recommendations that make sense and take into account new data from two recent research studies. and for the first time give concrete suggestions in regard to the use of the PSA or prostate specific antigen for screening.

The problem has been that no one has been very clear as to who or who not should be screened. Prostate cancer is the second leading cause of cancer death in men in the United States with approximately 186,00 new cases oer year and 28,000 deaths. But in many cases prostate cancer is indolent or slow growing and may not create significant clinical problems for some men. There have been no markers or screening tests that have been able to determine which men are at risk of dying of the disease and which men aren't. The test used is a blood measurement of the PSA or prostate specific antigen which is expressed by cancer cells but can also be elevated for other reasons. The concern has been that excessive use of this test may result in unnecessary biopsies and unnecessary treatment. Researchers are studying other potential markers for the disease but for now the PSA is all we have. Not screening anyone is tantamount to just giving up at this time and reconciling to the fact that many men are simply going to die of the disease. So no one has really known what to suggest to me regarding screening for prostate cancer.

A PSA level of over 4 nanograms per milliliter has been used as a cutoff value for determining who should get a biopsy. One recent study involving 1,200 men however have shown that men whose initial PSA screening was 1 or less by age 60 have very little likelihood of dying of the disease (less than 1%). A second larger study involving 29,000 men showed that men whose initial screening by age 60 noted PSA values of 1 or 2 or less were at very low risk of developing aggressive disease. So the new recommendations of the American Urological Association are that men be screened at age 40 (the previous recommendation was 50 but many men die of prostate cancer before age 50) and that those whose PSA values are in the top fourth of normal be followed more closely and that those with very low normal PSA values do not need to be screened regularly but only every 5 years or so.

It seems to me these new guidelines strike a good balance between not screening at all and over testing.

Thought for the day

"These three remain, faith, hope, and love but the greatest of these is love".

St. Paul

Morning After Pill, Plan B, FDA. Age restrictions

Before I get into today's post I want to be clear that my opinions here do not represent the opinions of Cottonwood nor Cottonwood policies but are simply my own opinions.

Recently US District Judge Edward Korman ordered the FDA to lift age restrictions limiting the over the counter sales of "Plan B" to women 18 years of age and older. "Plan B" is often referred to as the morning after pill and can be taken within 72 hours after unprotected sex to reduce chances of unwanted pregnancies. Under this order the morning after pill can be available to 17 year olds over the counter as soon as the manufacturer submits a request to the FDA. "Plan B" has been controversial and politics continues to play a big role in the debate.

What people do not understand is that there are two issues here. One is the issue of the morning after pill as a mechanism of abortion and the other issue is that of parental vs. adolescent rights when it comes to the issue of health care matters regarding sexual behavior. By not separating these issues the debate has remained too polarized for reasonable discussion. Those who are pro life have not wanted the availability of an abortion method and those who are pro abortion do not want there to be any restrictions on a woman's rights. The thing that people don't realize though is that the morning after pill is not a method of abortion.. It is high dose hormones that prevent ovulation and decreases the likelihood of fertilization. This is the same mechanism of action as the the common birth control pill. With both of these methods there is the possibility that there will be a fertilized ovum which is prevented from implantation in the uterine wall but this is a low possibility with either one. It is totally inconsistent to be OK with the routine birth control pill and not OK with "Plan B". The Catholic Church is at least consistent on this issue.

By recognizing that the morning after pill works by the same mechanism of action as the birth control pill the debate can shift from one of abortion to the important social issue here of parental vs adolescent rights regarding sexual health care matters. To view the morning after pill as a mechanism of abortion is scientifically wrong and in my opinion simply polarizes and clouds the debate.

Thought for the day

The views expressed here do not reflect the opinions of Cottonwood but are simply my own thoughts.

Depakote, Pregnancy, Epilepsy, Bipolar Disorder. IQ

I read the other day that there has been shown to be a link between use of Depakote in pregnancy and lower IQ in the offspring of those who were on the medication. This has been suspected for some time but now has been demonstrated. Depakote has other risks and this is just one more.

Depakote is an anticonvulsant medication used to treat seizure disorders. It also was the third medication after Lithium and Tegretol to be approved by the FDA to treat bipolar disorder and for years has been one of the mainstay treatments for this disorder. Depakote is a good example of the difficulty with medication treatment for bipolar disorder in that it carries significant side effects and health risks. One problem in treating bipolar disorder is that there are four tasks; treating mania, treating depression, preventing further mania, and preventing further depression. There is no one medication good for all treatment goals and most people with bipolar disorder will end up on a combination of medication to cover all phases of treatment. This of course increases potential side effects and risks.

Depakote is a very effective antimanic agent. It also seems to do well in reducing risk of further mania, but is not a good antidepressant and may do nothing to prevent bipolar depressed episodes. It can cause side effects of sedation, significant weight gain and occasional hair loss. It is potentially toxic to the liver and liver function tests need to be monitored regularly. In addition for women there can be changes in the menstrual cycle as well as development of polycystic ovary disease. Depakote has long been known to be related to a variety of birth defects and has been avoided in pregnant women and those of childbearing age who might become pregnant. So lowered IQ in offspring is one more issue to add to the list. Unfortunately there are some women whose epilepsy can be controlled by no other anticonvuslant and there are women with bipolar disorder who cannot be stabilized enough to live in the community without Depakote.

I am writing this mostly to help people understand that treatment of bipolar disorder can be very difficult and fraught with risks. I hope that newer and better treatments will continue to be developed.

Thought for the day

Medications are neither good nor bad in themselves but every treatment carries potential risks as well as benefits.

Behavioral Health Technicians Immediate Openings Available!

Cottonwood de Tucson has immediate openings available for Behavioral Health Technicians. Full-time, Part-time and As-needed on All Shifts. The most qualified candidates are those with a Bachelor's degree. In lieu of a degree, a combination of education and recent work experience working with chemical dependency and/or a behavioral health care environment will be considered.

Our Behavioral Health Technicians enjoy highly competitive hourly rates, shift differentials and flexible schedules and the ability to learn and grow in our supportive and caring environment.

Individuals interested in joining our team should submit their resume or application to:

Human Resources Director
Cottonwood de Tucson, Inc.
4110 W. Sweetwater Drive
Tucson, AZ 85745
Fax: (520) 743-2133
E-Mail: bcox@cottonwoodrecovery.com

Prostate Cancer, Provenge, Therapeutic Vaccine, Dendreon Corporation

I read yesterday that Dendreon Corporation had announced initial findings of a second study that was completed evaluating the effectiveness of a vaccine for treatment of advanced prostate cancer. This is big news as there have not been very effective treatments for cancer that has spread outside of the prostate capsule. As I have mentioned before prostate cancer is the second leading cause of cancer death in men with 186,000 new cases per year in the United States and 28,000 deaths. There is no effective chemotherapy. Radiation treatment is only helpful for localized spread and hormone treatment for metastatic disease is not that good, so anything that might be helpful is good news.

Dendreon Corporation is trying to get FDA approval for Provenge cancer vaccine. It would be the first cancer vaccine on the market. It does not prevent disease but is a "therapeutic" vaccine that trains the immune system to fight tumors. Provenge is made from the patient's own immune blood cells that are mixed with a protein found on most prostate cancer cells and is given back to the patient in 3 separate infusions given 2 weeks apart. These "trained" immune cells then fight the cancer cells.

The company did not release the details of the Provenge study nor side effects which will be presented at an American Urological Association conference later this year. The study involved 512 men with cancer that had spread outside the prostate and was no longer responding to hormone treatment. It was found that the drug does not slow the progression of the disease but does increase survival time by 4 1/2 months or longer. While this as an average doesn't seem that much, in practical terms three year survival rates were 34% vs. 11% without treatment. For prostate cancer treatment those are big numbers. I am interested to see the full report when it becomes available.

Thought for the day

"Cast all your anxieties on Him because He cares for you"

St. Peter

Cottonwood Staff, Primary Counselor

Here is another great Cottonwood staff member, Peter Biava IV, MC, LPC

It's a pleasure to introduce myself on behalf of the primary counselors here at Cottonwood de Tucson. I am Peter Biava and this last December I celebrated my tenth year here as a counselor. I've worked as an adolescent, young adult and adult primary counselor as well as facilitated family program both here and in London. I also worked in marketing for a year. The most remarkable thing about the treatment here is the people. Talented, friendly, professional caring individuals that work together to make an impact on those in treatment and on each other. We all strive to make an impact on the lives of our patients so that they leave both supported and challenged to live a life of recovery. As the son of a social worker and a public school music teacher I was taught to be compassionate and creative in building strong relationships so that I could have an impact on the world. Cottonwood is a place that helps me to live those values as well as many others.

I've been humbled by the strength and courage that the patients access while in treatment and after they leave to face the same world but as a transformed individuals. To me growth and recovery is about facing your pain and fears and building the strength to live your life in accordance with your vision and purpose. So many patients and staff challenge themselves each day to do this with amazing results. I know for myself I have grown as a person and counselor by being here and experiencing the support and challenge of the treatment we do. One of the big lessons I'd like to share is about finding answers. So many of us try to find answers for our challenges in all the wrong places; drugs, alcohol, compulsive habits and hurtful relationships to name a few. I know for myself that I've thought almost certainly where or in what form the answer for a problem would be, only to realize later that the answer was somewhere else, thus learning that "you have to find the answer where it lies, not where you want it to be". This simple admission has saved me lots of struggle in the wrong direction and opened me up to possibilities I didn't consider.

"May Love and Courage guide you."

Depression, Recovery, part6

This post is the last in a series on depression. I want briefly to discuss bipolar disorder and how it differs from non bipolar depression. Bipolar disorder used to be called manic depressive illness. It is a modd disorder that affects 1-2% of the population and equally affects both men and women. It is a highly genetically influenced disorder and tends to run in families as well as sharing some links with migraine with aura. It is characterized by episodes of "highs" as well as depressed periods.

The bipolar highs can be euphoric but usually are not pleasant for the person with bioplar disorder but are characterized by frantic activity, racing thoughts, dosorganized behavior, loud, intrusive and at times obnoxious behavior, unrealistic highly inflated sense of one's abilities talents and greatness accompanied by rapid mood shifts with prominent agitation, irritability and at times hostile or aggressive behavior. The person in a manic state usually has remarably impaired judgment and is unable to see the behavior as abnormal or problematic and often will engage in reckless behavior or make very poor decisions. At times in severe cases there can be a loss of reality testing and the appearance of hallucinations or frank delusions.

Manic episodes can be dramatic but are treatable and the long term disability from this disorder is predominately due to the depressed periods which can become chronic and unremitting. Bipolar depression does not respond well to typical antidepressant medications and antidepressants can induce an episode of mania as well as lead to increased mood cycling. There are a number of mood stabilizing medications which are helpful but most of these are more effective for the manic phases of the illness Usually it requires a combination of medications to acheive longterm stability and medications are required life long.

A good resource for more information about depression and bipolar disorder an be found at www.dbsalliance.org which is the we site for the Depressiona and Bipolar Support Alliance.

Thought for the day

"A power greater than ourselves can restore us to sanity"

AA

Depression, Recovery, part 5

This is part 5 on my series on depression. Today I want to cover the question How is depression treated?

There are four aspects to the treatment of depression. The first is removing or modifying contributing factors. An example of this would be to stop alcohol use. A second step is cognitive-behavioral therapy which focuses on unhealthy thought patterns that contribute to the depressed state. A third aspect is the use of antidepressant medications. These are not needed in every case of depression but can be very useful, particularly in those forms of more severe depression. Fourthly we need lifestyle maintenance which includes adequate sleep, stress reduction, exercise, good diet, smoking cessation, support group, and spirituality.

What are antidepressant medications and how do they work? Antidepressant medication can be an important part of the treatment of depression just as blood pressure lowering and cholesterol lowering medications are important in the treatment of heart disease. Antidepressants are not "happy pills". They are not addicting. They work by affecting the way brain cells communicate by affecting certain chemical transmitter systems such as serotonin, norepinephrine, and dopamine which in turn changes the production of various proteins in the emotional regions of the brain. These changes take place over several weeks and usually the depression does not improve until the antidepressant medication has been taken for 2-3 weeks, though some people begin to respond more quickly.

I will finish up this series on depression next week discussing bipolar depression. Please comment if you find these rather didactic posts useful or not so I will know if I should do more in the future. Thanks!

Thought for the day

I really would like your comments.

Depression, Recovery part 4

I will continue this series on depression moving on to a few common questions.

Is there any test for depression? There is no medical test currently available to assist in the diagnosis of depression. Laboratory blood work is usually obtained to help assess for other medical conditions that may be contributing to depression or that may affect treatment.

What causes depression? There have been a variety of possible explanations that have been examined over the years. Ancient Greek physicians believed that depression was caused by abnormalities in what they called 'black bile". Although our understanding of physiology has advanced the idea that depression involves some abnormality in the body is an old idea. One psychological explanation has been that depression is anger that is "turned inward" and directed against the self. Another is the idea of learned helplessness. This is the recognition that we like all mammals will respond to stress which we are unable to change with a tendency to become helpless and give up. There is also the chemical idea that there is an imbalance of neurotransmitters which need to be corrected.

While all of these probably have some truth to them they are over simplistic and do not take into account that there are a variety of factors that may contribute to depression. One way to see depression is as a stress-vulnerability condition. This means that there are varying degrees of vulnerability to depression that each one of us has and that many different stresses may contribute to the development of depression. These factors include genetic predisposition, ongoing abuse of alcohol or drugs, history of early life trauma, chronic relationship stress, chronic pain, hormonal influences, medical illnesses, diet and exercise, and negative thinking patterns. Recognizing this is important for treatment as we want to address as many of these factors as possible and treat not just symptoms but also raise one's resiliency to development of depression in the future.

I will address treatment in my next post.

Thought for the day

Nothing is psychiatry is simple. All is multifactorial.

Depression, Diagnosis, Recovery part 3

In my last two posts I talked about some aspects of psychiatric diagnosis but today I want to get into the issue of depression which exists on a continuum of mild to severe. What is depression? Depression is a normal mood state that comes and goes but clinical depression is different. I wish we had a better name for it. Clinical depression is not just a transient mood state. It is a disorder that affects mood, thinking, and behavior in fairly characteristic patterns and which impairs the ability to function in areas of work, school, personal and other social relationships, and other activities. It involves not only emotions but also involves the body as a whole and is associated with a variety of changes in how the brain processes information and interacts with the body's stress response system and immune function.

Depression is fairly common and results in significant disability. The World Health Organization has determined that depression is the second leading cause of chronic disability world wide. In the United States depression affects anywhere from 8-11% of the population at any one time with a lifetime risk of developing a depressive episode requiring treatment to just over 20%. Woman are affected at greater than twice the rate of men.

How do I know if I have depression? DSM-IV-TR refers to clinical depression as Major Depressive Episode defined by at least two weeks of persistent daily depressed mood or significant loss of pleasure in activities associated with at least five of the following symptoms; depressed mood and/or loss of pleasure, significant changes in appetite or weight, persistent insomnia or hypersomnia, agitation or severe psychomotor slowing, profound fatigue and loss of energy, decreased ability to think and concentrate as well as severe indecisiveness, feelings of worthlessness or excessive guilt and recurrent thoughts of death or suicide. Another cardinal feature not listed is the sense that everything is overwhelming and that even simple tasks of daily living can be seen as insurmountable obstacles. There are often associated physical symptoms such as headaches, nausea, irritable bowel or constipation, increased muscle tension.

I will talk more on this tomorrow. I hope that even though these posts are somewhat didactic that they are still useful and of some interest.

Thought for the day

Run after mature righteousness- faith, love and peace.

St. Paul

Depression, Diagnosis, Addiction, Recovery part 2

I am doing a series on depression and discussed how psychiatric diagnoses are phenomenological ( based upon clinical signs and symptoms) and how this is similar to other conditions such a migraine and Parkinson's. But phenomenological diagnoses are simply approximations and may include different "entities" within the same diagnosis. These approximations are useful though as they give us a common language, help make predictions regarding prognosis and types of treatment and provide diagnostic criteria for research purposes so that groups of people and treatment responses can be studied. In psychiatry these diagnoses are listed in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision, or DSM-IV-TR. One of the limitations of DSM-IV-TR is that diagnoses are categorical, that is listed as discrete and separate problems while in reality there are many overlaps. What is missing is the dimensional character of many problems, that is symptom problems that may be associated with many categorical diagnoses that are measured on a spectrum from mild to severe. Despite these limitations DSM-IV-TR is quite helpful.

One of the main things to understand about categorical diagnoses is that all of the diagnoses do not carry the same "weight". That is some diagnoses are much more reliable than others and probably do represent discrete "entities" and some do not. A characteristic of this type of diagnosis is that the greater the severity of the problem the more stereotyped it is in presentation and more likely does represent a certain entity. For example binge drinking in college may turn out to be a number of things from a transient problem to the beginnings of a more severe problem. There is no way to predict who may go on to develop alcoholism. So binge drinking is not a reliable diagnosis or a single entity. End stage alcoholism is different. It looks the same in most people. The same signs and symptoms are present, the same health problems are experienced and it is very predictable that death will ensue if the person does not stop drinking. The same goes for eating disorders Many people with a variety of problems may engage in the purging behavior of bulimia but severe malnourished life threatening anorexia nervosa is different. It does appear to be an entity all of it's own whose signs and symptoms are the same from person to person.

Depression is also one of those diagnoses that occur on a spectrum. I will talk more about that tomorrow.

Thought for the day

Happy Monday!

Cottonwood Staff, Mental Health Technician

I want to introduce you to another great member of Cottonwood's staff, Andrea Quiroz, MHT

My name is Andrea Quiroz and I’m a Mental Health Technician I Here at Cottonwood De Tucson. I have been a tech here for nearly a year and have enjoyed my experiences greatly. The best thing for me to have experienced here at Cottonwood is patients who come to Cottonwood, sometimes at their worst and seeing them the day they leave, thankful and most times the best they have been in months (even years).
I was born here in Tucson, Arizona and raised in a small town that lies on the outskirts called Marana. I recently moved back to Arizona after living in Europe for 4 ½ years. I had the privilege of working along side the men and women of the 173d Airborne Brigade in those years. I was actively involved in family readiness working with soldiers as well as family members to prepare for the coming deployments or re-deployments. I have to say it was the most rewarding 4 ½ years of my life!
I found that working here at Cottonwood is very similar to the experiences I had working with the military. In both organizations I found myself working along side other outstanding team members to prepare individuals as well as family members for the unfamiliar road that lies ahead. Providing support and encouragement is also another common element of importance noted. However, providing a service for the greater good is far yet the best!
Because of my experience with the military and Cottonwood I have decided to return to military service and serve as a member of the Air National Guard. I will be fortunate enough to continue my service to Cottonwood while at the same time serving my country. I hope to work in a field similar to the one in Cottonwood, helping and encouraging individuals for a better life we all deserve. I now see that Cottonwood truly is a new beginning for everyone.

The best way out of a problem is through it - Anonymous

Depression, Diagnosis, Addiction, Recovery

I thought I would take some time over the next days to review depression, a common problem we see here at Cottonwood as we are a dual diagnosis treatment facility specializing in the treatment of addictions complicated by other psychiatric disorders. I will talk a bit about diagnosis in general, then about depression itself, what it is etc., and then how we appraoch the treatment of depresion here at Cottonwood. This will be a somewhat lengthy series which I will break up from time to time as other thoughts and other subjects come to me. I hope that it will be useful and not too boring as it will be a bit didactic and I welcome comments and questions as we go along.

Before we talk about depression itself though I want to talk a bit about psychiatric diagnosis in general, particularly the concern that some have that our diagnoses are too subjective since we don't have objective signs such as lab tests etc. There are four types of diagnoses made in medicine and the diagnosis by signs and symptoms is a legitimate diagnostic strategy that also has it's place in other branches of medicine. The first kind of disgnosis is that based upon tissue pathology. This is what we do in cancer. A biopsy of certain tissue is made and then there is a determination of whether or not there are cancer cells. The second kind of diagnosis is made by defining a deviation from the standard norm. This is how we define such conditions as hypertension, diabetes, and obesity. The third type of diagnosis is based upon the identification of the etiologic or causative agent. This is common in infectious diseases such as streptococcal pharyngitis,urinary infections, HIV, and hepatitis.

The fourth kind of diagnosis is phenomenological or based upon a common set of signs and symptoms This type of diagnosis is used in psychiatry but also includes such conditions such as migraine, Parkinson's disease, Alzheimer's disease, and suspicion of an acute abdominal condition such as appendicitis. So phenomenologic diagnoses can be quite specific and objective as well. I will speak further on this on Monday, how psychiatric diagnoses are made.

Thought for the day

"Let justice roll down like waters and righteousness like an ever flowing stream".

The Hebrew prophet Amos

Computer Problems

I may be on and off blog for a few days. I am having that bane of the twenty first century which is a computer problem. Actually I don't know if the problem is my computer or my wireless receiver. At any rate I will be trying to figure that out.

I usually write from home early in the morning. I like that time of day. No one else is up in the house and I enjoy my morning cup of coffee. I tend to think best in the morning and my mind goes somewhat downhill the rest of the day. So I am writing this from work before my day starts today.

I shouldn't really complain. What we have available to us in communication is absolutely amazing and it is unrealistic of me to expext that things will always work. I hope to have this problem figured out sooon. Until then

Thought for the day

Deep Breaths Jim, Breathe in, breathe out