Serotonin Transporter Gene Depression

The Daily Musings of an Addiction Psychiatrist is back after a short hiatus. For some reason I have not been sleeping well so instead of getting up early which I enjoy and writing I have been dragging myself to work at the last possible minute. Maybe it is a guilty conscience as they say but I don't feel anxiuous at night - just awake.

A recent study has once again caused dissapointment in those of us who are continuing to hope that we will learn more about the genetic links that predispose us to depression. It had recently been thought that mutations in the gene coding for the serotonin transporter protein might be one of those factors. This seemed to make sense as we have known that the neurotrasmitter serotonin is associated with depression and that many of our antidepressant medications have an effect on serotonin. A large scale study though has shown that this gene is not a factor. Instead what is more associated with depression are the number of stressful life events.

This once again show that enviromental factors strongly influence the occurence of depression but leaves us wondering what the genetic differences are that would make one person respond to life stressful events with depression and another doesn't. What are the genetic differences that either protect us from or make us more vulnerable to depreesion? We still don't know.

Thought for the day

"In all things give thanks".

St. Paul

American Society of Addiction Medicine, Certification Exam

I have some good news to share. Recently I, along with two other colleagues here learned that we passed an exam we took back in December. The exam was for The American Society of Addiction Medicine (ASAM) certification. Two of us were certified and one was re certified.

The American Society od Addiction Medicine is the largest group of physician addiction specialists in the country and consists not only of psychiatrists but Internal Medicine physicians, Family Practice physicians and Anesthesiologists who are interested in advancing the field of addiction medicine. Certification does not imply clinical competence but means that the person has the education and knowledge base required to be an addiction specialist. The exam was very hard and I really had my doubts as to whether I would pass or not as this was not a psychiatric exam but a medical exam and covered areas that I don't necessarily deal with on a day to day basis. I was very pleased to know that I had passed as this exam required a great deal of study and preparation. If I had to retake the test at a later date I am not too sure that I could have gone through that study process again!

So, I am happy to share good news.

Thought for the day

"Do nothing from selfishness or conceit but with humility of mind regard one another as more important than yourselves".

FDA, Warnings, Medication, Side Effects

I learned something new today which has gotten me to thinking about an old problem - that of medication risks and side effects.

I learned that many of the medication patches (transdermal delivery systems) that are now used commonly can cause skin burns if one is wearing them during an MRI scan. There are now 60 different medication patches that are used for a variety of conditions from nicotine cessation, to hormonal replacement to pain control and many others. Apparently about 1/4 of these patches contain traces of aluminum or other metals in their backing which can overheat and cause burns in the MRI scanner. I did not know this. The FDA is considering placing a warning label on every patch so patients will know to remove them during the scan.

This got me to thinking about FDA warnings and medication side effects in general and how it is becoming increasingly more difficult for doctors and patients to weigh the risks of taking a medication or undergoing a treatment.There are so many more medications now than in the past that it is hard for anyone person to keep up to date. In addition to side effects and risks there are many drug-drug interactions which can be harmful. On top of this there is now direct to consumer advertising from the pharmaceutical companies urging patients to discuss certain medications with their doctor to see if they are right for them. When I look at The Physician's Desk Reference (PDR) which is the detailed prescribing information on all medications it sometimes appears that any medication can cause any side effect! How to tell the the most common and potentially the most dangerous is not easy for us as patients. For example what does a person make of advertisements for antidepressants that tell of possible increase in suicidal risk or asthma medications which can cause respiratory problems and death. What about arthritis medication that says it can cause serious life threatening infections?

Medication data bases are the best way to screen for drug-drug interactions but are not helpful in making decisions about whether or not to take the medication in the first place. These decisions are based upon the relative risks vs the potential benefits in any one individual. What we all need to remember is that no medication is safe. There is no treatment without risk. I believe that the only good way to handle these dilemmas is a good doctor-patient relationship in which there is full freedom and opportunity to discuss these issues. We as physicians must take the time needed to have these kind of talks.

Thought for the day

"O love, you ever burn and are never extinguished".

St Augustine

Arizona, Addiction Psychiatry, Co-Occuring, Cottonwood, Treatment

One thing that is special about Cottonwood that few people are aware of is the availability that our psychiatrists have to work with patients, There are many substance abuse treatment centers that treat co-occurring psychiatric disorders but I believe we have the greatest psychiatrist to patient ratio in the world. We have 3 full time psychiatrists on staff, in house, for a center with less than 60 patient beds. My patient load is 20-24 , hardly ever above that. That is astounding! I don't believe there is a treatment center anywhere in the world that comes close. If you are one or know of one I would be happy to have you let me know.

Our situation is such that the psychiatrist, the most highly trained person on staff is not relegated to doing psychiatric evaluations and medication management. I am available for a wide variety of roles. With my on site presence I am constantly interacting with the therapists both formally and informally. The therapist and I are able to sit down with the patient several times during their stay to formulate and review the treatment plan together as well as come up with behavioral objectives and assignments. I am able to meet with every family of every patient during family program week alongside the patient's individual therapist and twice in the week if need be. We can treat patients who are very ill as I have the luxury of seeing a patient as often as needed even three to four times per day if necessary to help stabilize a patient. I can work with all my depressed and anxious patients providing cognitive behavioral therapy sessions twice per week. Our therapists are able to confer with me as often as needed. And we have three psychiatrists doing this! This luxury of psychiatric availability is otherwise unheard of.

Addiction psychiatry availability is one of many factors that convince me that Cottonwood is the place to come for those suffering from substance abuse and co-occurring psychiatric disorders.

Thought for the day

"I have not brought misery upon my fellows. I have not made the beginning of every day laborious in the sight of him who worked for me".

Ancient Egyptian-Confessions of the Righteous Soul

American Neuropsychiatric Association Conference

I got back last night from attending the annual meeting of the American Neuropsychiatric Association which was held in San Antonio, Texas this year. San Antonio is a great city to visit and I was especially happy to be able to spend sometime with my niece and her husband who live there. As I mentioned before this meeting has become my favorite to attend because it is a mixture of psychiatrists, neurologists, and neuropsychologists all interested in psychiatric aspects of neurologic disorders and neurologic aspects of psychiatric disorders. It is a conference where brain meets behavior and is a mixture of some aspect basic neuroanatomy review, research findings and clinical issues. This year topics included the brainstem, psychiatric aspects of the right hemisphere, glial cells (which are the cells in the brain that support neurons), the brain and the law, new research in gene therapy and modulation, and the role of estrogen in neuropyschiatric disorders. I learned a lot and may share some information on these topics in upcoming posts.

The last day was devoted to clinical presentations and I was struck by two things. The first was to again be reminded how difficult real life situations of our patients are. No one has the answers to many of our questions but it is nice to hear how other practicioners deal with very difficult problems. I particularly enjoyed a presentation of two cases where a physician discussed the difficulties in assisting the severely intellectually disabled. He encouraged us all to approach our work with a spirit of humility and and attitude of listening, empathy, and open mindedness. The other thing that stuck me was the relative lack of attention payed to addiction or possible addictions in these very tough neuropsychiatric dilemmas. We still have a long way to go in educating physicians about the pervasive effects of alcoholism and other addictions.

Thought for the day

May I approach my work in a spirit of humility and an attitude of listening, open mindedness and empathy.

Michael Phelps, Marijuana, Drug Use and Ambivalence

A reader asked me to comment on Michael Phelps and wanted to know what I thought about him being caught smoking marijuana. At first I was reluctant to do so. So many people have already weighed in on this issue. But the reader pressed me, saying he really wanted my opinion on this matter so I thought I would share a few thoughts.

The most striking thing to me about his marijuana smoking has been the mixed public reaction which has ranged from excoriating him to an attitude of leniency. I believe that this ambivalence reflects America's ambivalence about marijuana itself. Is marijuana addictive? Is it a "harmeless" drug or a gateway drug to more serious drug abuse? Should it be legalized? Should marijuana be allowed for medical purposes? As a society we have not yet come to terms with marijuana and how and if it should be used.

I believe that all discussion about marijuana should be taken in the broader context that the two most commonly used, dangerous and destructive drugs are both legal, alcohol and nicotine. The harm caused by these drugs far outweighs all the harm created by all other drugs combined. I think we forget this in the often passionate debate over marijuana.

So what is the truth? What do we need to know in order to have more informed opinions on marijuana? In no particular order I will indicate some of the facts that are clear. Marijuana is an addictive drug. While most people who use try marijuana or use occassionaly do not become addicted there is a group of people who are highly addicted and whose lives are torn apart by marijuana use. At Cottonwood I see patients whose use of marijuana has been casual despite their addictions to other drugs and I also see patients who are addicted to marijuana alone and have been unable to function effectively in life due to this addiction. While most people who use marijuana do not go on to other drug abuse there are hardly any other drug users who have not used tobacco and marijuana first. Tobacco though is the main "gateway" drug. Marijuana is no longer the main drug of abuse among teens after tobacco and alcohol. Prescription pain pill use has overtaken marijuana use among youth and is increasing while marijuana use has been decreasing. The marijuana used to today is much more potent and has much higher content of THC (the active drug) than the marijuana used in the 1960' and 70's. Chronic marijuana use can lead to psychosis in a subset of people who may be more genetically prone to developing a psychotic disorder. Marijuana is currently calssified by the Federal Drug Enforcement Agency as a schedule I drug, a drug that has no medicinal use. We know however that it does have medicinal use and can be particularly effective for the nausea often induced by chemotherapeutic treatments for cancer. Medical use of marijuana has been legalized in several states including our own Arizona but the Federal government restrictions overide state law.

So I don't have the answer to the question of marijuana use but I do think we should base our opinions upon the knowledge we have rather than just uninformed opinions.
As for Michael Phelps? My thought for the day is

"Let him who is without sin cast the first stone".

Jesus of Nazareth

Addiction Psychotherapy As Soul Tending

Addiction Psychotherapy As Soul Tending

One of the things about being human is that we all have the opportunity to learn new things every day. I have been learning about where some of our words come from and want to share with you one thing that has made me see what we do in a new light.

I have often thought about what those of us who treat addictions are really doing That is, what is our task? What do we as 'behavioral health providers have to offer? I have decided that I like the idea of us being psychotherapists. Why?

Psychotherapy comes from two Greek words. Psyche means the soul, that part which animates us, the higher part of us that makes us essentially human, our spiritual selves. Therapy comes from the word therapeia which means caring, tending, or serving. So in one sense we psychotherapists are "soul tenders" We assist healing by helping redirect the attention to one's own soul or spirit.

We are to tend to the soul as one tends a garden, nurturing the soul as one nurtures a young plant so that it will grow healthy and strong. But to do that requires me to attend to my own garden on a daily basis.

Thought for the day "If someone is able to show me that what I think or do is not right, I will happily change, for I seek the truth, by which no one was ever truly harmed. Harmed is the person who continues in his self deception and ignorance".

Addiction Psychiatrist - Daily Musings

The Daily Musings of an Arizona Addiction Psychiatrist

Hi and welcome to my part of the Cottonwood de Tucson blog! I am Dr. Jim Seymour, a psychiatrist and Assistant Medical director here at Cottonwood. For reasons still not clear to me (perhaps because I am not all there in the head) I have decided to write here on a daily basis. I do know this though, I love Cottonwood! I love my work, I love the people I work with. And I am honored to work with the many people who come here to do the difficult task of self examination and life changes.

I also love to talk about mental health issues and recovery and will be sharing what little wisdom and knowledge that I have as well as hoping to get comments and questions for discussion of a wide variety of topics. I find that by discussions on these topics I regularly learn new things and new ideas that help me help others who are seeking a good life, one that is good and fulfilling. I hope this blog will be of interest not only to you who happen to be reviewing our site for the first time but also to those of you who would like to return to discuss the daily musings of one who is also trying to grow and live a life worth living.

I will be back tomorrow but until then I will leave you the thought of the day.

"Are my actions appropriate for a communal being? If so, I have my reward"