What I find strikingly poignant was how painful this ordeal was for Thomas Jefferson. Jefferson’s draft of the Declaration of Independence was subjected to more than 80 changes during the period that the Continental Congress deliberated. Most of the changes were minor and served to enhance Jefferson’s work.

One section that didn’t survive the cutting room floor hurt him significantly though. Jefferson wanted to include a section that addressed the pain of parting from the British Crown. “After all, the Brits were our friends, we were leaving them, we might have been a free and great people together,” he lamented. The Congress however, was not in a conciliatory mood. The abrupt ending of old ties with England was not on their mind; their focus was on the denunciation of high-handed treatment.

We all know “the rest of the story.” We handed the Crown their heads in the Revolutionary War. They came back at us again in 1812, burning the White House and the Capitol in the process, but were eventually vanquished in New Orleans, never again to return to American soil as an army.

I believe Jefferson was troubled by the act of burning one’s bridges. I believe that in spite of the waging of two substantial wars on his watch, he perceived that the United States of America and Great Britain would eventually rekindle their relationship. How right he was, and how beneficial for us (World War II immediately comes to mind.)

Relationships that damage us, cause irreparable harm, or serve as an ongoing threat to our well-being should end, and stay that way. But these should be in the minority, because with ardent dedication to damage control and the contributions of father time, allies that became enemies can become allies again. We should all cherish the desire to grow old together in harmony.

Happy 234th Independence Day.

• Side Effects. In a “perfect drug” scenario, medications would zero in on their intended target systems generating only desired, therapeutic effects, then metabolize and leave the body. Unfortunately, it’s not that simple, as medications produce unintended consequences as well.

How healthcare professionals can help: It is important to be honest with clients about side effects. Point out that although practically every drug – prescription and over-the-counter – has side effects, many of them are short-lived and “run their course,” so to speak, after the body adapts to the new substance. Discuss the typical side effects of the medications that the client is taking, and suggest ways for combating them. For example, drugs that are associated with the side effects of anxiety and insomnia are best taken in the morning. Sedating medications should be taken at bedtime and those linked to nausea are to be consumed on a full stomach.

• Cost. Unfortunately, most brand name medications are outrageously expensive nowadays. So it is no surprise that the poor and particularly the elderly on fixed incomes are prone to breaking their medications in half or taking them every other day. As important as medication may be to quality of life and even survival, it’s not high in the pecking order when it comes to one’s hierarchy of needs.

How healthcare professionals can help: The place to start is with the client’s choice of insurance company or plan. Help them find out about the range of prescription benefits and whether or not the medications they’re taking are covered under their plan. Clarify co-pay information and whether or not brand drugs are covered. This is particularly important if they’re taking several medications. Medicare beneficiaries can switch their prescription-drug coverage between November 15 and December 31.

Suggest comparison-shopping among several pharmacies. There are often disparaging price differences for the same drug from pharmacy to pharmacy. There are also a number of useful Web sites that can assist clients with comparison-shopping. The site www.destinationRx.comwww.Rxvouchers.com for coupons that can be used for medications.

A number of assistance programs are available through states, nonprofits and drug companies. Contact the Partnership for Prescription Assistance at 888.477.2669 or www.pparx.org for eligibility requirements. PPA helps the uninsured or those struggling financially to gain access to about 475 assistance programs that are either free or very low cost.

Find out if the client’s physician is willing to prescribe either a less expensive brand of the medication they’re taking or a generic. More and more pharmacies are following Wal-Mart’s lead and are offering some generics for as little as $4.00 per prescription.

The purchase of prescriptions via mail order, particularly in larger quantities, offers handsome savings in many instances.

• Forgetfulness. Forgetting to take medication according to prescribed directions is the most common cause of non compliance. It is often the result of poor organization, memory compromise and sometimes downright obstinance, that is, some people “conveniently” forget.

How healthcare professionals can help: Compartmentalized pillboxes, medication calendars, post-it note reminders, timers and even high tech talking devices that sound an alarm when a dose is missed are all helpful. Help clients set up a strategy for taking medications at the same time every day and enlist the help of family members whenever possible. Available and supportive family members can either administer medication directly to the client or remind them via a phone call. The key here is to set up a clockwork pattern of daily repetition for the consumption of medication.

• The I’m Cured Syndrome. Way too many people treat prescribed medication as they would a Tylenol for a simple, uncomplicated tension headache. That is, once they either begin to feel better or their symptoms remit, they abruptly stop or gradually discontinue the drug. The reasoning for this action, albeit illogical, is simple. Most people want to be done with medication as quickly as possible because it is viewed as a necessary evil. For many, having to take medication serves as an ever-present reminder of something undesirable, such as a physical illness or mental disorder.

How healthcare professionals can help: This one can be tough and is at times met with resistance. But clients need to be reminded that medication is a vehicle that has fostered improvement in the first place, and that abrupt or gradual discontinuation isn’t warranted without the approval or recommendation from the client’s prescriber. Some clients need to bluntly hear that this is a matter they shouldn’t take into their own hands.

• Frequency of Use. This is a rather linear issue. The more times per day someone has to take a medication, the greater the frequency of a missed dose. It’s that simple. There’s also a” multiplier effect” associated with frequency of use that is exacerbated in the client taking multiple medications. This can make for a real mess.

How healthcare professionals can help: Research whether the client’s medication is possibly available in a once-daily formulation. If so, teach them how they can advocate with their physician on their own behalf for once-daily preparations. If not available, the aforementioned clockwork pattern of medication use that fosters a cycle of daily repetition becomes even more important.

The big Pharma company Novartis owns the rights to market Valdoxan in the United States, but lists the drug as scheduled for submission to the FDA for possible approval no earlier than 2012.

Why? Well, this medication seems to be having difficulty outperforming placebo. And this makes sense because the regulation of circadian rhythms doesn’t necessarily mean that Valdoxan will have antidepressant effects.

Valdoxan promises enhanced norepinephrine and dopamine release, but the drug’s branding plays up its effects on melatonin, raising the question as to who would most likely benefit from its use. Those prone to seasonal affective disorder? Shift workers?

I suspect that Valdoxan will reduce sleep latency, helping people get to sleep faster. It also promises no sexual side effects or weight gain. But these advantages must not be sufficient enough to motivate Novartis to push for swifter FDA approval. Methinks something is amiss here.

Intuniv (guanfacine LA). Intuniv is a long-acting formulation of the alpha-2 agonist Tenex (guanfacine). Intuniv is FDA approved for the treatment of ADHD in children and adolescents ages 6-17. The drug is available in 1mg, 2mg, 3mg, and 4mg tablets, and is dosed once daily.

Guanfacine was first marketed as an antihypertensive for the control of high blood pressure. Its use then expanded to the treatment of some anxiety conditions and to control hyperactivity and impulsivity associated with ADHD. Guanfacine has also been used “off label” to help manage irritability and aggression associated with oppositional defiance, conduct disorder and temper tantrums linked to the pervasive developmental disorders (autism, Asperger’s syndrome).

Intuniv can be used alone, but probably works best in combination with the classic methylphenidate or dextroamphetamine psychostimulants. Because it lowers blood pressure and slows pulse rate, it is likely to be most effective in controlling the peripheral symptoms of ADHD – hyperactivity, impulsivity, and irritability. In my view, claims that Intuniv acts directly on the prefrontal cortex to improve focus and distractibility are pharmacologically questionable, poorly explained and merely drug company hype.

Side effects include: sleepiness, headache, sedation and possible fainting. Blood pressure and heart rate should be regularly monitored in children and adolescents taking Intuniv.

Trazodone Extended-Release. This long-acting offspring of the popular immediate-release antidepressant trazodone sports a combination rapid and sustained-release technology that claims to maintain blood levels within therapeutic range for 24 hours, thereby potentially reducing the incidence and severity of side effects while maintaining efficacy in the treatment of major depressive disorder in adults.

So what’s really new here? Nothing. Again, we’re lead to believe that with advances in release technology, efficacy is maintained and is accompanied by an improved adverse events profile. I’m far from convinced. Haven’t we been down this road before with other psychotropic medication classes? The psychostimulants certainly come to mind.

This ongoing trend of pharmaceutical companies to develop long-acting formulations from existing immediate-release medications and then, if gaining FDA approval, marketing them as “new” drugs is shallow. They’re not new drugs, and for that matter, neither is the technology. Intuniv and Trazodone Extended-Release are apt representatives of this disturbing trend.

Millions of people fail to take their medications correctly, and it’s a serious problem. Worse, some quit taking their medications altogether, without giving any consideration to discussing this decision with their prescribers or other health care providers.

Consider these findings on medication non compliance from the nonprofit National Council on Patient Information and Education:

• Only 50 percent of patients with heart disease, asthma or hypertension follow prescribing directions.
• Adherence to prescribing guidelines is a problem for all age groups, and it’s not just an issue of poverty or poor education. Even the wealthy and most educated among us skip their medication.
• Consequences don’t necessarily enhance compliance. Only 58 percent of glaucoma patients already blind in one eye were protecting their other eye.
• Doctors mess up, too! One study indicated physicians adhered to their own prescriptions less than 80 percent of the time.
• Noncompliance can run an extra $2,000 a year per patient in additional doctor visits alone.

Some might say that the high cost of prescription drugs contributes to the problem, but medication non compliance goes far beyond prescription affordability. So what accounts for this non adherence? Here are a few culprits:

Hurried visits at the doctor’s office result in many patients leaving with new prescriptions without having asked a single question about the prescribed drug. Others, after purchasing their medications, ignore label directions and how much they are supposed to take. Anybody can forget a dose, of course. But many, after they begin feeling better, toss out the remainder of the prescription. Also, there is no doubt that the fear of side effects is a principal reason.

Another factor driving noncompliance is intimidation. Nowadays, there is as much information stapled to the prescription bag as one might find in the Physicians’ Desk Reference. This results in overkill – turning an ordinarily compliant patient into a noncompliant one out of fear or confusion about what they’ve just read – because the vast majority of these drug facts are for physicians anyway.

Additionally, some prescription drug bottles and vials are covered with so many brightly colored warning stickers they resemble a tiny Christmas tree. Then there’s the label, with wording open to interpretation and print so small, it requires a Sherlock Holmes Magnifying Glass to read. Yet another problematic issue is the number of people that attempt to take medications without the benefits of proper lighting.

If you suspect or know of medication non-adherence on the part of your clients, be a part of the solution by instructing them to do the following: (Conducting role play exercises may help clarify understanding).

• Before leaving the doctor’s office with a new prescription, ask detailed questions. For example: How and when do I take this drug? Are there any foods, beverages or other medications I should avoid while taking this drug? What is this drug supposed to do, and how can I tell if it is working? What side effects might I have, and what should I do about them? When do I discontinue this medication?
• At each doctor’s visit, bring a complete list of all prescription and non-prescription medications, including the names of any vitamins and supplements. This way the physician can screen for possible interactions.
• If reading or understanding the medication information insert poses a problem, ask a pharmacist for help. Pharmacists routinely simplify complex and confusing directions.
• If forgetfulness is an issue, consider compartmentalized pillboxes or even a high-tech “talking” model that sounds an alarm when a dose is missed.

1. The severity of the traumatic event.
2. Parental reaction to the traumatic event.
3. Physical proximity to the traumatic event.

As a general rule, most studies that have examined
the risk factors associated with PTSD emergence in children find that children and adolescents reporting experiences with severe trauma also report the greatest levels of PTSD- related symptoms.
The extent of family support as well as parental coping capacities also correlate with symptom development in pediatric populations. As such, children and adolescents with a supportive family structure that includes less distress between their parents have a less acute PTSD symptom profile.

Lastly, children and adolescents with a greater proximity from the traumatic event report less distress.

There are a number of other factors that affect the occurrence and severity of PTSD. Interpersonal traumatic events such as rape and direct physical assault are more likely to result in PTSD as opposed to witnessing a school shooting or experiencing a natural or man-made disaster. Gender specific studies tell us that girls are more likely than boys to develop PTSD. Finally, it is not yet clear in what way a child’s age at the time of traumatic event exposure influences the occurrence or severity of PTSD. While some studies allude to a correlation, others simply do not.

On a 3X5 index card, have your client write down the following five questions, and recommend that they ask these after the doctor has completed the initial assessment and has evaluated the client’s history and presenting symptoms.

1. “What do you think is wrong with me?”
2. “What might be causing this?”
3. “What else could it be?”
4. “Is there more than one treatment for my disorder?”
5. “Would you please tell me about the medication(s) you’re prescribing for me?”

Why suggest clients do this? Because these questions, simple as they may be, often go unanswered due to the flurry of activity in physician offices. So clients have to empower themselves to maximize the benefits of office visits. And an empowered client is usually a compliant client.

Therapists are at times reluctant to pursue collaboration with physicians who are intimidating, boorish, insulting, controlling or egotistical. Physicians also carry their own stereotypes of therapists as being too ‘theory oriented,” “touchy-feely” or not “symptom focused.”

These contradicting viewpoints demand that professionals sharing client care become familiar with each other’s role and respect the value of each other’s views and opinions. For the non-medical clinician though,

With this in mind, here are some tips for working with physicians:

• Approach physicians in an assertive, confident manner. This will endear you to doctors faster than anything else. If you find yourself apprehensive or anxious, jot down your points or questions on an index card or notepad. Be succinct and make eye contact.
• If you work in an on-site system, find the “main traffic area” and place yourself in the middle of it. Greet physicians as they walk by with a smile and where appropriate, a handshake. This builds goodwill – an ally you’re going to need.
• Establish your expertise as a competent worker, and respond timely to physicians that reach out to you. This speaks for itself. Do your job, do it well, and be available. Once you establish your competence, you’ll become the “go-to” person, particularly for difficult cases.
• Speak their language. This means focusing on symptoms and eschewing any theory jargon. For example, if after placing Ms. Jones on Cymbalta for a few days she has become more restless or agitated, report this only. This is not the time to discuss her repressed memories from childhood.
• Never recommend a specific medication treatment. This is an egregious boundary violation, unless the doctor asks for your suggestion(s). Medication decisions are made by the physician in concert with input from the client system.
• Understand and appreciate cultural differences. Physicians are under severe time constraints, which should be respected. Physicians take a tremendous amount of responsibility for their patients’ well-being and in facilitating change in their patients’ condition. Non-medical clinicians on the other hand, often place the responsibility for change on the backs of their patients. This difference can create conflict which in turn fuels skewed expectations of one another. So recognizing and appreciating role differentiation between the non-medically trained practitioner and the physician can be a productive step toward working collaboratively.

Placebos account for the successful treatment of depression, pain, asthma, arthritis, hypertension, insomnia and other conditions. In the classic placebo effect, a person consciously believes that a substance is therapeutic, and this belief generates a positive effect on medical or psychological symptom improvement.

For several decades however, scientists and researchers have known that placebo effects can also arise from subconscious associations as opposed to conscious beliefs. Any stimuli that a patient may link with symptom improvement – a physician’s white lab coat, a physical examination, the touch of the stethoscope to the chest or the smell of alcohol in the examining room – may induce positive physiological responses even if a patient has no explicit belief or faith in the treatment being administered.

The placebo effect probably accounts for most of the benefit associated with treatments such as acupuncture, aromatherapy, homeopathy and most other alternative treatments. Thirty three percent of the response to antidepressants is attributed to the placebo effect.

Conditions linked to significant psychological distress are most likely to respond to placebo.

Some possible mechanisms for this are as follows:

• Psychological theory – psychology affects biology, beliefs affect biochemistry.
• Nature taking its course – we often get better by doing nothing at all.
• Process of treatment – touching (when appropriate), displaying a caring attitude, being attentive and communicating effectively – may elicit a placebo response.

Using the placebo effect:

• Inspire patient confidence by looking and dressing professionally.
• Display symbols of comfort – soothing artwork, positive affirmations or the gentle sound of water tricking from a “mini-fountain” – in your office.
• Discreetly take notes during therapy sessions.
• Lean slightly forward when addressing the client and asking questions.
• Solicit the client’s beliefs and input when selecting treatment interventions.
• Most importantly, instill HOPE and OPTIMISM when discussing the prognosis of the client’s presenting problem.

Although this comes as no surprise to me, there is now clear evidence that lithium is the most efficacious single agent for managing bipolar mania and bipolar depression. If, for whatever reason, lithium is not effective as monotherapy, combining Depakote with it does increase efficacy – although not markedly. The lithium/Depakote combination therefore is optimal in the treatment of bipolar mania.

From clinical experience, what are your impressions?