Evidence-based medicine is valuable only to the degree that what is presented is done so in a thorough, encompassing way.   

Many of the studies I read to stay abreast of what’s trending in the Psychopharmacology field aren’t worth the paper they’re written on or the cyberspace in which they’ve been transmitted. Take the FDA approval process for example. All that’s needed to pass FDA muster is that a potential new drug candidate outperform placebo. In blunt terms, it needs to beat out sugar. The fact is many of these drugs are weakly beating placebo! We’re supposed to be excited about that? As a consumer, an informed prescriber or Psychopharmacology speaker (me), you want to know how well a possible newcomer stacks up against the existing competition. That is, you want to know how it ranks head-to-head compared to other established agents within the genre. This is a real weakness with the FDA approval process, and I should add that it’s a process and content problem with all medication classes within the bounds of physical and mental health medicine.

As consumers, when we’re bombarded by direct-to-consumer advertising to buy something, our dukes go up because we’ve learned the hard way that it’s vital we protect ourselves from misrepresentation and outright fraud. By contrast, we healthcare professionals tend to have very little skepticism when it comes to what we read and digest in medical journals.

Realize that the peer review system is not perfect and is subject to publication bias and that a study which reads professionally and is footnoted to the hilt doesn’t necessarily render it credible. “Studies” and “clinical evidence” should be but one component of your overall decision-making. Also, look for who published the data – that is, consider the source. If the authors are employees of the pharmaceutical company, or if they’re in the company’s speakers’ stable, be wary and takes those conflicts into account.

Threatening or salacious news sells, regardless of the medium in which it is delivered. The lead story is uniformly negative; the “feel good” story comes at the tail end of a broadcast.

Perhaps exposing ourselves to some bad news can be timely and germane, but when we’re inundated with doom and gloom, it becomes increasingly more difficult to refocus our energy on what’s uplifting and positive.

There’s an ample supply of good news in our world. Finding it and aligning ourselves with optimistic people who support it makes for an incalculable investment in our sanity.

Charge them a monthly rent, and have them pay 25 percent of the monthly utilities. Also have them pay a fixed sum for food and other household expenses, again monthly. As you collect the money each month, place it in a savings or money market account.

Then, establish a firm date for when you want them out, and stick to it. You know your child best, what’s reasonable? One year? Eighteen months? Please, two years maximum.

At the end of the time period you’ve specifically defined, give them back all of the money and add that they’ve got 30 days to find a place of their own.

Accomplishments? You’ve conveyed the importance of them contributing to their own subsistence and they’ve got a stash of cash to get started. That’s win-win in my book, and it keeps your relationship with them on firm ground by elevating personal responsibility.

Jeanne often receives questions about defensive behavior. So I got to thinking about defensiveness in terms of when it’s inappropriate and also when the phrase “don’t be defensive” is an overused reprimand. Here’s my take:

Defensiveness is inappropriate when it shuts us off to the notion that we actually may be wrong about something. It serves us poorly when we are willing to turn a disagreement or a difference of opinion with someone into a grim contest where there’s a winner and a loser.

On the other hand, it’s quite acceptable to defend your beliefs and values if they are threatened. It’s fine to be defensive when someone with seemingly malicious intent is offering you unsolicited, unwanted advice or is maligning you.

Never allow yourself to become an object of derision. And, keep in mind that in certain situations that life throws at us, the best defense is a potent offense.

One of the hardest things to accept about life is that some circumstances will stay unresolved – and that, in and of itself – is a resolution. So we should all do ourselves a favor and stop trying to extract fairness from a world that never claimed to be – or had a history of being fair. There’s simply no way to attain justice without outside cooperation.

We can however seek relief independently, through faith, therapy, fitness, spirituality. Or generosity and giving of ourselves.

The skilled mental health diagnostician is not seeking perfection as there is no such thing. Instead, this clinician is seeking diagnostic assuredness. It begins with a thorough assessment of the presenting client and not a memorization of the DSM. In fact, the mental health bible stays on the sidelines, serving only as confirmation and as a reference for coding purposes. Savvy practitioners rely on the “art of the question.” That’s not to say they don’t bring an excellent command of the signs and symptoms of the mental disorder spectrum to the process. They do. But the essence of their skill lies in the ability to frame a series of insightful, intuitive questions around the client’s presenting problem. Adroitly, assertively, yet tactfully, they approach assessment with tactical precision and are aware that success with any client means this: the language controls the discussion; the discussion controls the relationship; and the relationship controls the quality of the outcomes. As such, the highest premium is placed on rapport building.

Observation is also important. The nuances of client head movements, facial expressions and overall body language are every bit as important as the changes in their vocal delivery. What these clinicians see in a client is every bit as important to them as what they hear.

The inability to confirm a diagnosis by way of objective findings notwithstanding, mental health work has another strike against it – the intimacy of the practice setting. When a patient visits his or her primary care physician, there are often layers of staff – receptionists, lab technicians, nurses, and physician’s assistants – to sift through before seeing the doctor. Mental health settings tend to be more one-on-one, so it’s natural for someone to guard their information at first. The experienced mental health clinician tackles this head on by first putting the client at ease before getting down to work.

Systematically then, the clinician shapes the client’s responses and non-verbal behavior – gathered though their questioning and aided by insight and intuition – into a diagnosis. Then and only then does the hard work of helping the client reach their expectations for treatment begin.

A final point. Those professionals who are undeniably accomplished and highly sought after understand that while diagnoses have utility, there will probably never be clear, undeniable “markers” as found in general medicine and that the notion of chemical imbalances and neurotransmitter difficulties is highly speculative. So they don’t go there; they deal instead with what and how the patient presents.

For some time now, I’ve been taking improvisation classes and have become part of an improv group. I began taking the classes to help me with spontaneity and to think quickly when on the spot. In the very first class – all newcomers – we were welcomed and then immediately brought on stage. There was no theorizing about improv’s place in history as a viable art form. As ill-prepared as I was with the techniques at first, my journey had begun.

You can read all the books you want about improv, skydiving or poker playing, but it’s all theoretical until you step up on the first stage, jump out of the first plane or deal your first hand. I’d much rather work with someone who helps me to actually do something than someone who talks incessantly about the theory of doing it.

Antidepressants: There do not appear to be any significant gender issues in response to antidepressants.

Antipsychotics: Women respond better to antipsychotics during their first episode of illness. They require half as much medication for maintenance than men. Because women have higher body fat content, long acting injections can be given less frequently.

Anticonvulsants: Polycystic ovary syndrome (PCOS) is a metabolic condition that occurs in 7-15% of reproductive-aged women. These women have elevated testosterone, chronic anovulation, insulin resistance, elevated LDL’s with low HDL’s, and a 3x risk of endometrial cancer. (They do not necessarily have polycystic ovaries.) Women with epilepsy and women with bipolar disorder have a high risk of anovulatory disorders and PCOS.

Pregnancy: There is no such thing as a drug that is “no risk” to the fetus. All psychoactive drugs pass through the placenta. All drugs are secreted in breast milk. The more a drug is studied, the more risky it is found to be. Anticonvulsants are especially problematic. Depakote is suspected of causing developmental delays in children without birth defects. Lamictal is now linked to a small incidence of cleft lip and cleft palate (GlaxoSmithKline).

Side effects: Acute dystonia occurs more frequently in women. Tardive dyskinesia is more common in elderly men than elderly women. Men are more disturbed by side effects that detract from their performance. Women are disturbed by side effects that affect their appearance. Women are more likely to gain weight from psychotropics.

Anxiolytics: Though the benzodiazepines carry an attendant risk of tolerance development and dependence, as a class, they are generally safe unless combined with alcohol. Deaths in this instance are due to respiratory depression. These medications however, may be life saving in an acute suicidal episode when anxiety is prominent.

Lithium: Lithium has strong anti-suicidal properties. The risk of suicide in bipolar clients treated with lithium falls 10-fold. When lithium is discontinued, suicidal behavior increases 20-fold within the next 6-12 months. The anti-suicidal properties of lithium are not present with the anticonvulsant mood stabilizers such as Tegretol, Depakote.

Clozaril: The second-generation antipsychotic Clozaril (clozapine) also has strong anti-suicide properties. It is FDA approved as a suicide deterrent in clients with schizophrenia or schizoaffective disorder. Evidence of suicide protection is not as strong with the other antipsychotics.