John M. Talmadge, M.D.

A Blog Covering Many Topics

Mindfulness Therapy: Alternative to Antidepressants

Many psychiatrists like me recommend mindfulness and cognitive therapy to our patients. These two approaches work well together because psychotherapy ("talk therapy" is best when individualized rather than using a "cookbook" approach. One size does not fit all. The legendary British medical journal The Lancet (April 2015 includes a recent scientific paper showing that mindfulness-based cognitive therapy (MBCT) could provide an alternative non-drug treatment for people who do not wish to continue long-term antidepressant treatment. This is one example of brain science at its best.

Mindfulness-based cognitive therapy aims to change the way people think and feel about their experiences. How we think affects how we feel. And the use of mindfulness practice is relatively easy for most people. Just 10-15 minutes two or three times daily makes a difference. The current study compares MBCT with maintenance antidepressant medication for reducing the risk of relapse in depression. The results are encouraging.

The study aimed to establish whether MBCT is superior to maintenance antidepressant treatment in terms of preventing relapse of depression. Although the findings show that MBCT isn't always more effective than maintenance antidepressant treatment in preventing relapse of depression, the results, combined with those of previous trials, suggest that MCBT may offer similar protection against relapse or recurrence for people who have experienced multiple episodes of depression, with no significant difference in cost.

"Mindfulness gives me a set of skills which I use to keep well in the long term. Rather than relying on the continuing use of antidepressants mindfulness puts me in charge, allowing me to take control of my own future, to spot when I am at risk and to make the changes I need to stay well." — Study Participant

MBCT builds on the insight that when people with a history of depression experience even a brief period of feeling low they tend to be especially vulnerable to negative thinking. That negative thinking is often accompanied by what’s known as “processing biases”: worrying about past problems, for example, or returning to unpleasant memories. Thinking like this raises the risk of a full-blown depressive episode.

MBCT focuses on helping people to become more aware of these thoughts and feelings, and thus better able to gain distance from them. As its founders put it: “We discover that difficult and unwanted thoughts and feelings can be held in awareness, and seen from an altogether different perspective – a perspective that brings with it a sense of warmth and compassion to the suffering we are experiencing.”

Talk Therapy? Medication?

"We are more than a brain in a jar," Dr. Richard Friedman wrote recently in the New York Times. In his timely article about psychiatry, he goes on to say, "Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front." He points out that billions are spent on pharmaceutical research — the quest for the magic pills that will change the way we think and feel — but comparatively little money goes to psychotherapy research.

image of poster about pills

I am an old-timer, and when my generation trained in psychiatry virtually all of us planned on being psychotherapists who were well educated in the use of medication as an adjunct to talk therapy. All psychiatrists I knew back then had been in psychotherapy themselves; personal therapy was considered part of becoming a competent clinician: "Physician, know thyself."

If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients?

Research shows that when psychotherapy and medication are both available, the combination is synergistic. It's like saying 1 + 1 = 3. Today, however, fewer than 10% of psychiatrists are trained and skilled in psychotherapy. My opinion is that this is why a good psychiatrist is very hard to find. I have been teaching young psychiatrists for over thirty years, and I have been a training director in one of our finest medical schools, and I can say with authority that many psychiatrists coming out today get failing grades when it comes to important skills like writing, speaking, and communicating clearly. I'm talking about basic errors in English grammar, syntax, and sentence structure — the stuff most people should learn by the time they enter high school! If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients? This is one reason that psychiatrists today are, in general, poor psychotherapists with little interest in what talk therapy has to offer.

Writing in a medical chart is similar to text messaging. It's easy, and grammar doesn't count. In fact, the modern electronic medical record discourages thoughtful writing, just like text messaging does. A good psychiatrist should not only speak well and write well. A good psychiatrist should be a superior thinker and communicator. Every doctor should have a big sign on the wall behind the chair where the patient is sitting: "DOCTOR, YOUR PATIENT IS TRYING TO TELL YOU SOMETHING!"

Here's Dr. Friedman again: "With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s."

"Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective."

Prescribing a pill is easier and cheaper than offering the patient psychotherapy. Psychiatrists are paid more to prescribe pills than to counsel with patients. It is understandable, then, that the incentive is to see five patients in a single clinic hour. This saves insurance companies a lot of money. Many insurance companies will not even pay for psychotherapy with a qualified psychiatrist. And think about this: if a patient doesn't like the psychiatrist, there are fewer repeat or return visits. The winners are the insurance companies.

Dr. Friedman is also critical of trends in research, not because they are wrong, but because of simplistic logic. "The doubling down on basic neuroscience research" he says, "seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders." He points to an editorial in May in one of the most respected journals in our field, JAMA Psychiatry, emphasizing the brain but not mentioning the mind, the complexity of mental illness, or anything about how psychotherapy scientifically helps the brain. Friedman believes that "an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders."

"Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses."
—Professor and Psychiatrist Richard Friedman

Dr. Friedman's article generated a number of replies, including this one from Christopher Lukas, a noted author:

"Over the years, I have had talking therapy for my depression and post-traumatic stress disorder, and I don’t believe I would be alive were it not for those sessions. I have also taken a whole range of medications for depression and find that psychotherapy outweighs the benefits of any of those drugs.

"Some psychiatrists and some patients think that drugs are better because they work like aspirin: Take two and call me in the morning. But, as Dr. Friedman pointed out, and as I have experienced, other patients find doses of talking therapy can work well if we’re patient and if we understand that many emotional problems may take time to go away.

"Persistence, willingness to give yourself over to the process and willingness to change therapists if the talk isn’t helping you: These are key to talk therapy’s benefits."

The comments by Lukas remind me of something I pointed out to a patient just last weekend. Asking about Alcoholics Anonymous, she wanted to know what it takes to succeed in finding sobriety through AA. "An easy way to think about it," I said, is to remember the three letters H-O-W." The old AA acronym stands for "honesty, open-mindedness, and willingness."

Another writer, who is a physician herself, also agreed with Dr. Friedman:

"For the past 30 years psychotherapy has been given short shrift as drug therapy has become the treatment of choice. There are many reasons for this, but the most powerful are economic.

"Doctors can manage medication for many more patients in a day than they can treat with psychotherapy. More important, pharmaceutical companies, which profit from the drug sales, support research, thus providing funds to psychiatry departments that receive no similar support for psychotherapy research.
Sadly, in the past generation or two there has been a huge loss in professional expertise as fewer psychiatry residency programs provide top-notch psychotherapy education and supervision.

"Twenty-eight years ago I went to medical school planning a career in child psychiatry. My interest had been primed by fascinating conversations I’d heard in high school between my father, a psychoanalyst, and his colleagues.
My medical school psychiatry rotation was a disappointment. There was no attempt to solve the riddles of patients’ emotions and behavior, only the adjustment of medication doses to treat symptoms. Still wanting to solve puzzles, I chose a career in radiology.

"When my father died, I was tremendously moved to hear some of his patients who attended his funeral tell me how the treatment he provided had profoundly changed their lives. Psychotherapy should be an integral part of psychiatric training."

Since I do both — I am a psychotherapist who prescribes medication when appropriate — it's understandable that I agree with Dr. Friedman. It's also true that I practice this way because that approach provides the best care for the brain, the mind, and the whole person.

The Adderall Phone Call Trend

At least twice a week, and more often during certain times of the year, I get calls from college students looking for a doctor who prescribes medication for attention deficit disorder. I also get a lot of calls asking for sedatives like Xanax and Klonopin. Although these medications can be very helpful, my experience is that most of these students are not really suffering from ADD, and I tell most of them (not all) that I am not in the business of managing Schedule II drugs. Schedule II is the class of medications most closely monitored by the Drug Enforcement Administration. Special numbered prescription forms are mandatory and required, and the doctor found guilty of bad prescribing may likely lose his license to practice.

The underground trade in stimulants is massive. People will pay $20 for a single pill on the street.

ADD medications like Adderall and Ritalin are stimulants, amphetamines or amphetamine-related compounds. They can be miraculously helpful when the doctor has the right diagnosis and prescribes them appropriately. I am a big believer in the value of such medications, because they work. I also know from experience that they can be terribly abused.

Here are some tips from the American Academy of Child and Adolescent Psychiatry:

Many students with Attention Deficit Hyperactivity Disorder (ADHD) attend college. College students with ADHD face a number of challenges, including choosing a supportive school and community where they can find and access medical services, get help with organizing their schedule and life, and succeed academically

Most people with ADHD are diagnosed before college. However, some people may not recognize the signs and symptoms of ADHD until they are at college. Trying to balance school work and the freedom of living away from home for the first time may be challenging. It can be natural to feel unfocused, distracted, overwhelmed, or disorganized when attending college. However, if these issues have caused significant problems in the past and are getting in the way of current functioning, the student may have ADHD.

If a student is struggling, it may be helpful to seek consultation with a qualified mental health professional. The diagnosis of ADHD is made based on a comprehensive clinical assessment. This may include information from multiple sources, including rating scales, getting history from the student, family, or past teachers if possible. There is no single test (brain imaging, blood testing, or psychological testing) that can reliably diagnose ADHD. Research shows that medication is the most effective treatment for ADHD. Cognitive-behavioral therapy, social skills training, and academic support can also be helpful.

There are many ways to successfully manage ADHD before and during college.

Preparing for and Staying Organized While at College

Consider the best college environment to meet your needs, such as class size, workload, academic calendar, and availability of support services. Resources to help you find the best college include: high school counselors, parents, friends who are in or have attended college, and national ADHD organizations or websites.

Learn about the medical services available at colleges before choosing where to go. Some college and university health centers do not prescribe ADHD medications. You may need to find a doctor in the surrounding community. Think about the transportation options and ease of access to that provider.

Talk with your doctor about how to best manage your medications when at college. Do not make changes in your medication without consulting your doctor. Ask your current doctor and the doctor at college to coordinate care. It is also helpful to have a history of your medications and your response to those medications for your new doctor.

If you have used tutors or support before college, think about continuing at college, at least for a little while.

If you need specific support or accommodations, register at the college disability office. If you have a summary of treatment or any psychological tests that were done within the last 3 years, bring them to the visit.

Practice using planners, calendars, or scheduling apps while still in high school. The demands on time management and organization increase greatly in college. Even if your parents helped you in the past, it is important to learn to do it yourself.

Managing Medications at College

Many medications prescribed for ADHD have to be monitored regularly. While at college, you need to schedule and keep your own medical appointments. Changes to your medication should only be made after talking with your doctor.

Learn how to use pharmacy services. Pay attention to prescription start dates and expiration dates. Many medications prescribed for ADHD are “controlled substances” so states may have additional rules on how these medicines can be provided, including limits on how often prescriptions can be refilled.

Taking medication that is not prescribed for you, sometimes called “diversion” or “academic doping,” is illegal and unsafe. Your medications were prescribed by your doctor who knows you and your medical history. They should only be taken by you. There are serious cardiac, neurological, and psychological risks of misusing ADHD medications. There can also be serious risks to mixing medications with alcohol or other drugs.

Keep medications safely stored or hidden to protect against theft. If medications are stolen, report it to campus or local police.
Adjusting to the academic, social, and organizational demands of college is difficult for most students. It can be especially difficult for students with ADHD. Arranging for support from medical and school professionals can help students with ADHD have a successful college experience, as well as a long career after graduation.

Should Children Take Antipsychotic Drugs?

A current article in Scientific American addresses a serious problem in psychiatry: the overmedication of children, not only by psychiatrists but also by pediatricians and family physicians. Some years ago I reviewed the case of a child who was admitted to a psychiatric hospital, and at the time of the admission this five-year-old was on three psychiatric medications. Five days later the child was discharged on five medications, four of which the child was not taking on Day One of the hospitalization. I was astonished. In the 1980's, when I was a medical director in a specialty hospital treating young children, these kids would stay with us for months, not days. The entire first month was devoted to getting the diagnosis right and developing a coherent treatment plan. Our assumption, which is still true today, is that the doctor and the team must get to know the patient.

According to Scientific American: "Modern antipsychotic drugs are increasingly prescribed to children and adolescents diagnosed with a broad variety of ailments. The drugs help to alleviate symptoms in some disorders, such as schizophrenia and bipolar disorder, but in others their effectiveness is questionable. Yet off-label prescribing is on the rise, especially in children receiving public assistance and Medicaid. Psychotic disorders typically arise in adulthood and affect only a small proportion of children and adolescents. Off-label prescriptions, however, most often target aggressive and disruptive behaviors associated with attention-deficit hyperactivity disorder (ADHD). “What's really concerning now is that a lot of this prescription is occurring in the face of emerging evidence that there are significant adverse effects that may be worse in youth than in adults,” says David Rubin, a general pediatrician and co-director of PolicyLab at Children's Hospital of Philadelphia. Here we review the evidence for the effectiveness of antipsychotic medications commonly prescribed for five childhood conditions. But do the benefits outweigh the risks?" To read the entire article, click here.

The mental health system can sometimes be complicated and difficult for parents to understand. A child's emotional distress often causes disruption to both the parent's and the child's world. Parents may have difficulty being objective. They may blame themselves or worry that others such as teachers or family members will blame them.

If you are worried about your child's emotions or behavior, you can start by talking to friends, family members, your spiritual counselor, your child's school counselor, or your child's pediatrician or family physician about your concerns. If you think your child needs help, you should get as much information as possible about where to find help for your child. Parents should be cautious about using the internet as their only source of information and referral.

Whole Brain Teaching

On my media page I have posted a video from PBS, a report on "whole brain teaching."

Research on the brain and how we think and act is influencing the way some teachers teach. Special correspondent John Tulenko of Learning Matters goes into a classroom where the instructor uses different methods to engage different parts of the students’ brains, then checks with a neuroscientist about whether that strategy actually works.

Whole Brain Teachers of America is a grass roots, education reform movement begun in 1999 by three Yucaipa, California teachers: Chris Biffle (college), Jay Vanderfin (elementary school) and Chris Rekstad (elementary school).
Whole Brain Teaching rests upon the principle that teachers at every level share the same difficulties: students lack discipline, background knowledge and fundamental problem solving skills. From kindergarten to college, teachers face students who have difficulty with reading and writing. Nonetheless, our students respond to challenges, enjoy well-designed learning games, and can make, in the proper setting, astonishing educational progress.

From their website: "At the root of Whole Brain Teaching is a large amount of highly structured, educational tomfoolery. Students learn the most when they are having fun. Whole Brain Teaching classrooms are full of task-focused laughter. Humor and games are used to increase the number of times students repeat core information and practice basic skills. Classes are highly disciplined and tightly organized because students have more fun following our rules, than ignoring them."

Drug Overdose Deaths, Injuries

Texas Had the 39th Highest Rate of Injury Deaths in U.S.

The good news? We are better off than 38 other states when it comes to events like drug overdose, car wrecks, killings, drownings, and the million other ways to die in The West. I just reviewed the report sponsored by the Robert Wood Johnson Foundation, a leading source of funding for medical research and education.

In The Facts Hurt: A State-By-State Injury Prevention Policy Report, Texas ranked 39th highest for the number of injury-related deaths in the state, with a rate of 55.3 per 100,000 people. Overall, the national rate is 58.4 per 100,000.

Rates in Texas decreased over the past four years for injury deaths, which includes drug overdoses, motor vehicle crashes, homicides and others. Overall, 17 states increased, 24 remained stable and 9 decreased. Injuries are the leading cause of death for Americans ages 1 to 44 – and are responsible for nearly 193,000 deaths per year.

Drug overdoses have become the leading cause of injury in 36 states, not including Texas, surpassing motor vehicle-related deaths.

Some key findings include:

Drug abuse: More than 2 million Americans misuse prescription drugs. The prescription drug epidemic is also contributing to an increase in heroin use; the number of new heroin users has doubled in the past seven years.

Key report indicators include the finding that 34 states and Washington, D.C. have “rescue drug” laws in place to expand access to, and use of naloxone - a prescription drug that can be effective in counteracting an overdose - by lay administrators. This is double the number of states with these laws in 2013 (17 and Washington, DC). While every state except Missouri has some form of Prescription Drug Monitoring Program (PDMP) in place to help reduce doctor shopping and bad prescribing, only half (25) require mandatory use by healthcare providers in at least some circumstances.

Motor vehicle deaths: Rates have declined 25 percent in the past decade (to 33,000 per year).

Key report indicators include observation that 21 states have drunk driving laws that require ignition interlocks for all offenders;
and while most states have Graduated Drivers Licenses that restrict times when teens can drive, 10 states restrict nighttime driving for teens starting at 10 pm; and 35 states and Washington, D.C. require car safety or booster seats for children up to age 8.

Homicides: Rates have dropped 42 percent in the past 20 years (to 16,000 per year).

The rate of Black male youth (ages 10 to 24) homicide victims is 10 times higher than for the overall population. One in three female homicide victims is killed by an intimate partner. Research shows that 31 states have homicide rates at or below the national goal of 5.5 per every 100,000 people.

Suicides: Rates have remained stable for the past 20 years (41,000 per year). More than one million adults attempt suicide and 17 percent of teens seriously consider suicide each year. Seventy percent of suicides deaths are among White males.

Falls: One in three Americans over the age of 64 experiences a serious fall each year, falls are the most common nonfatal injuries, and the number of fall injuries and deaths are expected to increase as the Baby Boomer cohort ages.

A key report indicator includes: 13 states have unintentional fall-related death rates under the national goal (of 7.2 per 100,000 people – unintentional falls).

Traumatic brain injuries: (TBIs) from sports/recreation among children have increased by 60 percent in the past decade.

Nationally, drug overdose deaths have more than doubled in the past 14 years – resulting in 44,000 deaths per year, and half of those deaths (22,000) are related to prescription drugs. Texas ranked sixth lowest for drug overdose deaths—at a rate of 9.6 per 100,000 people.

Texas scored three out of 10 on key indicators of steps states can take to prevent injuries – nationally, 29 states and Washington, D.C. scored a five or lower. New York received the highest score of nine out of a possible 10 points, while four states scored the lowest, Florida, Iowa, Missouri and Montana, with two out of 10 points.
Drug overdoses are the leading cause of injury deaths in the United States, at nearly 44,000 per year. Prescription drugs are the leading cause. 

These deaths have more than doubled in the past 14 years, and half of them are related to prescription drugs (22,000 per year).  Overdose deaths now exceed motor vehicle-related deaths in 36 states and Washington, D.C. And, in the past four years, drug overdose death rates have significantly increased in 26 states and Washington, D.C. and decreased in six.

The Facts Hurt report uses10 key indicators of leading evidence-based strategies that help reduce injuries and violence.  The indicators were developed in consultation with top injury prevention experts from the Safe States Alliance and the Society for the Advancement of Violence and Injury Research (SAVIR). 

The 10 indicators include:

Does the state have a primary seat belt law? (34 states and Washington, D.C. meet the indicator and 16 states do not.)

Does the state require mandatory ignition interlocks for all convicted drunk drivers, even first-time offenders? (21 states meet the indicator and 29 states and Washington, D.C. do not.)

Does the state require car seats or booster seats for children up to at least the age of 8? (35 states and Washington, D.C. meet the indicator and 15 do not.)

Does the state have Graduated Driver Licensing laws - restricting driving for teens starting at 10 pm? (11 states meet the indicator and 39 states and Washington, D.C. do not. Note a number of other states have restrictions starting at 11 pm or 12 pm.)

Does the state require bicycle helmets for all children? (21 states and Washington, D.C. meet the indicator and 29 states do not.)

Does the state have fewer homicides than the national goal of 5.5 per 100,000 people established by the U.S. Department of Health and Human Services (HHS) (2011-2013 data)? (31 states meet the indicator and 19 states and Washington, D.C. do not.)

Does the state have a child abuse and neglect victimization rate at or below the national rate of 9.1 per 1,000 children (2013 data)? (25 states meet the indicator and 25 states and Washington, D.C. do not.)

Does the state have fewer deaths from unintentional falls than the national goal of 7.2 per 100,000 people established by HHS (2011-2013 data)? (13 states meet the indicator and 37 states and Washington, D.C. do not.)

Does the state require mandatory use of data from the prescription drug monitoring program by at least some healthcare providers? (25 states meet the indicator and 25 states and Washington, D.C. do not.)

Does the state have laws in place to expand access to, and use of, naloxone, an overdose rescue drug by laypersons? (34 states and D.C. meet the indicator and 16 states do not.)

Score Summary: Texas Scores 3 out of 10

For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator. Zero is the lowest possible overall score, 10 is the highest.

9 out of 10: New York
8 out of 10: Delaware
7 out of 10: California, New Jersey, North Carolina, Tennessee, Washington and West Virginia
6 out of 10: Alaska, Colorado, Hawaii, Indiana, Kentucky, Louisiana, Maine, Minnesota, Nevada, New Mexico, Oregon, Rhode Island and Virginia
5 out of 10: Alabama, Arkansas, Connecticut, Georgia, Illinois, Kansas, Massachusetts, Oklahoma, Utah, Vermont and Wisconsin
4 out of 10: Arizona, District of Columbia, Idaho, Maryland, Michigan, Mississippi, New Hampshire, North Dakota and Pennsylvania
3 out of 10: Nebraska, Ohio, South Carolina, South Dakota, Texas and Wyoming
2 out of 10: Florida, Iowa, Missouri and Montana