Political Involvement of Psychiatrists

Here's another excellent question from a visitor to the site:

Political involvement of psychiatrists: We live in a "therapeutic culture". [There] are changing sociocultural norms for what is considered normal and acceptable. Are--and should--psychiatrists be aware of the sociological and political changes occurring as a result of the millions taking antidepressants or receiving psychotherapy? Should psychiatrists take a more active role in managing forces that influence communities, given the positive therapeutic effects of unconditional positive regard, hope, trust, interpersonal connection, and belonging (some of the common factors)?

Psychiatrists as a group are extremely heterogeneous, in terms of personality style, intellectual background, and political beliefs. Those who involve themselves in administration or politics may do so in a loving attempt to help their community, but may also do so due to a need to have more influence, control, money, or self-aggrandizement (to be fair, I suppose most people would be motivated by all of these factors, to some degree). There are a lot of big egos in psychiatry, just like everywhere else.

I've often thought of the ideal role of psychiatrist (politically) as some kind of monastic figure ("Jedi-like", if I could indulge in a popular culture metaphor): serenely outside the political machine, possessing wisdom but healthily setting aside the need to exert power or control at all. This type of paradigm is in conflict with the competitive and ambitious world of politics or administration.

I do agree that we all need to be more active in informing ourselves about political concerns, and attempting to help not only individuals, but also groups, communities, or nations. And psychiatry as an organized group most definitely needs to be aware of large-scale social effects of treatments such as psychotherapy and medications.

In very dark and troubled times, or in dark and troubled parts of the world, very bad things can happen politically. The institution of psychiatry has sometimes been involved in these events. At other times, psychiatrists or therapists are themselves persecuted. It is a luxury to live in a peaceful and free nation, and we need to be vigilant to maintain social and political freedom.
Here are a few articles about this:
http://www.atypon-link.com/GPI/doi/pdf/10.1521/prev.88.2.295.17677 (an essay about psychiatry in Nazi Germany)
http://www.nybooks.com/articles/16082 (an 2003 excerpt published in the New York Review of Books about psychiatry in China)

Neurology & Psychiatry

Here's another question from a visitor to the site:

"Neurology and Psychiatry: ...I continue to read the scientific literature and I find it somewhat arbitrary how different fields are divided up. What do you think of joining psychiatry and neurology?"

The field of "neuropsychiatry" is extremely interesting. At UBC there is a specialized ward devoted to helping patients who suffer from a combination of neurological diseases (such as epilepsy, head injuries, etc.) and psychiatric illnesses. Some "neuropsychiatrists" have completed specialty training in both neurology and psychiatry. At UBC a particular focus in neuropsychiatry has been the treatment of severe somatization and conversion disorders: these are psychiatric illnesses which present with severe physical or neurological symptoms (such as paralysis, blindness, or seizures). In conversion disorders, symptoms such as paralysis, blindness, or seizures, are not caused by neurologic problems such as stroke or epilepsy, but by severe, complicated depression in most cases. Treatment of the underlying psychiatric illness causes the neurological symptoms to disappear.

So, neurology and psychiatry do have an intersection in current practice. However, many neurologists may not be predisposed to dealing with psychiatric problems, or may not be willing to offer the type of regular follow-up which I believe is a healthy standard of care in psychiatry (unfortunately, the same could be said of some psychiatrists). Conversely, most psychiatrists would be uncomfortable dealing with acute or esoteric neurological problems.

So, in practice, while neurology and psychiatry have an overlap, the areas outside of the overlap are sufficiently large for the specialties to exist separately.

Passion Flower

There's not a lot of research information about passion flower's medical effects.

It's a beautiful flower though! I would encourage having some in your garden if possible.

Here's a reference to a 2007 Cochrane review:
http://www.ncbi.nlm.nih.gov/pubmed/17253512

Passion flower is mentioned in a good 2006 review article on complementary medicines in psychiatry, from The British Journal of Psychiatry:
http://www.ncbi.nlm.nih.gov/pubmed/16449696

Here's a reference to a 2001 study from Iran, showing that passionflower relieved anxiety to a similar degree as oxazepam (a benzodiazepine), over a 4 week trial.
http://www.ncbi.nlm.nih.gov/pubmed/11679026

The same author published a study suggesting that passionflower could help with opiate withdrawal symptoms:
http://www.ncbi.nlm.nih.gov/pubmed/11679027

In conclusion, not a lot of evidence. The existing studies are only of short duration. But passionflower extract does look like an interesting substance to research further.

"Micronutrient Treatment"

There are examples of "micronutrient treatments" being marketed to help various mental health problems.

These treatments may be marketed aggressively: there may be slick internet sites, perhaps with an enthusiastic following of people who believe strongly in the product.

If the manufacturer of such a product is quoting "research studies," I encourage you to look carefully at the studies referred to. If you are seriously considering products of this type, I would suggest looking at the articles in their entirety at a library.

I encourage anyone interested in pursuing treatments of this sort to ask the following questions:

1) What type of evidence exists regarding effectiveness & safety? Is the evidence from large, double-blinded, randomized, controlled studies conducted by researchers who do not have financial connections with the manufacturer?

2) Is the research pertaining to the product published in a journal with high scientific standards? (In order to answer this question for yourself, I would invite you to leaf through numerous issues of the journal, and compare this with an independent, peer-reviewed journal such as Lancet or The New England Journal of Medicine).

2) Is the evidence mainly from enthusiastic testimonial accounts or case studies? Is this type of evidence reliable enough for you?

3) How much money is required to purchase the treatment? Does the manufacturer encourage you to involve yourself in a long-term financial commitment?

4) After acquainting yourself with common sales and marketing tactics (for a primer on this subject, see Robert Cialdini's book, The Psychology of Persuasion), do you see evidence of highly persuasive or biased sales tactics being used in the marketing of the product? Are vulnerable people being taken advantage of in the marketing of the product?

Have a look at this link, which gives a brief history and overview of charlatanism--being familiar with this history may allow you to make more informed choices about your own medical care:
http://en.wikipedia.org/wiki/Quackery

I do not mean to single out alternative remedies in this post--I encourage the same critical standards to be applied regarding all types of therapy. Mainstream pharmaceutical manufacturers and other providers of mainstream therapies may often be guilty of devious marketing behaviours. In my opinion, though, mainstream pharmaceutical manufacturers have a much harder time getting away with overt charlatanism at this point, compared to many manufacturers of alternative remedies.

Also, I wholeheartedly acknowledge that there can be alternative remedies which are helpful, and which are marketed ethically.

Here in Canada, we live in a free society, with a strong emphasis on freedom of speech. Imposing more strict legal restrictions or regulations upon health choices would limit freedom. I support maintaining a free society, but the presence of charlatanism is one of the costs of this freedom.

Inositol

Inositol is chemically similar to glucose (the type of sugar required by the brain for energy). It is a precursor in a so-called "second messenger system," which cells require to communicate with each other. In the brain, these second messenger systems are activated by various neurotransmitters including serotonin. There is some evidence that brain levels of inositol are reduced in depression and anxiety disorders. Inositol is present in a typical diet, in amounts of about 1 gram per day. Doses of supplemental inositol are typically 10-20 grams per day.

A Cochrane review from 2004 concluded that there was no clear evidence of supplemental inositol being beneficial in the treatment of depression:
http://www.ncbi.nlm.nih.gov/pubmed/15106232

Here's a 2006 reference from Bipolar Disorders showing that supplemental inositol could help treat bipolar depression in some patients already taking lithium or valproate. In 4 out of 9 patients taking 6-20 grams per day of inositol, their depression substantially improved over 6 weeks, with continuing improvement over an additional 8 weeks. However, the other 5 out of 9 patients either did not improve, or actually had worse symptoms. The patients who got worse had more manic or irritable symptoms at the beginning of the trial. When the results were averaged, the inositol did not appear to help significantly--however, it is notable that a subgroup of patients appeared to benefit significantly.
http://www.ncbi.nlm.nih.gov/pubmed/16542187

This 2001 study from the Journal of Clinical Psychopharmacology compared 1 month of inositol (up to 18 grams per day) with fluvoxamine (up to 150 mg per day) in the treatment of panic disorder. Both groups improved similarly. The fluvoxamine group had more side effects of tiredness and nausea. The study is limited by its short duration.
http://www.ncbi.nlm.nih.gov/pubmed/11386498

This 1995 study from the American Journal of Psychiatry compared 12 grams per day of inositol with placebo, for one month, in the treatment of panic disorder. The authors conclude that inositol was effective with no significant side effects. Mind you, when eyeballing the chart of data from individual patients, the results did not look very impressive.
http://www.ncbi.nlm.nih.gov/pubmed/7793450

Here's a negative study, showing no difference between inositol and placebo, when added to antidepressant therapy for OCD:
http://www.ncbi.nlm.nih.gov/pubmed/11281989

The same author as above published a study in 1996 showing that inositol on its own was superior to placebo for OCD treatment. However, despite "statistical significance" being found, eyeballing the data from each patient (presented in the body of the paper) reveals doubtful clinical significance (that is, the amount of benefit looked quite unimpressive to me):
http://www.ncbi.nlm.nih.gov/pubmed/8780431

Here's a reference to a 2001 study showing that inositol was superior to placebo in treating binge eating and bulimic symptoms. In this case, I found the data to be clinically significant. However, the study was limited by its small size.
http://www.ncbi.nlm.nih.gov/pubmed/11262515

Here's a small 1995 study showing that 4weeks of inositol (12 grams per day) was superior to placebo in treating depressive symptoms. The data appeared clinically significant, though modest.
http://www.ncbi.nlm.nih.gov/pubmed/7726322

Here's a 2004 reference from a dermatology journal showing that inositol supplementation led to improvement of psoriasis in patients taking lithium:
http://www.ncbi.nlm.nih.gov/pubmed/15149510

In conclusion, inositol may be modestly effective for treating anxiety, eating disorder, and depressive symptoms. It may perhaps be quite variable in its effectiveness, i.e. some individuals might have much more benefit than others. It appears to be well-tolerated with few side-effects. I could not find good data on long-term safety though. The quality of the evidence is not very robust-- the studies have involved only small numbers of patients, for short periods of time. More research is needed.