The Brain Science of Caffeine

It's Pumpkin Spice Latte Season -- what better time to pour a cup of Caffeine: Neurological and Psychiatric Implications? It's the next up in my PsychiatricTimes.com Appreciation Month.

Sergi Ferré, MD, PhD offers this continuing education course for doctors and other health care providers. The goal of this activity is to provide an understanding of the mechanisms involved in the innervating effects of caffeine and the impact that caffeine may have on psychiatric disorders.

So settle in to learn about your favorite beverage.

Disclaimer: Though I have read the thing many times and looked up many big words, I cannot honestly say that I have satisfied all of the learning goals. Specifically, I cannot:

• Explain the adenosine-dependent modulation of striatal dopamine and glutamate neurotransmission

nor

• Describe the adenosine-dependent modulation of glutamate neurotransmission in the amygdala.

Good thing I don't need the grade.

Nevertheless, I gleaned a few fun facts which I will share with you.

Caffeine is the most commonly consumed psychotropic drug in the world, used primarily for its psychostimulant properties on the central nervous system. Yes, I think we already knew that, but it's nice to begin with a softball.

Trading Symptom Relief for Side Effect Relief

Why do people stop taking their psych medication?

Psychiatrists spend a lot of time on this question. They used to call it noncompliance. Then they figured out that the word fed the power struggle between doctor and patient. Now they call it nonadherence. Me, I am not convinced that the word change reflects an attitude shift on doctors' parts, i.e., that they have changed their attitudes toward noncompliant patients, have abandoned the power struggle themselves, and instead want to partner with their patients. I suspect the word change is a cosmetic shift designed to change the patient's attitude.

Psychiatric Times regularly publishes articles on why patients don't take their meds and best practices for improving adherence. Suboptimal adherence is pervasive among individuals with chronic health conditions, including psychiatric disorders... However, many mental health practitioners ascribe nonadherence to the mental illness itself.

Physician-Assisted Suicide for Mental Illness - It's Complicated, or Not

Two years ago, Mark Komrad attended and presented at a symposium in Belgium on physician-assisted suicide for people with mental illness. Komrad is a clinical psychiatrist, ethicist, and faculty member at Johns Hopkins. He just finished a 6-year tenure on the APA Ethics Committee and helped craft the current APA position on Medical Euthanasia for non-terminally ill patients. [That position joins the AMA to say, in a word, Don't.]

Komrad reported back on his experiences to PsychiatricTimes.com. You can read or listen to the his entire report here. This post quotes the parts that particularly struck me from a suicide prevention perspective.

In 2002 Belgium legalized euthanasia by physician (typically by injection) at the request of patients, and removed any distinctions between terminal vs. nonterminal illness, and physical vs. psychological suffering. As long as the condition is deemed "untreatable" and "insufferable," a psychiatric patient can be potentially eligible for euthanasia. There is a consultative process that basically needs a minimum of two doctors to agree about the patient's eligibility. Also, the patient gets to weigh-in on whether their condition is "treatable." Since the patient has the option to refuse treatments, this refusal may create an "untreatable" situation.

Got Bipolar 2? Chris Aiken Can Help

If you want to know best practices for treating bipolar, "bipolar not so much," recurrent depression, "more than depression," "something-about-this-depression-treatment-just-isn't-working," read  Chris Aiken.

When I needed a subtitle for my book, I tried really hard to sell my publisher on What if it's more than depression? - a subtle reference to Bipolar Not So Much by Aiken and Jim Phelps, who is another of my mental health go-to resources. I flatter myself that Prozac Monologues is the companion piece, written from the other side of the prescription pad. The publisher had something else in mind, but if you find one book useful, you will like the other.

When my new nurse practitioner talked me into a chart review by the cookie cutter psychiatrist employed by the practice, the recommendation came back, Abilify and Zoloft. I said, No thanks, and sent her an article by Aiken. I hope it helps my NP get over her Free-Range Bipolar on Aisle 2 (i.e., non-medicated) panic before my next appointment. Aiken reports that Social Rhythms Therapy (my lifeline for years) can be as effective as medication, without the sedating effects that would have ended my writing career. Not to mention most other reasons to get up in the morning. Or even capacity to get up in the morning.

Preventing Suicide Among Gun Owners

Can we reconcile a most basic suicide prevention strategy, means restriction with the 2nd Amendment? Gun owners and public health people have to find a way to talk about this. In Oregon, the conversation has begun.

Gun owners in rural have a sense of responsibility and honor. It's a thing. Part of that responsibility is to protect one's family, one's livestock, and oneself. So let us begin by acknowledging that some gun owners, the ones who live in rural areas where suicide rates are growing the fastest, need guns for protection. But they have to do the protecting themselves. The government, on account of distance and distrust, cannot do the job. And then let us acknowledge that one of the things they need to protect their families (and maybe themselves) from is suicide.

Compare states to states.  Compare regions to regions.  Compare states within regions to other states within the same region.  Compare people of the same age group, in any age group, men to men and women to women.  Compare unemployed people to unemployed people, working folk to working folk.  Compare city dwellers to city dwellers, country folk to country folk.

Compare people with depression to other people with depression; people who are suicidal to other people who are suicidal; people who have a plan to other people who have a plan; people who have a past suicidal attempt to other people who have a past suicidal attempt, for God's sake!

More Guns = More Suicides.

Get it? Rural areas have more suicides largely because they have more guns.

Warning Signs and Suicide Hot Lines Won't Fix This

A psychiatrist remembered his first days on his ER rotation. He dealt with a woman who had tried to kill herself. She was homeless, had been taking meth so she wouldn't sleep ever since she had been raped on the street. The supervisor asked what the young doc intended to do. "Prescribe antidepressants?"

They both knew how stupid that sounded.

In the 80s and 90s, they thought they had this suicide thing figured out. As the number of prescriptions for Prozac rose, the suicide rate was falling. It was widely claimed by people who flunked logic that this was epidemiological evidence that Prozac prevented suicide. Just get more people into treatment. This kind of error is common enough to have its own name: post hoc ergo propter hoc. Or maybe there was some economic incentive behind that sloppy thinking...

Passive Suicidal Ideation and Suicide Prevention Awareness Month

Anna Borges speaks truth about suicidal ideation. In the midst of Suicide Prevention Awareness Month, with its lists of warning signs and gearing us up for the crisis, Anna brings to light the sometimes everyday-ness of suicidal ideation.

I am not always very attached to being alive, she wrote in at article for The Outline, an online magazine. It's not about being in crisis, not about having a "plan," not about needing an intervention. It's more like an indifference to life that sometimes surges into something more serious and then falls back. Like the waves of an ocean.

At 27, I’ve settled into a comfortable coexistence with my suicidality. We’ve made peace, or at least a temporary accord negotiated by therapy and medication. It’s still hard sometimes, but not as hard as you might think. What makes it harder is being unable to talk about it freely: the weightiness of the confession, the impossibility of explaining that it both is and isn’t as serious as it sounds. I don’t always want to be alive. Yes, I mean it. No, you shouldn’t be afraid for me. No, I’m not in danger of killing myself right now. Yes, I really mean it.