You Asked

Questions from Dr. Michels' Lecture
November 9, 2010

Is ADHD/ADD a mental health/psychiatric illness? Is there any relation or link to depression, PTSD or other mental illness or abuse? (i.e. emotional physical abuse)

Attention Deficit Hyperactivity Disorder (formerly Attention Deficit Disorder) is a mental disorder listed in the Diagnostic and Statistical Manual of Mental Disorders. The disorder is characterized by inattention, hyperactivity and impulsivity. In order to be diagnosed with the disorder, one must have symptoms prior to the age of 7 years. Untreated ADHD in childhood can be considered a risk factor for other psychiatric disorders in adulthood.

Which mental illness in not polygenic?

Huntington's Chorea, which is a neurodegenerative genetic disorder characterized by a progressive loss of muscular control, cognitive decline and dementia. Other single gene disorders can manifest along with neuropsychiatric symptoms, but are not necessarily strictly classified as mental disorders, such as the porphyrias.

Is there medication that is helpful for narcissism? What treatment is helpful? How affective is it?

Narcissistic personality disorder is considered a severe personality disorder. There are different theories regarding its origin and a number of psychotherapies which address the disorder. There is no specific FDA approved drug treatment.

Some medicines like Clozaril seem like new chemistries, not just replications of previous medicines. How similar are they?

Clozapine (the generic name for clozaril) is actually quite old, its discovery going back to the early 1960s. Due to its sometimes remarkable effects in treating psychosis, pharmaceutical manufacturers have attempted to create medications that had similar efficacy while attempting to avoid its side effects. In the case of clozapine, these side effects (agranulocytosis, metabolic syndrome, risk of myocarditis, seizures) have limited the medication to treatment resistant schizophrenia. Its closest chemical cousin, olanzapine, has similar risk of metabolic complications but it is not as effective in treatment refractory schizophrenia. However, at the moment there are clinical trials involving other potential medications that may mimic clozapine's method of action.

Inheritability male vs. female - Would you be more apt to have a problem if your father or mother had the problem?

While there appears to be a greater preponderance of major depressive disorder in females versus male as opposed to the rates for bipolar disorder and schizophrenia, (which are equal in both sexes), there is no evidence for a significant difference with regard to heritability.

Bipolar <--------> Schizophrenia - one continuous line?

This is a very good and complex question that has occupied biological psychiatrists since the beginning. While our system of classifying Bipolar I (formerly manic-depressive illness) and schizophrenia have relied on the clear separation of the disorders from a diagnostic and prognostic standpoint, there is other evidence that in terms of genes that there may be a significant overlap. However, the treatment for the disorders as well as their life course, in general, is different.

Is there a cure for mental illness or only coping mechanisms and pills?

There is nothing more that most psychiatrists would wish for than a cure for major mental illnesses. However, these complex disorders are much more like other chronic medical conditions such as diabetes and hypertension and much less like infections that can be managed by a short course of antibiotics. Often in the course of a person's lifetime there are periods of remission and reoccurrences. Medications, while often effective, have rarely provided a definitive cure.

How concerned should we be about the effects of long-term use of anti-psychotics & anti-depressants? Are there any surgical solutions to depression and/or severe anxiety being studied?

Psychosurgery has a somewhat notorious past. Prior to the introduction of antipsychotics, frontal leucotomy (popularly known as lobotomy) irreparably damaged people for a period in which its use was quite popular. A famous case is that of Rosemary Kennedy (sister of JRK) who underwent the procedure in her 20s. After the introduction of antipsychotic medications, psychosurgery became much less prevalent. There are presently, a number of neurosurgical procedures for mental disorders and these are reserved fro the most serious cases where all approaches have failed and there continues to be severe functional impairment. For severe medication-resistant major depressive disorder, somatic treatments like ECT, vagal nerve stimulation, and deep brain stimulation may be considered. For severe medication-resistant obsessive compulsive disorder, procedures such as bilateral cingulotomy have been reported.

With regard to the effects of the long-term use of antipsychotics, this question is something that concerns all psychiatrists. Antipsychotics, are important medications that can help restore functioning in psychotic individuals, but are unfortunately not without risk. The older the antipsychotics had very significant rate of movement disorders where the newer medications (so-called atypicals) have a significant risk of metabolic disorders. As a result, the prudent psychiatrist will discuss these risks with the patient and family and monitor for these side effects. If the side effects cause significant problems, the psychiatrist will seek to treat these or if necessary change to another medication.

With regard to antidepressants, the newer antidepressants developed since the late 1980s have a somewhat better safety profile than older medications. For instance, tricyclic antidepressants were known to have significant toxic overdose effects, while the newer medications (SSRIs) are safer. However, no medication is without risk and the prudent physician (most prescriptions for antidepressants are actually by primary care physicians) should discuss them with the patient.

What do you see as the value in the theory of a viral cause in people with some minor mental illnesses?

We know for instance, that some people who get infectious illnesses (infectious mononucleosis) can develop significant mood symptoms following the illness and may take some time to recover. Theories have been put forth proposing the role of viruses in the development of mental disorders, none to date have been proved or disproved.

What are the chances of a spiritual emergency being mistaken for Schizo-affective disorder? Seeing the Devil, Hearing Demonic Voices, Isolating, Being "Hyper Religious"

The symptoms you describe appear to be psychotic. The question is in what context a person is experiencing these. For anyone who comes to a psychiatrist with these symptoms, before making a definitive diagnosis of a psychotic illness a number of other causes need to be ruled out. Among the most common are substances which cause psychotic symptoms and certain medical conditions. However, once those are ruled out and the context of the symptoms is established through a work-up and diagnostic interview, a diagnosis is highly unlikely to mistake spiritual beliefs for psychosis.

I am a concerned mother of a bipolar manic depressant addicted to alcohol. My question is what in the future will be available for addiction, to drugs or alcohol, that sometimes is part of mental illness?

Unfortunately, there is no definitive medication treatment for alcohol dependence. A number of medications exist, but need to be given along with psychosocial treatments (such as Alcoholics Anonymous). There is research in this area and we are hopeful that in the future better treatments may be developed.

Do you think reduced stays in psychiatric hospitals is due to insurance regulations? Rather than the rapid improvement of the mentally ill? Usually it takes 4-6 weeks to see therapeutic effect of psychotherapeutic drugs.

Better treatments and administrative reasons have contributed to the reduction in the length of stay in recent times.

What is your opinion of non-drug treatments for depression/long term clinical depression (i.e. ECT, TMS)? When should a patient consider trying any of the above after having tried many drug treatments?

ECT (Electroconvulsive therapy) is a highly effective treatment for severe, depression that is medication resistant. However, it should not be casually considered due to potential side effects, such as y memory loss. TMS (Transcranial Magnetic Stimulation) has shown some promise in the treatment of depression and has been approved by the FDA. However, cost and availability are factors that have presently limited its use. Another modality that is under investigation is DBS (Deep Brain Stimulation). The field is continually looking for news; safe and effective treatments.

With regard to when a patient should consider these, this would be a discussion that an individual patient should have with their psychiatrist.

Do other countries have other percentages of mentally ill (than America's 1/3 of citizens?) Less? More?

That depends on how one defines mental illness. For instance, countries with strict legal prohibitions on alcohol have much lower rates of alcoholism. However, it is thought that for the major mental illnesses there is little significant difference between the rates in different countries.