Researchers discover that heavy smoking during adolescence leads to anxiety disorders in young adults.

Scientists supported by the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) have documented that chronic cigarette smoking during adolescence may increase the likelihood that these teens will develop a variety of anxiety disorders in early adulthood. These disorders include generalized anxiety disorder, panic disorder and agoraphobia, the fear of open spaces.

Researchers from Columbia University and the New York State Psychiatric Institute report their findings in the November 8 edition of the Journal of the American Medical Association (JAMA).

Scientists have known of strong connections between panic disorder and breathing problems in adults. Given this association, the research team hypothesized that smoking might also relate to risk for panic disorder in children and adolescents through an effect on respiration.
"Numerous studies have shown that smoking causes a number of diseases, " says NIDA Director Dr. Alan I. Leshner. "This study is important because it highlights how cigarette smoking may rapidly and negatively affect a teen's emotional health-perhaps even before any of the widely known physical effects such as cancer may occur."

"These new data provide further evidence of commonalities between processes associated with anxiety in children and adults," says Dr. Daniel Pine, Chief of NIMH's Section on Developmental and Affective Neuroscience.

The researchers interviewed 688 youths and their mothers from 1985 to1986 and from 1991 to 1993. They found that a startling 31 percent of those adolescents who smoked 20 or more cigarettes per day had anxiety disorders during early adulthood. Among those who smoked every day and had an anxiety disorder during adolescence, 42 percent began smoking prior to being diagnosed with an anxiety disorder and only 19 percent were diagnosed with anxiety disorders before they reported daily smoking.

The research team used a community-based sample that has served as the foundation of a longitudinal study that has been ongoing for the last 25 years. They were able to exclude a wide range of other factors that might determine whether or not a smoking adolescent or young adult develops anxiety disorders, including age, gender, childhood temperament, parental smoking, parental education, parental psychopathology, and the presence of alcohol and drug use, anxiety, and depression during adolescence.

Source: NIMH, Nov. 2000

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The Difficult Boss

At one time I had a boss named Tom who operated his business on a continuous stream of crisis management. His modus operandi was stress and panic. He was quick to criticize, rare to praise, and was always on the look out for who to blame.

"Transform an apparent disadvantage into an opportunity."

I wasn't enjoying the working there, it was not a fun place to be. I found myself being more stressed and spending more and more precious time and energy involved in gripe sessions with the other employees. It's like we were all comparing notes to makes sure we weren't insane.

After a few months on the job, I realized I was complaining about him almost daily to my husband. It seemed like every time I'd discuss work, it would begin with "guess what he did today!" At some point I asked myself, how can this situation be an opportunity? What possible good could come of this?

Then it hit me. This man pushed my buttons! Here I was talking about how no one can make you feel anything without your permission, yet I was thinking and speaking as if my boss was making me feel stressed, unappreciated and unhappy.

Ah ha! What an opportunity! This was an opportunity for me to really walk my talk. It was a change for me to identify and remove the buttons my boss was pushing. It was not only an opportunity to prove to myself it could be done, but if successful, I would be creating a better work environment for myself.

There was no way I would ever be able to change him or his behavior. It simply was not possible. If the situation, or my response to the situation to be more accurate, was to change, I would have to change myself.

The first thing I did was identify and describe the buttons (beliefs) he was pushing. What were the situations where I felt the most stressed? When did I feel the most unappreciated? When was I most unhappy at work?

continue story below

Using the Option Method, I was able to identify three core beliefs that were operating and contributing to my dismay. Those were....

If a boss approaches you with stress in their voice, and asks if you have something completed yet, that means that you're someone who can not be trusted to complete jobs on your own. And that translates into you being incompetent.

If you don't receive appreciation for your work (i.e.: no at-a-boys, good job, nice work, type comments) that means you're not doing a good job.

If a boss is stressed out, you too have to become stressed out to show him or her you care as much as he or she does.

I was able to re-examine those beliefs for accuracy and find out if they were really true.

1. To address the first belief, I needed some standard of measurement to determine if I was a good worker. So I asked myself, am I a trustworthy and competent worker? After a lot of soul searching, the answer came out to be Yes. Yes, I am skilled in what I do, I put out quality work quickly, and I meet deadlines. I also identified certain activities I procrastinated doing because I didn't enjoy doing them. I vowed to change those. But on the whole, I'm a responsible, trustworthy and competent worker.

So with this in mind, what did it mean when Tom became stressed and questioned my work? I determined that this was his way of dealing with responsibility and it had nothing to do with me and my work. He acted this way with everyone. His approach had everything to do with him, and nothing to do with me.

2. What about not receiving any praise? Did that necessarily mean I wasn't doing a good job? Again, I determined that someone could be doing good work and receive no acknowledgment for it. I concluded that if I wanted any praise, I was going to have to give it to myself.

3. Was it possible to care about your work and NOT be stressed out about it? Yes, that was not only possible, but doable. One could care yet not make themselves miserable when there were snags or difficulties. I did care but I didn't want to feel stress.

After going through this process of examining my beliefs, I realized that there was still some lingering doubts and fears. I was changing my beliefs which would change my responses and how I felt, but what about Tom? I wasn't changing him. He might interpret my not being stressed as a sign that I don't care about my work. What if he thinks all those things and fires me?!?

Did getting fired mean my work was bad? No. I had already established the value of my work. I was afraid I wouldn't be able to find another job I liked as much or got paid as well. I concluded that that belief was not true. I COULD find another job that paid as much. And, if I was fired for not being stressed, that was actually a GOOD thing, cause I didn't want a job where I had to be stressed out to demonstrate my caring.

So with all these newly revised beliefs and fresh perspectives, I was actually eager to go to work and face Tom. It became a challenge I was excited about facing. So far, it had only been conceptual. Would I be able to pull it off when faced with reality?

By George, it worked! After a month or so, I completely changed my experience at the job. I won't kid you, it wasn't instantaneous. There were times I would react out of habit. But for the most part, my work environment changed enormously. I was no longer riddled with self doubt about my work, or stressed.

And there were some surprising manifestations to my new beliefs that I hadn't anticipated. Since his words and actions no longer meant anything about me, I was able to see him more clearly. I no longer felt disdain but compassion for him. He was so hard on myself, putting himself through so much angst. It wasn't pity, but more like a new connection with him because I could relate. He was doing the best he could. We ended up developing a friendship.

My co-workers noticed the difference as well. We use to joke around about "who's turn is it today?" meaning, who was going to be the one he picked on that day. Now they made comments like "he doesn't pick on you as much." I also think I was able to help them see that his comments said nothing about them, but more about his "style" of working and management.

What an opportunity this apparent disadvantage turned out to be.

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Social phobia, a paralyzing fear of social situations, may be brought on by a combination of genetics and child-rearing methods.

Teenagers are notorious for blaming all their problems on their parents. Sometimes they may be right, but just as often they may be wrong. But if your teen has a social phobia, he or she may have hit paydirt in the blame department.

According to a group of American and German researchers, social phobia -- a paralyzing fear of social situations -- may be brought on by a combination of genetics and child-rearing methods. The researchers found that children overprotected or rejected by parents who suffer from depression or anxiety are more likely than other kids to develop the mental disorder, though not necessarily destined to develop it.

"We've studied parental mental illness and parenting style as potential risk factors for adolescents developing social phobia, and we found that both contribute to the risk," says study author Roselind Lieb, PhD. She is with the department of clinical psychology and epidemiology at the Max Planck Institute of Psychiatry in Munich, Germany. Her study appears in the September issue of the Archives of General Psychiatry.

The researchers conducted two sessions of extensive interviews 20 months apart with more than 1,000 teen-age subjects. The participants were 14 to 17 years old, mostly middle class, attending school, and living with their parents at the time of the first interview session. One parent of each child -- the mother, unless she had died or could not be located -- also underwent similar, independent interviews.

They used several questionnaires to assess parenting style (rejection, emotional warmth, overprotection), and how well the family was functioning (problem solving, communication, behavioral control), and they diagnosed the parents and children using internationally accepted psychiatric criteria.

Lieb's team found no link at all between family functioning and teenage social phobia. They did find, however, that teenagers with parents who had social phobia, depression, or other anxiety disorders or who abused alcohol, as well as those with parents who were overprotective or rejected them, were at a significantly increased risk of developing social phobia.

When asked why and how these parental factors might be leading to social phobia in the teenagers, Lieb says that "the design of the study doesn't let us determine cause." Both parental history of mental illness and child-rearing traits are playing important roles in the equation, she says, "but we do not know how they interact."

She will, however, hazard a guess. "It's possible that it's a genetic mechanism, and it's also possible that it's behavioral modeling, [that is] children learn how to act in social situations by watching their parents." Because anxious parents might not encourage social activities in their children, the children never learn how to behave in such situations. "Finally, we can imagine complicated interactions between genetic and environmental factors," she says, although the nature of that interaction remains unclear.

But according to Debra A. Hope, PhD, who reviewed the study, Lieb's team has "overreached their conclusions a little bit." For one thing, she says, the parental interview responses were inconsistent with those of the teenagers. So what the study tells us "is that adolescent perception of parenting style is related to social anxiety." This may be important, but "it is very different from saying that the actual parenting style is to blame," she says.

"Another really important point is that this study was not about parenting," says Hope, "it's about mothers. They interviewed very few fathers, which is a poor design." Hope is a professor and director of the Anxiety Disorders Clinic at University of Nebraska in Lincoln.

Still, Hope adds that the data has a hopeful message for concerned parents. "It's important for the public to know that social phobia has both family environment and genetic components. Not all anxious parents have anxious kids, and not all anxious kids have anxious parents. It does run in families, but that's not the whole picture by any means. Parents with anxiety disorders shouldn't be excessively worried about passing it on to their kids. "

Lieb says that future work will "look deeper into parts of the puzzle in very early childhood that might lead to developing social phobia in adolescence."

Sources:

• Archives of General Psychiatry, Sept. 2000.
• Debra A. Hope, PhD, professor and director of the Anxiety Disorders Clinic at University of Nebraska.

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Two potentially fatal side-effects of antipsychotic medications - NMS and Serotonin Syndrome. Could you recognize these psychiatric emergencies?

Virtually all antipsychotic drugs-and even some dopamine-blocking agents and antidepressants-carry the risk of a potentially fatal reaction. Your ability to recognize the symptoms and intervene quickly can save a patient's life. Two days after being admitted to the psychiatric ICU for an exacerbation of paranoid schizophrenia, 35-year-old Scott Thorp was still not improving. Not only did he continue to suffer psychotic symptoms, but he complained of feeling "extremely uneasy" and "jittery inside." Because Mr. Thorp was being treated with the high-potency antipsychotic drug haloperidol (Haldol), the staff conducted a routine assessment for extrapyramidal symptoms (EPS) and recognized his restless movements as akathisia-a common adverse effect of such medications-rather than illness-related agitation. The akathisia subsided after four doses of the anticholinergic agent benztropine mesylate (Cogentin) were administered over two days.

But on day 3, Mr. Thorp's condition worsened. He developed lead-pipe muscular rigidity with resistance of the upper extremities. His BP fluctuated wildly, and he was mildly tachycardic, with a pulse rate of 108/114. His nurse also noted tremulousness and, to her surprise, urinary incontinence.At shift change, his temperature was 101.4° F (38.5° C), he was confused, lethargic, and noticeably diaphoretic. The nurse looked again at the elevated temperature and began to suspect an adverse reaction to haloperidol-and she was right. Mr. Thorp had developed neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening side effect of antipsychotic medications.1 Besides elevated temperature, Mr. Thorp had other signsautonomic dysfunction (which includes hypertension, tachycardia, urinary incontinence, and diaphoresis) and muscular rigidity-that are "red flags" for NMS. The nurse immediately contacted the attending psychiatrist, who ordered that haloperidol be discontinued and Mr. Thorp be transferred to the medical ICU.

There, lab results confirmed a diagnosis of NMS. They showed increased levels of lactic dehydrogenase (LDH), serum creatine phosphokinase (CPK), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). Mr. Thorp's WBC count was also elevated-another lab finding that confirms NMS, in which WBC levels as high as 40,000/mm3 have been reported.2 Mr. Thorp's labs also revealed that he had become dehydrated and was hyperkalemic. His urinalysis revealed proteinuria and myoglobinuria, two signals of muscle deterioration and early indicators of renal insufficiency.

Recognizing the signs of NMS

NMS is an extreme medical emergency. Although it occurs in no more than 1% of patients who take antipsychotic medications,1 NMS develops rapidly, and death occurs in about 10% of cases, largely because of the consequences of severe rigidity and dehydration, including acute renal failure, respiratory distress, and deep vein thrombosis.2,3 NMS is believed to be caused by an acute reduction in dopamine activity as a result of drug-induced dopamine blockade. It was first described in 1960 during early studies of haloperidol, but it can occur with virtually any antipsychotic medication. Although NMS was not originally thought to occur with newer "atypical" antipsychotics such as clozapine (Clozaril) and risperidone (Risperdal), the syndrome has been associated with both those agents as well as with lithium carbonate (Eskalith, Lithane, Lithobid) and with dopamine-blocking antiemetics such as metoclopramide (Reglan) and prochlorperazine (Compazine).1,2 NMS or NMS-like side effects may also occur with some antidepressants, such as monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants.2-4 Signs of NMS usually appear within two weeks after therapy is begun or the dosage of the medication is increased. Hyperthermia, severe muscular rigidity, autonomic instability, and changing levels of consciousness are the four major hallmarks.1,2 Temperatures of 101° F (38.3° C) to 103° F (39.4° C) are not uncommon, and, in some cases, rise as high as 108° F (42.2° C).3 The leadpipe rigidity of the upper extremities Mr. Thorp exhibited is the most common form of muscle rigidity, but the ratcheting movement of the joints known as cogwheeling is also seen; in addition, the muscular rigidity can affect the neck and chest, leading to respiratory distress. As seen with Mr. Thorp, rapid physical decline occurs over the course of two to three days. NMS may be difficult to recognize. It can occur along with a cluster of other extrapyramidal symptoms and has been associated with dystonia and parkinsonism. Many times akinesia, a generalized slowing of movement, with fatigue, blunted affect, and emotional unresponsiveness, is present rather than akathisia. Akinesia can easily be mistaken for the vegetative symptoms of a major depressive disorder. In addition, several disorders have symptoms similar to those of NMS, including catatonia, degenerative diseases of the brain, heat stroke, infections, and malignant hyperthermia.

The rise in temperature caused by NMS could be mistaken for a sign of pneumonia or urinary tract infection. But symptoms of confusion, disorientation, muscle rigidity, and rapid change in temperature for no physiological reason should always trigger an evaluation of a patient's medications. Tachycardia, for example, can be a side effect of drugs like clozapine and chlorpromazine hydrochloride (Thorazine). Furthermore, high temperature, confusion, and disorientation are not usually seen with psychosis. Which patients are more likely to develop NMS? The syndrome occurs twice as often in men as in women, and patients who have had prior NMS episodes have a higher risk of recurrence.2 Certain medications, alone or in combination, and how they are administered increase the risk of NMS: rapid titration or high-dose administration of a neuroleptic, IM medications that form a deposit and are released over time (called a depot injection), use of high-potency neuroleptics like haloperidol and fluphenazine hydrochloride (Prolixin), lithium alone or in combination with an antipsychotic, and the combination of two or more neuroleptics. Exhaustion and dehydration put patients who are taking neuroleptics at higher risk of NMS, as do akinesia and organic brain disease. The syndrome also occurs more frequently in hot geographic regions.

Providing treatment and supportive care

Given its life-threatening complications, NMS calls for early recognition and immediate intervention. A psychiatrist or neurologist with expertise in NMS should be consulted at the first signs of this syndrome. The most critical intervention is to discontinue neuroleptic therapy. If the patient had received a long-acting depot injection, however, it may take as long as a month to bring symptoms under control. Medications that are most frequently used to treat the syndrome are bromocriptine mesylate (Parlodel), an antiparkinsonian dopaminergic drug; and dantrolene sodium (Dantrium), a muscle relaxant. As seen in Mr. Thorp's case, anticholinergics such as benztropine, while effective in the treatment of extrapyramidal symptoms, are not helpful in treating NMS. As medications are administered, be alert to potential toxicity or adverse effects. With dantrolene, there is an increased risk of liver toxicity as well as phlebitis at the IV site. You will also need to provide supportive care to control and reduce fever, treat secondary infections, and regulate vital signs and cardiac, respiratory, and renal function. Renal failure is treated with hemodialysis, as necessary. Since the patient may well become confused, determine whether additional safety measures are needed. Sedatives may also be called for. A change of position and decreased environmental stimulation may make the patient more comfortable. Understandably, NMS is painful and frightening for the patient and emotionally upsetting to the family. Make time to explain what has happened and why, and what the treatments are designed to do. With the measures described, NMS usually resolves in one or two weeks. The patient's level of consciousness should improve, and delirium and confusion should decrease. However, the patient's episode of psychosis may continue until after an antipsychotic medication can be reintroduced. You'll want to do frequent mental status assessments, monitor I & O, and evaluate lab results. Once the NMS symptoms are under control (and, ideally, not until two weeks after they've resolved), alternative antipsychotic medications should be explored. In some cases, it may be necessary to gradually reintroduce the original antipsychotic, a process called "rechallenge." Rechallenge should always begin with the lowest dose possible and then proceed with gradual upward titration. Because of the high risk that NMS will recur, however, monitor the patient closely for extrapyramidal symptoms and other side effects.

A new syndrome looks like NMS

Serotonin syndrome is another potentially fatal drug reaction that resembles NMS in its presentation. Until recently, it was described as NMS without the involvement of neuroleptics. Drug history is the most important factor for distinguishing between the two.(3) Whereas NMS results from the depletion of the neurotransmitter dopamine, serotonin syndrome results from excess levels of serotonin. Typically, the excess results from the combination of a serotonin-enhancing drug with an MAOI. For example, the syndrome could develop if a depressed patient on an MAOI is switched to a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac) without allowing a sufficient "washout" period for the MAOI to be eliminated from the body. Symptoms include hyperthermia as well as mental changes, muscle rigidity or exaggerated reflexes, autonomic instability, and seizures or pseudoseizures. Comprehensive assessment and early recognition of NMS and serotonin syndrome are critical to a positive outcome. The nurse who was quick to recognize Mr. Thorp's symptoms, for example, could literally have saved his life.

REFERENCES

1. Varcarolis, E. M. (1998). Schizophrenic disorders. In E. M. Varcarolis
(Ed.), Foundations of psychiatric mental health nursing (3rd ed.), (pp. 650 651). Philadelphia: W. B. Saunders.
2. Pelonero, A. L., & Levenson, J. L. (1998). Neuroleptic malignant syndrome: A review. Psychiatric Services, 49(9), 1163.
3. Keltner, N. L. (1997). Catastrophic consequences secondary to psychotropic drugs, Part 1. Journal of Psychosocial Nursing, 35(5), 41.
4. "Clinical reviews: Neuroleptic malignant syndrome." MICROMEDEX Healthcare Series, 105. CD-ROM. Englewood, CO: MICROMEDEX Inc. Copyright 1999.

NMS at a glance

Sources:

1. Varcarolis, E. M. (1998). Schizophrenic disorders. In E. M. Varcarolis (Ed.), Foundations of psychiatric mental health nursing (3rd ed.), (pp. 650 651). Philadelphia: W. B. Saunders.

2. Pelonero, A. L., & Levenson, J. L. (1998). Neuroleptic malignant syndrome: A review. Psychiatric Services, 49(9), 1163.

3. Keltner, N. L. (1997). Catastrophic consequences secondary to psychotropic drugs, Part 1. Journal of Psychosocial Nursing, 35(5), 41.

Differentiating NMS from other medical disorders with similar signs

Sources:

1. Pelonero, A. L., & Levenson, J. L. (1998). Neuroleptic malignant syndrome: A review. Psychiatric Services, 49(9), 1163.

2. Keltner, N. L. (1997). Catastrophic consequences secondary to psychotropic drugs, Part 1. Journal of Psychosocial Nursing, 35(5), 41.

About the author: CATHY WEITZEL, an RN certified in psychiatric and mental health nursing, is a staff nurse at the Psychiatric Adult Partial Hospital, St. Joseph's Campus, Via Christi Regional Medical Center, Wichita, Kan.

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Vivid images of electrodes attached to human heads and the resulting seizures are what we remember from barbaric electric shock therapy decades ago. But 50 years on, the therapy is still commonly used in New Zealand hospitals. Miriyana Alexander reports.

"It's a hell of a good treatment. If I ever needed to, I'd have it. I'd give it to my wife and parents too."

IT MADE author Janet Frame confused, terrified and disturbed. It gave her nightmares and once caused her to smash a window with her fist.

That was 52 years ago, when electric shock therapy was used without anaesthesia or muscle relaxants and patients were restrained to prevent injury from violent fits.

Many would be surprised to learn that ECT (electroconvulsive therapy) is still commonly used in New Zealand. But now, according to psychiatrists, it is used more discriminately and humanely.

Frame suffered through 200 applications of the treatment, which sees an electric current passed through the brain for several seconds, at Christchurch's Sunnyside Hospital and Dunedin's Seacliff Hospital. In the just-published biography Wrestling with the Angel, she talked of the trauma of the procedure, the memory loss and nightmares it triggered.

"I dreamed waking and sleeping dreams more terrible than any I dreamed before . . . (if) only I had been able to talk about some of the terror, I know I would not have so readily translated my feelings into action. It sounds silly, but my clothes haunted me . . . Everything tortures (me) and is on fire and is coloured."

ECT is also known for its controversial use at Cherry Farm, Carrington and Oakley mental hospitals. It was used to punish children at Lake Alice Hospital in the 1970s for trivial offences like not making a bed or not eating dinner, and compensation is now being sought.

In 1982, Michael Watene died after receiving ECT at Oakley. In a subsequent inquiry, ECT procedures at the hospital were labelled "alarmingly deficient" at the time of his death. Watene received the ECT on a mattress on the floor of a small strongroom. After the death, the inquiry ordered changes to the way ECT was administered, and said an anaesthetist should remain in the treatment room until a patient recovered fully.

According to psychiatrists, we've come a long way since then. ECT is now administered in operating theatres with patient consent, patients are anaesthetised and given muscle relaxants. They say it is not used indiscriminately: patients suffering from serious and life-threatening depression and some manias where other treatments have failed, are given the therapy.

Hospitals nationwide confirmed they used ECT, and a top psychiatrist believed its use would increase to counter growing rates of depression.

Health Minister Annette King has no plans to review its use.

Controversy has raged about the treatment for decades. Psychiatrists spoken to by the Sunday Star-Times were big fans of ECT, saying it was a legitimate and effective treatment for severe depression.

Many said it had saved lives, and they would have the treatment themselves if necessary.

Opponents label it inhumane and a Waikato patient advocacy group has presented a petition to parliament asking for ECT to be outlawed.

ECT works by replenishing neurotransmitters in the brain. The chemicals the nerves use to communicate with the brain, they are depleted in depressed people. The Royal Australian and New Zealand College of Psychiatrists guidelines for ECT said its effectiveness had been " established beyond doubt".

It said the therapy was among the least risky of medical procedures carried out under general anaesthesia, and was substantially less risky than childbirth.

Deputy director of mental health at the Health Ministry, Dr Anthony Duncan, also a psychiatrist, acknowledged public concern about memory loss associated with ECT.

"People definitely often have gaps in their memories around the time of the treatment.

"This is because ECT induces seizures, which impair the laying down of memory tracks."

Duncan said research showed it was not thought ECT caused long-term memory loss, but that possibility had to be balanced against the desperate state people were in when ECT was considered.

"People are often at risk of suicide or dying from dehydration or starvation because they are so severely depressed they have stopped eating and drinking."

Last year, 53 patients were treated with ECT at North Shore Hospital, getting an average of 10 or 11 each.

About four patients a week are treated with ECT at Auckland Hospital. They usually have two treatments a week for about four weeks. Director of mental health Dr Nick Argyle said while ECT "was an odd thing to do to people" it flipped them out of their depressive state.

Duncan said psychiatric medication such as Prozac simply suppressed the symptoms of depression, while a treatment of ECT meant a patient would no longer be depressed.

"There is no significant harm from ECT. It has saved the lives of some of my patients, and in many cases I wish I'd used it earlier. I sometimes have patients begging for it because they know it's the only thing that works for them.

"I think it's a hell of a good treatment. If I ever needed to, I'd have it and I'd give it to my wife and parents too."

Waikato Hospital delivers 35 ECT treatments a month for an average of five patients. At Timaru Hospital, 30 patients have been given the electric shock therapy since January, while Taranaki Hospital treats just two or three patients a year with ECT. Wellington Hospital treats eight patients a week with ECT. Two ECT treatments were provided at Palmerston North hospital in the last six months, and 45 patients at any one time are being given the treatment in Christchurch. Dunedin health officials confirmed they used ECT, but could not provide figures.

Capital Coast Health's director of mental health Peter McGeorge, a psychiatrist, said the public was probably not aware it was still being used. "But used properly it has its place. When Janet Frame was in hospital it was used quite indiscriminately, but that's not the case now. And the fits used to be violent, causing fractures and tears, but a muscle relaxant is given now, meaning the reaction is not so severe.

"Its use is likely to increase because by 2020, depression will be the most common illness in the world. So if rates of depression increase, so will ECT use."

A woman who was given ECT 42 times 40 years ago at Porirua Hospital when she was 18 told the Sunday Star-Times she feared the treatment would kill her.

The woman, who did not want to be named, said ECT made her "wake up feeling half dead. Everything was swimming in front of me and I could hardly stand up or walk. It was like being hit by a sledgehammer."

Lying in her bed waiting for the treatment was the worst part, she said. "It was like waiting to be executed. Nurses held you down by the knee and shoulder and we had a gag put into our mouths. Then the big bang came and I was unconscious."

The woman suffered short term memory loss after the treatments. "My brain was all scrambled and it took a long time to remember things. It's affected my whole life. My memory is very bad, I have nightmares and every now and then I get lost, even though I've lived here for years.

"It was my worst nightmare. The staff had no regard for our feelings, they were like custodians of concentration camps. ECT is a criminal assault and it should be outlawed."

Waikato Patients Rights Advocacy spokeswoman Anna de Jonge said ECT caused brain damage and should be abolished.

"It is torture. They do it to cattle in the slaughterhouse before they cut their throats, and they shouldn't do it to people. The brain is the most important part of the body, why are we doing this to it?"

She said ECT was not acceptable just because psychiatrists said that was all they had to treat severely depressed people. "If you had a headache I wouldn't be able to hit you on the head with a hockey stick and say sorry, that's all I've got to treat you. It's unacceptable."

Overseas opinion is also divided. Some psychiatrists want ECT banned, while others have said the procedure is as safe as extracting teeth.

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A report from the American Academy of Pediatrics

Monday, July 3, 2000

Medical staff and parents should refrain from immediately assigning a gender to newborns with genital abnormalities until the child's condition can be thoroughly reviewed and given careful consideration, according to a new AAP technical report.

Intersex disorders, including ambiguous genitalia, are caused by genetic and/or hormonal abnormalities.

The report recommends that these children should undergo a physical examination and series of laboratory tests before gender determination. Some intersex disorders are not as visibly apparent, and therefore may not be diagnosed until childhood or adolescence.

In the last decade, medical research has shown that a variety of physical factors including endocrine function and testosterone imprinting can help determine the sex of a child born with ambiguous genitalia. The report says that most infants with intersex disorders are evaluated immediately after birth. Once doctors, working with a child's parents, have determined the child's sex, treatment will be outlined. This may or may not include surgery.

Pediatricians should take a leadership role in coordinating the diagnostic evaluation, helping families understand their child's medical condition, and maintaining open communication between the family and other health care team members.

The American Academy of Pediatrics is an organization of 55,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.

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Untreated depression. It's the number one cause of suicide among teens and adults. Risk factors of teen suicide, and what to do if a child or adolescent may be suicidal.

The statistics are startling. As many as 8 percent of adolescents attempt suicide today. And completed suicides have increased by 300 percent over the last 30 years. (Girls make more attempts at suicide, but boys complete suicide four to five times as often as girls.) It is also known that 60-80 percent of suicide victims have a depressive disorder. A 1998 study showed, however, that only 7 percent of suicide victims are receiving mental health care at the time of their death.

Characteristics of Depression

Up until about 30 years ago, many in the field of psychology believed that children were incapable of experiencing depression. Others believed children could be depressed, but would most likely express their dysphoria indirectly through behavior problems, thereby "masking" their depression.

Three decades of research have dispelled these myths. Today, we know that children experience and manifest depression in ways similar to adults, albeit with some symptoms unique to their developmental age.

Children can experience depression at any age, even shortly after birth. In very young children, depression can manifest in a number of ways including failure to thrive, disrupted attachments to others, developmental delays, social withdrawal, separation anxiety, sleeping and eating problems, and dangerous behaviors. For the purposes of this article, however, we will focus on school-aged children and adolescents.

In general, depression affects a person's physical, cognitive, emotional/affective, and motivational well-being, no matter their age. For example, a child with depression between the ages of 6 and 12 may exhibit fatigue, difficulty with schoolwork, apathy and/or a lack of motivation. An adolescent or teen may be oversleeping, socially isolated, acting out in self-destructive ways and/or have a sense of hopelessness.

Prevalence and Risk Factors

While only 2 percent of pre-teen school-age children and 3-5 percent of teenagers have clinical depression, it is the most common diagnosis of children in a clinical setting (40-50 percent of diagnoses). The lifetime risk of depression in females is 10-25 percent and in males, 5-12 percent.

Children and teens who are considered at high risk for depression disorders include:

• children referred to a mental health provider for school problems
• children with medical problems
• gay and lesbian adolescents
• rural vs. urban adolescents
• incarcerated adolescents
• pregnant adolescents
• children with a family history of depression

Diagnostic Categories

Transient depression or sadness is not uncommon in children. For a diagnosis of clinical depression, however, it must be causing an impairment in the child's ability to function. Two primary types of depression in children are dysthymic disorder and major depressive disorder.

Dysthymic disorder is the less severe of the two, but lasts longer. The child exhibits chronic depression or irritability for more than a year, with a median duration of three years. Onset typically occurs at about 7 years of age with the child exhibiting at least two of six symptoms. A majority of these children go on to develop a major depressive disorder within five years, resulting in a condition known as "double depression." However, 89 percent of pre-teens with untreated dysthymic disorder will experience remission within six years.

Major depressive disorders have a shorter duration (greater than two weeks, with a median duration of 32 weeks) but are more severe than dysthymic disorders. A child with major depressive disorder exhibits at least five of nine symptoms, including a persistent depressed or irritable mood and/or a loss of pleasure. Typical onset for major depressive disorder is 10-11 years of age, and there is a 90 percent rate of remission (for untreated disorders) within one and a half years.

The prevalence of depression increases with age, affecting as many as 5 percent of all teenagers, and as many as one-in-four women and one-in-five men in adulthood. Fifty percent of those with a major depressive disorder will have a second episode in their lifetime.

In many cases, depressive disorders overlap with other diagnoses. These may include: anxiety disorders (in one-third to two-thirds of children with depression); attention deficit hyperactivity disorder (in 20-30 percent); disruptive behavior disorders (in one-third to one-half of patients); learning disorders; eating disorders in females; and substance abuse in adolescents.

The Risk of Suicide

As mentioned above, the rate of suicide has increased three-fold since the early 1970s, and is the major consequence of untreated depression. It is a trend that demands greater awareness, in order to prevent these deaths and better treat those at risk.

Completed suicides are rare before the age of 10, but the risk increases during adolescence. Risk factors for child and teen suicide include psychiatric disorders such as depression (often untreated), substance abuse, conduct disorders, and impulse control problems. There are many behavioral and emotional clues that can also be signs that a young person is at risk for suicide. A lack of coping skills and/or poor problem-solving skills are also risk factors that should not be overlooked. Drug and alcohol abuse is prevalent among those who commit suicide. Approximately one-third of young people who commit suicide are intoxicated at the time of their death. Other risks include access to firearms and lack of adult supervision.

Stressful life events, such as family conflict, major life changes, a history of abuse and or pregnancy are also factors that can trigger thoughts of suicide and even action. If a young person has attempted suicide in the past, there's a good chance they will try again. More than 40 percent will go on to make a second attempt. Ten to 14 percent will go on to complete a suicide.

Unfortunately, suicide can be difficult to predict. For someone at risk for suicide, a precipitant may be a shameful or humiliating experience such as the break-up of a relationship (19 percent), conflicts over sexual orientation, or failure in school. Another "trigger" for suicide may be ongoing stressors in life, with a sense that things will never get better.

Assessment, Treatment and Intervention

Assessment for childhood depression begins with initial screening, typically by a child psychologist, using a measure such as the Children's Depression Inventory (Kovacs, 1982). If the assessment is positive, classification includes further assessment for symptoms listed previously, the onset, stability and duration of symptoms, as well as family history. It is also important to assess the child for anxiety disorders, ADHD, conduct disorders, etc; school performance; social relationships; and substance abuse (in adolescents).

Alternative causes for the child's depression should also be considered and ruled out, including causes associated with the child's developmental and medical history.

Targeting those children and teens who are at high risk for depression, or who are facing high-risk transitions (such as moving from grade school to junior high) is key to prevention. Protective factors include a supportive family environment and an extended support system that encourages positive coping. The Optimistic Child, by Martin Seligman, 1995, is a good book to recommend to parents on preventing depression and building a child's coping skills.

Interventions for diagnosed clinical depression can be highly successful and include both medications and individual and family therapy.

If there are any concerns that a child or adolescent may be suicidal:

• Do not hesitate to refer them to a mental health professional for assessment. If immediate assessment is needed, take the child to the emergency room.
• Always take threats of suicide seriously.
• If the child has stated an intent to commit suicide, and has a plan and a means to carry it out, they are at very high risk and need to be kept safe and supervised in a hospital.

The major "treatment" for suicidal behavior is to find and treat the underlying cause of the behavior, whether it's depression, substance abuse, or something else.

Conclusion

While 2-5 percent of children and adolescents experience clinical depression (nearly as many kids as have ADHD), it is often "missed" by those around them, because it can be less obvious than other more disruptive behavior disorders. Left untreated, it can have a significant negative impact on development, well-being and future happiness, with untreated depression being the major cause of suicide. However, with treatment, including medications and/or psychotherapy, the majority of patients show improvement, with a shorter duration of their depression and a reduction in the negative impact of their symptoms.

Source: A Pediatric Perspective, July/August 2000 Volume 9 Number 4

For the most comprehensive information about Depression, visit our Depression Community Center here, at HealthyPlace.com.

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It's taken me almost 40 years to realize that activities take time. I know, I know, to you that's an obvious truth. But for me, time was expandable. I could fit anything in. Nothing took that long to do. I was going to do it all and make the time for it. After all, I am powerful beyond measure. I WILL make it all fit in. Throw another assignment on the pile.

"Did you know doing stuff takes time?"

Yesterday I took my cat to the vet. That sounds so simple a task ... and quick. The words are so short on my To Do List. "Cat to Vet." How short and sweet. One would think it would only take a moment to accomplish. Imagine my amazement when upon reflection I realized it had, in reality, taken three hours.

I hadn't taken into consideration the time to locate the cat carrier.

I hadn't considered that the cat would not want to go in the carrier.

I thought the drive should only take 10 minutes or so.

I didn't realize I would have to fill out a "new patient" form.

I assumed the vet would see me at the appointment time.

I had hoped she's examine the cat and make her recommendation.

I had no idea she was going to take blood from her jugular.

I couldn't have predicted the cat would get so stressed out.

I couldn't have predicted they'd hold her in the back until they were sure she wasn't having a heart attack.

I didn't calculate the additional time for making multiple trips to the car with it's new food.

I hadn't anticipated spending time with the cat once we got home to make sure it was okay.

I didn't know the sister cat would freak out at the smell of the vet when we returned home.

continue story below

"Cat to Vet." A moment of time. Three hours.

I still do want to do everything. There are so many things I enjoy doing, like reading, writing, re-designing a site, discussing a good book.

I could look at my pile and say I'm procrastinating on all the things I haven't finished or am not doing. I could and have at times done just that. But with this new realization that doing stuff takes time, I have a new perspective.

So if you don't hear from me, know that I'm doing a whole bunch of things that only take a moment to do. And the rest of the time, I'm procrastinating.

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Chronically ill children tend to be more submissive and less socially outgoing than healthy children, a new study shows. Further, kids who live with pain and physical restrictions may be more likely to have problems relating to their peers.

Study author Susan Meijer, DrS, a behavioral researcher at Utrecht University Medical Center in the Netherlands, and colleagues explored the effect of disease on social development in children 8 to 12 years of age. More than 100 chronically ill children and their parents participated in the study, which was published in the Journal of Child Psychology and Psychiatry.

The children's diagnoses included cystic fibrosis (a hereditary disease characterized by lung disease and problems with the pancreas), diabetes, arthritis, the skin inflammation eczema, and asthma. The children and their parents were asked about the children's social activity, behavior, self-esteem, physical restrictions, and pain.

Compared with healthy Dutch children, the participants had fewer positive peer interactions and exhibited less aggressive behavior. Compared with other chronically ill participants, children with cystic fibrosis and eczema had more social anxiety. And kids with physical restrictions and pain had significantly less social involvement than others.

Researchers say the reasons for these findings are not yet clear. "Sick kids may unconsciously avoid aggressive exchanges that they're unable to deal with," Meijer says. "It's also possible that sick kids don't learn some social skills because they receive less feedback about inappropriate behavior than healthy kids."

Meijer says that intervention programs can boost social development in chronically ill children. Child psychiatrists say school involvement and parental strategies may be even more effective.

"When kids are out of school for long periods, they miss both cognitive and social learning," says Nina Bass, MD, a behavioral medicine specialist and assistant clinical professor of psychiatry at Emory University School of Medicine in Atlanta. "And no matter how hard they try, parents can't give kids the same social experience they get at school."

Bass maintains that chronically ill children need both individual and group social activities. "An example of an individual activity is corresponding with a pen pal; an example of a group activity is participating in a book club," Bass says. "And if the child can't keep pace, parents should identify some better alternatives."

Chronically ill children also are at increased risk for depression. "Kids with chronic illnesses are 30% more likely to become depressed," she says. "And even if it's just a side effect of medication, parents can help with symptom management." But an awareness of factors that may lead to depression helps tremendously, she says.

In fact, parents' intuition may be more useful than record keeping. "Diaries are helpful, but they can turn a child into a guinea pig," Bass says. "It's often more helpful just to compare adverse symptoms to the child's normal rhythms and routines."

Bass says questions remain about the study's findings, and the researchers agree.

"Because parents of the participants were highly educated, the results could be biased," Meijer says. "So in the future, longer studies with more participants may provide more insight."

Vital Information:

• Chronic illness can affect a child's social development; children who have physical restrictions and pain are particularly vulnerable.

• Psychiatrists recommend both individual and group social activities for chronically ill children.

• Children with chronic illnesses are 30% more likely to develop depression, but parents can help manage symptoms by being aware of a child's depression and of the factors that may lead to it.

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The Washington Post
Tom Graham
06-06-2000

The extensive memory loss described by Ann Lewis in the accompanying article reinforces some of the widespread negative impressions about electroconvulsive therapy. Even supporters of ECT acknowledge that memory loss is a common side effect, though they say it is typically far less severe than that reported by Lewis.

Juan Saavedra, the Bethesda psychiatrist who treated Lewis before she underwent ECT, says he generally considers this therapy only for a very old person who would have trouble tolerating medication or for a person who is "in danger of suicide [where] you really cannot wait for the antidepressants to be effective." In discussing this as an option, he says, "my approach will be to say that the most important thing is preservation of life."

"There is always a lot of fears, and it's understandable" in light of publicized cases of "people who have been mistreated," says Saavedra, who adds that in his experience the majority of patients who are urged to receive ECT agree to do so.

"There is no way to predict" the degree of memory loss from ECT, Saavedra says. "Every treatment has its possibilities of something going wrong," but ECT is "a very safe procedure these days." Not nearly safe enough, in the view of those who believe ECT remains more dangerous than it's worth.

"The shock induces an electrical storm that obliterates the normal electrical patterns in the brain, driving the recording needle on the EEG up and down in violent, jagged swings. This period of extreme bursts of electrical energy often is followed by a briefer period of absolutely no electrical activity. . . . The brain waves become temporarily flat, exactly as in brain death, and it may be that cell death takes place at this time."

That's the view of another Bethesda psychiatrist, Peter Breggin, in his book "Toxic Psychiatry." Breggin's Web site, breggin.com, is only one of many (ect.org, antipsychiatry.org, banshock.org, etc.) that warn about the nasty repercussions of ECT.

Last year's Surgeon General's Report on Mental Health gave ECT's opponents little solace, though it did acknowledge some of the scientific mysteries and past misuses of the therapy since it was developed in the 1930s:

"ECT consists of a series of brief generalized seizures induced by passing an electric current through the brain by means of two electrodes placed on the scalp. . . . The exact mechanisms by which ECT exerts its therapeutic effect are not yet known. . . . Accumulated clinical experience--later confirmed in controlled clinical trials . . .--determined ECT to be highly effective against severe depression, some acute psychotic states and mania. No controlled study has shown any other treatment to have superior efficacy to ECT in the treatment of depression."

On the issue of memory loss, the report suggests that most patients are far less affected than Lewis was: "The confusion and disorientation seen upon awakening after ECT typically clear within an hour. More persistent memory problems are variable. Most typical . . . has been a pattern of loss of memories for the time of the ECT series and extending back an average of six months, combined with impairment with learning new information, which continues for perhaps two months following ECT."

The report also reiterated the medical establishment's conclusion that ECT is a worthwhile tool for treating certain mental disorders:

"Although the average 60 to 70 percent response rate seen with ECT is comparable to that obtained with pharmacotherapy, there is evidence that the antidepressant effect of ECT occurs faster than that seen with medication, encouraging the use of ECT where depression is accompanied by potentially uncontrollable suicidal ideas and actions. However, ECT does not exert a long-term protection against suicide. Indeed, it is now recognized that a single course of ECT should be regarded as a short-term treatment for an acute episode of illness."

Or as Saavedra said last week, "ECT doesn't cure anything."

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