Monthly Archives: August 2023

#Alcohol Use Disorder

Alcohol Use Disorder (formerly called Alcohol Abuse) is a significant cause of sickness and death in the U.S. During colonial times, people believed that alcohol had medicinal properties, and excessive drinking was due to lack of willpower. Some mistaken people still think that.

Risky Drinking

Today, about 60 million Americans are binge drinkers (5 or more drinks for males and 4 or more for females during a single occasion). Due to larger livers and a greater volume of body water, males can drink more alcohol before impairment than females. Most binge drinkers are age 18-25.

Heavy drinking is defined as 5 or more days engaging in binge drinking in one month. This significantly increases the risk of addiction. The definition of Alcohol Use Disorder (AUD) is having a “problematic pattern of alcohol use accompanied by clinically significant impairment or distress.”

AUD is accompanied by several mental disorders “(e.g., drug use disorders, major depression, bipolar disorder, and antisocial personality disorder), medical problems (e.g., alcohol withdrawal, liver disease, pancreatitis, and cancer of the head, neck, liver, colon, or rectum), and psychosocial problems (e.g., accidental injuries, aggression, violence, and suicide).” Alcohol is the 4th leading cause of preventable death in the U.S.

“The risk of AUD is nearly equally genetic and environmental. AUD is responsive to psychosocial treatments, including cognitive-behavioral therapy and motivational enhancement therapy.” Alcoholics Anonymous remains a powerful program to assist in managing AUD.

Alcohol “affects multiple neurotransmitter systems” so medications for treatment can play an important role. There are 3 FDA approved medications to treat AUD and 2 off label ones. Unfortunately, although these medications enhance psychsocial treatments, they are not often prescribed.

I recommend that anyone with AUD find a therapist experienced in treating AUD, a physician who will prescribe medication for AUD when appropriate, and you should regularly attend AA meetings. It helps to get a sponsor in AA (better sooner than later) who will support you in recovery.

Based on ongoing research, psychedelics appear to be promising adjunctive treatments for AUD. If the research provides adequate evidence of safety and efficacy, one or more of them may be made available for treatment of AUD.

This blog was based largely on an article by Henry Kranzler in the American Journal of Psychiatry 180:8, August 2023. All quotes are from this article.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Smoke from #Wildfires

Wildfire and Smoke

The recent devastating wildfire in Hawaii reminds us of the dangers involved. It isn’t only the fire itself, but smoke also kills.

Smoke can hurt eyes, irritate the respiratory system, and worsen chronic heart (e.g., heart failure) and lung diseases (e.g., COPD and asthma).

Children are at higher risk because their airways are still developing, they inhale more air per pound of body weight, and they tend to spend more time outdoors.

Pregnant women need to be extra cautious because physical changes during pregnancy (e.g., higher breathing rate) puts them at risk of their baby having a preterm birth or low birth weight.

Recommendations from the CDC to limit these risks include evacuating from an area with smoke, checking regularly for air quality reports, and follow instructions from local officials.

Do not rely on dust masks for protection. They only trap large particles such as sawdust and not the fine particles found in smoke.

If you stay indoors, you need to keep inside air as clean as possible. Keep windows and doors shut. Use your air conditioner but keep the fresh-air intake closed and be sure the filter is clean. if you don’t have an air conditioner, and it is too hot inside, go to a shelter.

Don’t increase indoor air particles by burning candles, using a fireplace, or gas stoves. Do not use a vacuum cleaner because they stir particles into the air.

If you have trouble breathing, consider evacuating. If pregnant, continue your prenatal care (e.g., prenatal vitamins), and find out where to go if your OB’s office is closed.

If you go into labor, call your doctor or 911. If you are in labor, go to a hospital if it is safe.

After the smoke has cleared, keep in mind that you can be exposed to ash and other products that could cause health problems. Learn how to clean up safely.

This information was taken from the CDC online site about Wildfire Smoke from May 2023.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

# Suicide Among Young People

Distressed Teen

An interesting research study on suicide among Japanese people age less than 30 was published by Okada and colleagues in JAMA Network Open on August 7, 2023.

The researchers learned that the suicide rate increased in this population during the COVID-19 pandemic. Rates of suicide and triggers varied as young people went from middle-school to high-school to university.

The rate of suicide at all age groups in the study were 2 to 2 1/2 times higher in boys than girls. This is a typical pattern seen throughout the lifespan.

There were 4 main stressors associated with suicide in these young people. One was school-related (underachievement and conflict with classmates). Another was family issues (conflict with parents and receiving severe verbal reprimands). A third was health issues (depression and other mental illnesses). The fourth was worry about the future.

Here are some additional findings:

1. Although the rate of suicide was higher in boys than girls, the rate increased more for girls than boys during the pandemic. 2. Depression and other mental illnesses were more common in girls. This is consistent with studies showing females typically struggle with more negative emotion than males. 3. The negative effects from family conflict became less important as the students moved from middle school to high school to university. However, school and health issues became more significant over that timeframe. 4. Young people under age 30 represent a high risk group for suicide.

This study supports current understanding that suicide is a serious risk among children and young adults. It is aggravated when there is more stress and less supporting relationships in their life.

Adults need to be alert for indications of suicidal thought among young people. Take statements of suicidal thoughts seriously. Have them evaluated quickly.

Also, don’t forget that there is a national suicide hotline: 988. Calls are confidential, and you can call about yourself or another person

Peter M. Hartmann, MD

Family Medicine & Psychiatry

A Healthier World

What change, big or small, would you like your blog to make in the world?

Improving People’s Health

My goal is to improve people’s health through education. This includes awareness of social determinants of health and wellbeing.

Sadly, there is a lot of misinformation on the internet about health topics. By using research- supported information, I hope to counter this trend.

I am not naive enough to think that my blog will succeed in overturning a lot of the misinformation that is out there. However, I am trying to do my part.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Happiness

List 30 things that make you happy.

Enjoyment

I felt sorry for those who wrote that they couldn’t think of very many things that made them happy. So, I sat down and started to make a list.

Afterwards, I realized that most of them were experiences rather than things. That is consistent with research that shows that relationships, experiences (vs things), and “buying time” are the ways money can enhance happiness.

Buying time means paying someone else to do things that need to be done, but you don’t like to do them, e.g., paying to have your lawn mowed or your driveway shoveled after it snows.

Here is my list in no particular order:

1. Spending time with my wife. 2. Eating a tasty and nutritious meal. 3. Drinking cold water when the weather is very hot. 4. Laying on an inflatable floater in a swimming pool. 5. Travel to an interesting place. 6. Time with close family and friends. 7. Learning something new. 8. Having a great workout at the gym (when it’s over 😅). 9. Helping a homeless person at my church. 10. Getting sound, restful sleep at night for at least 7 hours. 11. Watching a sunset over the Gulf of Mexico. 12. Going on a cruise to somewhere new. 13. Eating ice cream or frozen yogurt. 14. Trying a new restaurant with really good food. 15. Having a therapeutic massage. 16. Hugging my grandchildren. 17. Feeling healthy. 18. Getting a heartfelt compliment. 19. Buying a fun, new car. 20. Giving a lecture appreciated by attendees. 21. Watching a patient recover from an illness. 22. Writing a blog. 23. Being able to pay my bills. 24. Watching a good movie (especially with popcorn to eat). 25. Coming home after being away for awhile. 26. Recalling good memories, e.g., getting my sport pilot license. 27. Having my checkbook balance. 28. Having an article or book I wrote get published. 29. Realizing most of my problems are first world problems. 30. Being able to quickly come up with these 30 items!

#Postpartum #Depression

Postpartum Depression

There is a new FDA approved oral antidepressant (zuranolone) specifically for postpartum depression. Remarkably, it shows significant benefit beginning within 3 days. This is in contrast to ordinary antidepressants that typically take a couple of weeks to start working and are taken for at least 9 months.

Zuranolone is the first oral medicine specifically produced to treat postpartum depression. Treatment involves taking one 50 mg pill at night for 2 weeks.

The FDA reported on their website that “postpartum depression is a serious and potentially life-threatening condition in which women experience sadness, guilt, worthlessness -even, in severe cases, thoughts of harming themselves or their child.”

Although the name of the disorder includes the word “postpartum” (meaning, “after birth”), the FDA states that it “can also begin during the later stages of pregnancy.”

The medicine is usually well-tolerated. However, it may cause drowsiness and/or dizziness so patients should not “drive or operate heavy machinery for at least 12 hours after a dose.”

Also, the FDA states that “women should use effective contraception while taking, and for one week after taking Zurzuvae.” This is because it “may cause fetal harm.”

This medicine is a wonderful addition to treatment options for women with postpartum depression.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Treatment of Trans Children

Curiosity

What are you curious about?

The American Academy of Pediatrics (AAP) has had a statement supporting affirmative treatment of children and teens with gender dysphoria. This may include psychotherapy, puberty blockers, cross-gender hormones, and surgery (some or all of these treatments).

Recently, their leadership reaffirmed their position on treatment. However, I was surprised to learn that they are engaging an outside research organization to review existing studies on this topic.

Why? I have not found a clear answer, so I am curious.

One potential explanation is that they are hoping that a neutral third party would be able to either solidify their position or find evidence that their position should be modified. This would make sense in light of controversy about this topic.

Another possibility is that they are not as confident in their current position as they would like to be. This may be, at least partly, because Sweden has reviewed studies on transgender care for children and have concluded that existing research is inconclusive.

That, too, raises my curiosity. What research is Sweden aware of that our AAP is not aware of or does not agree with? This is interesting because Sweden is not the only country reconsidering current treatments.

Sweden was an early adopter of medical management of transgender children. So, it may be surprising that they now think that there is insufficient evidence to confidently support current practice.

From what I can gather, it may be related to a desire to have longer term data on the effects of treatment. There is evidence of short term benefit, but I gather that there is controversy about whether the benefits persist and whether there are potential unknown long term harms.

Perhaps, these questions are why the AAP is seeking outside experts to review research findings. I trust that my curiosity will be settled once the review is completed.

#Marijuana #Addiction

Feeling Awful

For many years it was thought that people did not get addicted to pot (marijuana). That was largely because there was no evidence of withdrawal when the person stopped using it.

That has all changed. The marijuana used in the ‘60s had only a small amount of THC, the active ingredient producing the desired effects. Recreational use was common and was considered to be no different than having a drink of alcohol.

However, now it is clear that you can become addicted to marijuana. Largely, that is due to the fact that the THC content is much higher today.

According to the NIH, the THC content increased by 212% between 1995 and 2015. Also, “we now have concentrated THC products such as oil, dab, and others that have been able to get the THC concentration upward of 95%.” For perspective, keep in mind that the concentration prior to the 1990’s was less than 2%.

Elizabeth Stuyt, MD in Mo Med 2018 pointed out that we now know there can be a withdrawal syndrome, which we would expect from an addiction.

She writes that there is a “definite recognizable withdrawal syndrome, which includes increased anger, irritability, depression, restlessness, headache, loss of appetite, insomnia, and severe cravings for marijuana.”

Her paper states “that 9% of those who experiment with marijuana will become addicted; 17% of those who start using marijuana as teenagers will become addicts; and 25-50% of those who use daily will become addicted.”

An article in the journal Addiction in 2021 by Freeman and colleagues states that the “higher potency of THC is associated with intoxication, anxiety, and cognitive impairment during use; long-term exposure has been associated with psychotic disorders and cannabis use disorder.” (Cannabis is a different name for marijuana.)

The bottom line is that the THC content of today’s pot is dramatically higher than it was years ago. As a result, it is now possible to become addicted. It is especially important for teens to avoid using products with THC because their brains are still developing, and they have an increased risk of significant negative consequences.

Peter M. Hartmann, MD

Family Medicine & Psychiatry