Update on PTSD 2017: hope!

I have just spent a week in San Antonio, Texas at the AAFP FMX: American Academy of Family Physicians Family Medicine Experience.

Whew. Long acronym.

However, I attended two programs on PTSD. One was a three hour offsite one put on by the U. of Texas Health Sciences Department of Family Medicine. The other was a one hour program about active duty military and PTSD.

The biggest message for me is HOPE. Hope for treatment, hope for diagnosis, hope for destigmatization, hope for remission. I am not sure if we should call it a “cure”. Once a diabetic, always a diabetic, even if you lose 100 pounds.

In medical school 1989-1993 I learned that PTSD existed but that was about it. There was no discussion of medicines, treatment, diagnosis or cure.

Ditto residency. I learned much more about psychiatry reading about addiction and alcoholism and Claudia Black’s books then I did in residency.

Fast forward to 2010, when I opened my own clinic. I worked as a temp doc at Madigan Army Hospital for three months.

The military was aggressively pursuing treatment and diagnosis of depression, anxiety, PTSD and traumatic brain injury. I worked in the walk in clinic from 6:30 to 8:00 four days a week. Every walk in had to fill out a screen for depression. They were trying to stem the suicides, the damage, the return to civilian life problems and addiction too. They were embedding a behavioral health specialist in every section of the military. I was amazed at how hard the military was working on behavioral health.

In 2010 I took the buprenorphine course, which is really a crash course in addiction medicine, at the University of Washington Med School. I took it because it was free (I had just opened a clinic) and I thought we were as a nation prescribing WAY too many damned opioids. Yes! I found my tribe!

This gave me a second DEA number, to prescribe buprenorphine for opiate overuse, but also hooked me up with the University of Washington Telemedicine. I presented about 30 opiate overuse problem patients (anonymously, there is a form) to the team via telemedicine over the next year. The team includes a pain specialist, addiction specialist, psychiatrist and physiatrist. They do a 30 minute teaching session and then discuss 1-2 cases. They often do not agree with each other. They reach consensus and fax recommendations to me. The Friday addiction one was shut down and now I present to the Wednesday chronic pain one.

But, you say, PTSD? Well, chronic pain patients and opiate overuse patients have a very high rate of comorbid psychiatric diagnoses. It’s often hard to sort out. Are they self medicating because they have been traumatized or were they addicted first and then are depressed/traumatized and anxious? And what do you treat first?

There was an ADHD program at this conference that said we should deal with the ADHD first. One of the PTSD courses said deal with the PTSD first. The thing is, you really have to address BOTH AT ONCE.

Tools? PHQ-9, GAD-7, PCLC and there is an ADHD one too. These are short screening tools. I don’t diagnose with them. I use them to help guide therapy along with the invaluable urine drug screen. Love your patients but verify. That is, the chronic pain patient and the addiction patient tell me the same thing: but one is lying. I don’t take it personally because they are lying to themselves. Also, studies have shown that many patients lie, about their hypertension medicine or whatever. If they have to choose between food and medicine…. I think food may come first.

The San Antonio program has a behavioral health person embedded in their clinic (like a diamond) and if a PTSD screen is positive, the doctor or provider can walk them over and introduce them and get them set up. This is more likely to get the person to follow up, because there is still stigma and confusion for ALL mental health diagnoses and people often won’t call the counselor or psychologist or god forbid, psychiatrist.

They have a protocol for a short term four week treatment. Four weeks? You can’t treat PTSD in four weeks! Well, sometimes you can. But if you are making no progress, the person is referred on if they will go. I have the handouts. I do not have an embedded behavioral health person. I wish I did. I am thinking of setting a trap for one or luring them in to my clinic somehow, or asking if the AAFP would have one as a door prize next year, but…. meanwhile, I may do a trial of DIY. No! you say, you are not a shrink! Well, half of family medicine is actually sneaky behavioral health and I have the advantage of being set up to have more time with patients. Time being key. Also I have seven years of work with the telemedicine and access to that psychiatrist. Invaluable.

So what is the most common cause of civilian PTSD? Motor vehicle accidents. I didn’t know that. I would have said assault/rape. But no, it’s MVAs. Assault and rape are up there though, with a much higher PTSD rate if it is someone the victim knows or thought loved them. Rates in the US general population is currently listed at 1%, but at 12% of patients in primary care clinics. What? One in ten? Yes, because they show up with all sorts of chronic physical symptoms.

Re the military, it’s about the same. BUT noncombatant is 5%. High intensity combat has a PTSD risk of 25%, which is huge. One in four. Not a happy thing. In 2004 less then half the military personnel who needed care received it. PTSD needs to be destigmatized, prevented, treated compassionately and cured.

The risk of suicidality: 20% of PTSD people per year attempt. One in five.

Men tend to have more aggressiveness, women more depression.

Back to that PCLC. A score of over 33 is positive, over 55 is severe. There is sub threshold PTSD and it does carry a suicide risk as well. In treatment, a score drop of 10 is great, 5-10 is good and under 5, augment the treatment. Remember, the PCLC is a screening tool, not a diagnosis. I often ask people to fill out the PCLC, the GAD7 and the PHQ9 to see which is highest, to help guide me with medicines or therapy. If I need a formal diagnostic label, off to psychiatry or one of my PhD psychologists or neuropsych testing. Meanwhile, I am happy to use an adjustment disorder label if I need a label. If the patient is a veteran and says he or she has PTSD, ok, will use that.

Untreated PTSD, the rate of remission is one third at a year, the average remission is 64 months.

Treated PTSD, the rate of remission is one half at a year, and the average duration is 36 months. So treatment is not perfect by any means.

Pharmacology: FDA approved medicines include paroxetine and fluoxetine, and both venlafaxine and one other SSRI help.

Benzodiazepines make it worse! Do not use them! They work at the same receptor as alcohol, remember? So alcohol makes it worse too. There is no evidence for marijuana, but marijuana increases anxiety disorders: so no, we think it’s a bad idea. Those evil sleep medicines, for “short term use” (2 weeks and 6 weeks), ambien and sonata, they are related to benzos so I would extrapolate to them, don’t use them, bad.

Prazosin helps with sleep for some people. It lowers blood pressure and helps with enlarged prostates, so the sleep thing is off label and don’t stop it suddenly or the person could get rebound hypertension (risk for stroke and heart attack). I have a Vietnam veteran who says he has not slept so well since before Vietnam.

Part of the treatment for the PTSD folks at the U. of Texas Medical Center is again, destigmatization, normalization, education, awareness and treatment tools.

Hooray for hope for PTSD and for more tools to work with to help people!

halo stealthie

In the early morning in Wisconsin, I saw a halo… I am sending the halo to all the people who stood and stand up against white supremicism. I am sending the halo to all people, all colors, all genders. And we couldn’t see the halo unless the shadow were present, could we? There is no light without contrasting dark and we must love both the shadow and the light. I am not ok with white supremicism. Please, send this halo to those who stand up for love and equality and against discrimination.

Health care mandate in the United States

At a health care town hall last year, our representative said that US citizens have not given Congress a mandate for health care.

I raised my hand. “I beg to differ. The mandate is already law. The law says that no person in the US can be refused care at any emergency room. We have the mandate. Unfortunately the emergency room is the most expensive and cruel and last minute care that we could possibly choose.”

Expensive: any ER visit costs more than a whole day of visits to my rural family medicine clinic.

Last minute: the emergency room doesn’t do chronic care. Their purpose is to 1. try to stop someone from dying and 2. decide if the person should be hospitalized or should follow up in clinic. They do not do prenatal care, treat high blood pressure, treat diabetes, depression, high cholesterol, alcoholism. They do not do chronic care and aren’t meant to.

Cruel: you can go to the emergency room to try to keep from dying. Say you go coughing blood. They find a lung cancer. Now, you have a choice: be treated and maybe you will survive or maybe you will die anyhow and your house will be sold to pay for the medical care. Do you choose to go home instead and die so that your family inherits the house?

The United States spends twice as much per person as the next most expensive health care system in the world and they have universal health care and we don’t. We care more for corporate profit then US citizens and visitors health. I cringe when the discussion is about health INSURANCE not health CARE.

I am a physician but I also own my own business. As a small business owner, I think that I will soon have to close. Why? I am in my 50s with a daughter. I think that within two years my HEALTH INSURANCE will cost more than I pay myself. And I will close the clinic.

We need health CARE not health INSURANCE. The Obamacare law said that health insurance companies can ONLY keep 20 cents of every health care dollar they collect, down from 22.5 cents. They have to spend 80 cents on health care. For medicare the overhead is 2-3 cents per dollar.

Medicare for all, single payer. Put 97 cents of every health care dollar to health care instead of only 80 cents. Or shall we continue down the road to small business and local government collapse and citizen health collapse?

Congress, you can’t wheel and deal your way out of this one. We want health care for our dollar not insurance.

For the Daily Prompt: wheel.

Dream log: June 20, 2017

I am with my father and my sister. My mother is not around. I am not sure if she’s gone or dead. Dead, I think.

My father has gone off. My sister is 3 or 4 and I am 6 or 7. I am taking care of her. We are at a park and I am trying to get food. It is Thanksgiving. It is not cold, it’s warm. There are large family groups at picnic tables.

My technique is to move in on a family group. We play near them and I listen for adult names. We play close enough that I can hear but not close enough to impinge on the group. When they start to clean up and take things to the cars, I am ready. I slip in and hold my hands out for a bowl. The adult looks at me. “Aunt Norma’s.” I say confidently, because I know which bowl belongs to each adult. And which bowl I want. The adult hands me the bowl. They can’t remember which kid I am, but I know Aunt Norma’s name….I head confidently with the bowl towards the cars and quickly slide it under my loose sweatshirt. I bypass the cars and head around to my sister.

Now the game changes a little. We have a couple bowls so she guards them. I work the next table alone and score a left over turkey.

The problem now is that we cannot carry it all to the car in one trip. I debate about safety. We are living in the car. I tell my sister to stay with the rest of the food and I leave her, carrying the turkey. It’s still light and there are still a lot of people around. She is sitting on the curb, bowls behind her, between two family groups. I will get the turkey to the car and then run back to her. The two of us can carry the rest of the food in one trip. Then we will have food for a while. She should be safe.

I wake up.

I took the photograph within the last month. What and where is it?

 

prayers for children

This is my daughter, five years ago, at Lake Matinenda in Ontario. I cried when I read about the baby thrown from the London fire.

Prayers for the children in the London fire and their parents and grandparents. Prayers for the refugee’s children, that they are not lost and drowned. Prayers for the Congresspeople shot yesterday and their families and friends.

Prayers for all the children in the world.

damage

This is not about one patient. It is about many. I have permission from the person I gave a copy to: one of many.

what do you say
to the person
with the terrible childhood
with addiction and chaos
and suicide attempts and hospitals
and that was the parents
that they ran away from

and then numbed themselves
in addiction for years
multidrug and chaos
and now stable
working their 12 steps

and grieving
their lost years
and their behavior
unforgiven, it takes time
to build trust after
thirty years of damage

and grieving
the next generation
following the same
path and feeling helpless
to stop them
and guilt for their
contribution

it is not a matter
of a pill
of a diagnosis

the simplicity of stopping
of getting clean
joy and pride
yes

and then the hard work
of grieving
begins

 

____________________________________________________________________________________________

I took the photograph at the Renwick Gallery.

bravery

There is more than one list of seven virtues. Courage, or bravery, goes back to Aristotle and Plato as one of the four cardinal virtues.

What is bravery to you? An extreme sport? A warrior?

My sister endured cancer treatment for 7 years, over 30 rounds of chemotherapy. She said, “People say I am brave, but they don’t understand. I don’t have a choice. It’s do the therapy or die.” It’s still brave, though, isn’t it.

The person who comes to my mind for bravery is a woman, a long time ago. She spoke Spanish and we had a translator. Her son had had rheumatic fever and they had gone to the pediatric cardiologist for the yearly visit. Her son had a damaged heart valve that was getting worse. He was somewhere between 9 and 12.

“The heart doctor says he needs surgery. He needs the valve replaced. But the heart doctor said he could die in surgery.” she said.

I read the notes and the heart ultrasound. “The heart valve is leaking more and more. If he doesn’t have the surgery it will damage his heart. He will be able to do less and less and then he will die. If he has the surgery, there is a small chance that he will die. But if he doesn’t, he will be able to grow and to run and to be active.”

She said, “I am so afraid.” But she returned to the pediatric cardiologist. And he got through the valve replacement surgery and did fine.

That is courage to me. The parents who take chances for their children: get into boats to escape war. Search for treatments. Fight for their home, their children, their loved ones. It is both men and women, mothers and fathers, grandmothers and grandfathers, and people who have no blood relation to a child that they reach out to help. Adoption, volunteering in schools, supporting a student, supporting an organization that helps children grow and thrive.

For the A to Z challenge….and last year.