IS LONELINESS CENTRAL TO OUR PROBLEMS?

Nicholas Kristof had an opinion piece in the Sunday Review section of the New York Times on Nobember 10, 2019 entitled "Let's Wage War on Loneliness." He contends that lonliness is killing us at similar levels to alcohol and cigarettes and more than twice as much as obesity according to research published by Julianne Holt-Lunstad, et al. (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316. doi:10.1371 /journal. pmed.1000316. Dr. Holt-Lunstad and her colleagues reviewed 148 prospective studies with data on an individuals' mortality as a function of social relationships. They found that there is a greater risk of death associated with social isolation, with the results summarized above. Dr. Holt-Lunstad has continued her research in this area, further showing the impact of social isolation on health as well as mortality [death] risk. Dr. Holt-Lunstad and her colleagues believe that they have enough data from their research to support advancing social connection as a public health priority in the United States as this is the title of a paper published by J. Holt-Lunstad, et al. in The American Psychologist, 72(6), 517-530. d0i:10.1037/amp0000103. 

Mr. Kristof goes on to say that loneliness is a significant "silent killer" as it causes more morbidity than smoking or alcohol or obesity and that it is recognized as a problem in other countries with talk of there being a loneliness epidemic. Great Britain has even appointed a Minister for Loneliness who is encouraging communities to address this problem with programs that attempt to bring people who are isolated, together with each other.  

Of additional significance is the connection between addictions and loneliness as well as frequent intermittant stress [often leading to PTSD] also involving isolation and loneliness. This would then greatly expand the number of people who are affected by loneliness. I have seen chronic stress [really frequent intermittant stress] lead to isolation and loneliness as people who have been traumatized frequently have automatic coping that will cause them to isolate in order to protect themselves from the possibility of being overwhelmed by interacting with others, as they were in the past. When the brain responds to a perceived threat based on past experiences, the activation of the pattern of coping is instantaneous [in a nanosecond = a billionth of a second]. So our brain has responded before we are aware of it and this response to reduce our stress can also isolate us from others. Medications can help reduce stress about the past such as propranolol that can stop stress being connected to past memories, although it is often difficult to find a helpful dose. There are specific therapies that help reduce PTSD symptoms that involve developing a trusting relationship with a therapist and then choosing to think about past stresses without becoming stressed and doing this repeatedly.

There are many people in the world who are anxious and afraid related to PTSD symptoms and they cope in negative ways that isolate them from others. They don't need to do cope this way anymore and yet they don't have the confidence to start to change their patterns and are often manipulated by others into seeing the world as us against them. The world is not us against them and when they can realize this they will no longer be afraid or lonely.

STIMULANT MEDICATION USE DURING PREGNANCY

IN REVIEWING INFORMATION ON THE USE OF STIMULANT MEDICATION [ADDERALL, DEXEDRINE AND METHYLPHENIDATE] DURING PREGNANCY, THERE ARE A NUMBER OF REFERENCES TO STUDIES ON MICE LEADING TO MISCARRIAGES AND BIRTH DEFECTS. THESE WERE ASSOCIATED WITH A SIGNIFICANT OVERDOSE OF THE MICE COMPARED TO DOSES TAKEN BY HUMANS. IN ADDITION, THERE HAVE ALSO BEEN MENTION OF HEART DEFECTS RELATED TO AMPHETAMINE USE DURING PREGNANCY AND YET A STUDY OUT FROM HARVARD BY LEAD AUTHOR KRISTA HUYBRECHTS INVOLVING A VERY LARGE NUMBER OF PREGNANT WOMEN [IN JAMA PSYCHIATRY 2018 FEB; 75(2): 167-175] FOCUSED ON THE SAFETY OF METHYLPHENIDATE AND AMPHETAMINES [ADDERALL AND DEXEDRINE] FOR PREGNANT WOMEN DURING THE FIRST TRIMESTER OF THEIR PREGNANCY.  THERE WERE NO CARDIAC MALFORMATIONS OR OTHER MALFORMATIONS RELATED TO THE AMPHETAMINES, HOWEVER, THERE WAS A 28% INCREASE IN CARDIAC MALFORMATIONS AND AN 11% INCREASE IN BIRTH DEFECTS FOR PREGNANT WOMEN TAKING METHYLPHENIDATE WITH THE CONCLUSION THAT THERE IS A SMALL INCREASE IN THE RISK OF CARDIAC MALFORMATIONS AND EVEN SMALLER RISK FOR BIRTH DEFECTS FOR PREGNANT WOMEN TAKING METHYLPHENIDATE.

A 2007 ARTICLE ENTITLED "EXPOSURE TO ATTENTION DEFICIT HYPERACTIVITY DISORDER [ADHD] MEDICATIONS DURING PREGNANCY", IN THE CANADIAN FAMILY PHYSICIAN JUL; 53(7):1153-1155, SUMMARIZES RESEARCH RELATED TO TAKING AMPHETAMINE TYPE MEDICATIONS FOR ADHD DURING PREGNANCY. IN THEIR REVIEW THEY REPORT THAT THERE IS NO EVIDENCE FOR AN INCREASE IN MALFORMATIONS USING THERAPEUTIC DOSES. THEY ALSO REPORT THAT ABUSE OF AMPHETAMINES DURING PREGNANCY HAS BEEN ASSOCIATED WITH LOW BIRTH WEIGHT, PREMATURITY, AND INCREASED MATERNAL AND FETAL MORBIDITY.  THIS WAS CONNECTED WITH USE OF COCAINE AND MAY REFLECT PLACENTAL VASOCONSTRICTION.  HOWEVER, THERE WERE OTHER CONFOUNDING FACTORS SUCH AS POLY DRUG ABUSE, POSSIBLE ALCOHOL ABUSE, AND OTHER MEDICAL PROBLEMS ASSOCIATED WITH LIFESTYLE CHOICES. ANY OF THESE COULD HAVE CAUSED THE PROBLEMS NOTED.  ADDITIONALLY, THERE IS A REPORT OF A MILD [100-400 GRAMS] WEIGHT LOSS FOR INFANTS BORN TO WOMEN WHO WERE PRESCRIBED DEXTROAMPHETAMINE FOR WEIGHT CONTROL. THE SIGNIFICANCE OF THIS IS NOT CLEAR AS THERE WERE A NUMBER OF CONFOUNDING VARIABLES IN THIS STUDY AS WELL.  INTERESTINGLY, A PROSPECTIVE STUDY EVALUATED THE RISK OF CONGENITAL ANOMALIES OF INFANTS BORN TO 1694 WOMEN WHO WERE USING AMPHETAMINES AS ANORECTICS [FOR WEIGHT LOSS] WITH NO INCREASE IN MALFORMATIONS. SO, IT APPEARS THAT EVEN WHEN AMPHETAMINES ARE USED [ABUSED?] TO LOSE WEIGHT, THERE ARE NO MALFORMATIONS IN THEIR INFANTS. 

MORE RECENT REVIEWS GO OVER THE STUDIES MENTIONED ABOVE.  THEY CONCLUDE THAT THERE IS NO EVIDENCE OF MALFORMATIONS WITH THE USE OF AMPHETAMINES [INCLUDING ADDERALL] DURING PREGNANCY BY WOMEN WHO HAVE ADHD AND YET WILL OFTEN STILL RECOMMEND STOPPING THE AMPHETAMINE. THIS IS POSSIBLY BECAUSE OF OLDER STUDIES WHERE PREGNANT MICE WERE SIGNIFICANTLY OVERDOSED ON AMPHETAMINES AND HAD SOME MALFORMATIONS IN THEIR INFANTS.

WHEN EVALUATING ANY STUDIES RELATED TO AMPHETAMINES AND PREGNANCY, IT IS IMPORTANT TO BE SURE THAT THE DATA IS FROM WOMEN WITH ADHD WHO ARE PREGNANT. IT IS CLEAR TO ME AFTER TREATING THOUSANDS OF PEOPLE WITH ADHD THAT PEOPLE WITH ADHD DO NOT RESPOND TO AMPHETAMINES LIKE PEOPLE WHO DO NOT HAVE ADHD. TAKING THE AMPHETAMINE TYPE MEDICATION, PEOPLE WITH ADHD ARE CALMER, MORE ALERT, MORE FOCUSED, NOT IRRITABLE AND DO NOT EXPERIENCE SUSTAINED SLEEP OR APPETITE DISTURBANCE.  IF THEY ARE MORE IRRITABLE, MORE HYPERACTIVE AND HAVE REDUCED APPETITE AND SLEEP, THESE ARE SIDE-EFFECTS AND OFTEN MEAN THAT THEY WILL NEED TO CHANGE TO ANOTHER AMPHETAMINE TYPE MEDICATION. 

FINALLY, A STUDY BY JM COHEN, ET AL. OBSTET GYNECOL. 2017 DEC; 130(6): 1192-1201 WITH DR. HUYBRECHTS AN AUTHOR ON THE STUDY, LOOKING FOR RISK FOR PLACENTAL-ASSOCIATED ADVERSE OUTCOMES IN PREGNANT WOMEN TAKING PSYCHOSTIMULANT [INCLUDING ADDERALL] MEDICATIONS, FOUND THAT IN A COHORT OF 1.5 MILLION PREGNANCIES THERE WERE 5000 PREGNANCIES EXPOSED TO STIMULANT MEDICATION AND THERE WAS A SMALL INCREASED RELATIVE RISK OF PREECLAMPSIA AND PRETERM BIRTH. THE RISK WAS SMALL ENOUGH THAT THE AUTHORS DID NOT RECOMMEND STOPPING THE STIMULANT MEDICATION IF IT WOULD HAVE AN IMPACT ON THE MOTHER’S FUNCTIONING. ALSO, THERE WERE SOME CONFOUNDING VARIABLES THAT COULD HAVE INFLUENCED THE FINDINGS OF THIS SMALL RISK.  THESE WERE THAT THERE WERE MOTHERS WHO DID NOT HAVE ADHD WHO TOOK THE STIMULANT MEDICATION AND THERE WERE MOTHERS IN THE CONTROL GROUP WHO HAD ADHD WITHOUT MEDICATION AND THESE MOTHERS WERE FOUND TO HAVE A TWO FOLD INCREASED RISK OF PRETERM BIRTH IN A STUDY BY SP BRO, ET AL. IN CLIN EPIDEMIOL. 2015;7:139-47. 

IN SUMMARY, A NUMBER OF STUDIES OF PREGNANT WOMEN WITH ADHD TAKING ADDERALL HAVE FOUND NO EVIDENCE OF MALFORMATIONS [INCLUDING HEART MALFORMATIONS] IN THEIR INFANTS OR ANY OTHER BIRTH COMPLICATIONS. HOWEVER, A STUDY OF PREGNANT WOMEN TAKING METHYLPHENIDATE HAS FOUND HEART MALFORMATIONS AND OTHER BIRTH COMPLICATIONS. I DO NOT BELIEVE THAT THIS STUDY HAS BEEN REPLICATED YET.  ALSO,THERE WAS ANOTHER STUDY THAT FOUND A SMALL RELATIVE RISK FOR  PREECLAMPSIA AND PRETERM BIRTH BUT NOT ENOUGH TO REQUIRE STOPPING THE MEDICATION IF THE MEDICATION HAD AN IMPACT ON THE MOTHER’S FUNCTIONING.

EXTERNALIZING COSTS: MAKING EVERYBODY PAY FOR WHAT OTHERS ARE DOING

Cost externalization or externalized costs usually refers to producers [often corporations] that off-load indirect costs, called negative externalities, to a third party [often all of us] in order to maximize their profits. An example would be a corporation not taking financial responsibility for the polution that they produce or paying their employees low wages and thus requiring them to use food stamps and other forms of public assistance that we all pay for through our taxes. The UN is currently studying the cost of polution and other environmental damage by the world's top 3,000 corporations. The price tag is $2.2 trillion. That represents 1/3 of the profits for these corporations. So, for the sake of more profit, these corporations are willing to contribute to the end of our planet as they put the burdon of this pollution on the rest of the world. Does it seem right that a very small percent of the world's population gets money at the expense of the rest of us. I believe that everbody would agree that this is very wrong. It is not part of a fair capitalistic system as externalizing costs can allow a corporation to lower the cost of their products giving them an unfair advantage over other corporations making the same type of product. It is not right. It is morally wrong and all of us know this. So why do we tolerate this? It may be because we are also guilty of externalizing our costs by: purchasing things that are cheap because of the manufacturer externalizing costs; by polluting [not carbon neutral, not recycling, etc.]; buying stocks of corporations that externalize costs; by electing people who promote externalization of costs; etc. So, many of us externalize costs. If we want those corporations to stop externalizing costs then it might be helpful for all of us to do likewise. This might increase our awareness and sensitivity to this problem and help all of us to work together to treat each other with more respect as we take responsibility for our own problems and help others to take responsibility for theirs.

Does this make sense?

UNALIENABLE RIGHT TO LIFE, LIBERTY AND THE PURSUIT OF HAPPINESS AND TO OWN ANY AND ALL THE GUNS THAT WE CHOOSE?.

I've read that the ancient Greek democracy failed because it did not protect the individual from the majority. If we believe that all life is sacred [precious, etc.] then we must protect the rights of the individual from the majority. So, something being good for most people does not justify it being imposed on the individual. Or does it? If we see that the right to life is being taken away from some people by individuals with assault style weapons then does any individual have the right to those weapons when exercising their right can take away the right to live for innocent people? So where do our individual rights end and the majority's rights begin? 

We as individuals are guaranteed by our constitution to be free to pursue our lives. So, any thing that interferes with our ability to pursue our lives interferes with our individual rights. But what about the rights of others, such as the rights of children and adults to not be killed by a male with an assault rifle. Their right to pursue their lives is over. So, is it right to pursue our lives if it can result in the right of others to pursue their lives be taken from them? It has been argued that it is wrong to take assault rifles from people who have not killed anyone and yet the fact of and availability of these weapons has taken the right of many to be alive to pursue their lives. I believe that it is our responsibility to protect the lives of those innocent people.  If this is true regarding guns then it must be true for protecting those innocent people from the hate being promoted on line or anywhere else. We are free to speak what we believe but not free to take away the rights of others to pursue their lives.

What do you think?

DOSING OF ADHD MEDICATIONS

Questions are sometimes raised about exceeding the maximum recommended doses of medications used to treat ADHD. I have reviewed the research studies for these medications and it is clear that the studies were to determine efficacy and were not dosing studies.  Specific doses were chosen to assess the benefit and minimize risk of side-effects.  Once efficacy was determined the study ended and there was no motivation to do further studies addressing the range of doses that were therapeutic. Thus, doses involved in efficacy studies can be mistakenly seen as being studies to determine limits of what is therapeutic. The studies could not recommend a different dose because they did not assess different [higher] doses.  Also, each person is unique and this uniqueness can include how they respond to medications with some people responding to higher doses and others to lower doses. The U.S. Food and Drug Administration recognizes this when they state “the dosing regimen [for stimulant and related medications] is adjusted according to a patient’s individual response to pharmacotherapy."

I believe that it is important to work with my patients to assess their response to medications and in collaboration with them determine an optimal dose. At times this dose may be higher than is “recommended.”  I hope that it is clearer now why this is the case and why it is necessary to prescribe higher doses for these patients.