Sunday, April 13, 2014

Snapshots: Viagra, Melanoma, and those Pre-Passover Blues

No, the two have nothing to do with one another.
Or they could, I suppose, if anyone thought Passover a sexy holiday, which would make for an interesting discussion that we will never have. 

Let's start with this.

(1) "Harmless" erectile dysfunction treatment associated with melanoma

No more Viagra for you son. And Laura Berman, a famous sex therapist who has at least one clinic to treat women with sexual intimacy problems, will have to put her prescriptions on hold, rewrite one of her books, too. The results of a new study indicate that penile enhancement medication, also used for female sexual arousal, is linked to one of our worst cancers ever, melanoma.

When I was young there was a song, Nature's Way. Spirit, sings the soulful, ominous warning.

It's nature's way of telling you dying trees,
It's nature's way of telling you soon we'll freeze.

We froze east of the Mason-Dixon line, and to the west, too, last winter. Or shvitzed.

Hearing the association between ED drugs and melanoma  I'm humming the song again, seemingly out of nowhere (that's how the brain works, people). We could look at our bodies, and our psychology, as one of nature's finest, most exquisite creations, capable of incredibly creative ideas, achievements. And we think nothing of messing with them.

A chunk of my patient demographic, people in their thirties and forties, barely middle age (forties are the new thirties, thirties the new twenties), impatient with therapy (or in denial) ask their primary care doctors for Viagra, Cialis, and Levitra, etc., penile enhancement drugs. Before this new study the docs couldn't say with certainty: The drugs are bad for you. Work on your relationships. As long as blood pressure and heart rate were relatively strong, they caved. So now they can say that. The drugs are bad.

Erectile dysfunction (ED) is nature's way of telling you something's wrong, probably with a relationship or an understanding of sexual relationships. Or the mechanics of sex. The most common cause of ED is anxiety, not only performance anxiety, but any kind of anxiety, and often, guilt. And anger.

Melanoma tells us something's wrong with the pharma treatment, too. The problem, if it is not vascular, is psychological or educational. ED drugs treat a symptom. They are a bad idea, the wrong way to treat the problem, if it even is one.

We can discuss the right way another time. I've got to get ready for next week's holiday.

(2) The Holiday Blues
Everyone knows that during the holidays, especially the first ones after the loss of a loved one, we're more vulnerable to depression. Just when we're supposed to be happy, a brick falls on our heads. There's no denying it. We remember faces sitting around the table, singing songs, smiling. These are good memories, and when we think about it, surely a blessing, a good opportunity to add to the positive memories, the legacy, of  people who made such a difference in our lives.

Of course, if I believed that, it would be a sign I'm not a therapist.

In fact, the stress of the holidays, the togetherness, brings on bad memories often, and the worst in people, especially if more alcohol is consumed than usual. The legacy memories, for many of us, aren't always good.

But for some of us they are.

Good or bad, the mental deluge, the stimulation of anniversaries, always has an effect. Great stuff to talk about at parties. (See video link below).

For me, being busy before a holiday also implies cooking and baking, happy busy which is productive, too. In this creative process, inordinate amounts of time are spent trying to remember the things my mother cooked and baked, reading over her recipes, tattered, but written in her beautiful cursive script, soon to be extinct, oil and batter stained (not her fault). I experiment like she did, write it all down. On a computer, obviously. Who has a index cards? I envy those of you who do.

Passover, one of the biggies when it comes to stress, is upon us. The office is closed for 8 days. You will see us at the zoo and the museums, sprung from the drudgery of everyday life.

But if you want to know what this holiday is really all about, you eat matzah. (These we buy at the store, hardly anyone makes them anymore, the rules of baking proper Passover matzah are too complicated.). No matter how ad agencies might make it sound, the stuff is nearly indigestible without lots of butter.

Matzah is the Passover food because it is difficult to digest, unleavened, no yeast allowed, the quintessential symbolic food of modesty. This is a low food, a symbol that reduces us to tears (let's not go that far) by the end of the week. The idea is to get the leaven out of our hearts, recognize it really isn't all about us, and that we're not the ones to thank for our successes, can quit patting ourselves on the back. After all, only a few thousand years ago we were slaves in Egypt, enslaved for a long time, over 400 years. We couldn't have got out on our own. Passover celebrates freedom from slavery and the Creator who made it happen in spectacular fashion. (The story is mind-blowing, as Cecil B. DeMille rightly tells it in  The Ten Commandments.

All that to link over to an irreverent video that made me smile. Sean Altman sent this pitch:

I follow your blog. Please enjoy my REAL story of Passover — JEWMONGOUS' new music video "They Tried To Kill Us (We Survived, Let's Eat)"

Yours, Sean Altman

Ex-Rockapella star Sean Altman's comedy song concert JEWMONGOUS is "tuneful and sharply witty" (Los Angeles Times), "relentlessly clever" (Chicago Tribune) and "bawdy with a wicked modern streak" (Washington Post), combining "the tunefulness of the Beatles and the spot-on wit of Tom Lehrer" (Boston Globe). Altman, who "writes hilarious and irreverent acoustic rock songs about his awakening Jewish awareness" (Jerusalem Post), is "part of a new breed of Jewish hipster comedy that includes Jon Stewart, Sacha Baron Cohen, Sarah Silverman and Heeb Magazine" (Philadelphia Daily News). He is a former, founding member of Rockapella and led that pioneering vocal group through its heyday years on the Emmy-winning PBS-TV series, Where In The World Is Carmen Sandiego?, for which Altman co-wrote the famous theme song.  His classic Passover song "They Tried To Kill Us (We Survived, Let's Eat)" has been featured on NPR's Fresh Air with Terry Gross. Altman has twice performed at the White House Chanukah party for the President, he has shared the stage with Billy Joel, Joey Ramone, Jay Leno, Whoopi Goldberg, Spike Lee, Jonathan Winters and They Might Be Giants, recorded with XTC and Richie Havens, and he performs vocal standards at the bedside of hospital patients as a volunteer with Musicians On Call.  Altman has performed JEWMONGOUS throughout the USA, Europe, Israel and once in China.

There you go. Not how it happens in most homes, but funny.

Oh, and the Passover Brownie recipe.

Pesach (Passover) Brownies, Gebrukst (for non-gebrukst add potato starch, not cake meal)
1 cup Mothers unsalted margarine melted (yes, the brand matters, use Mothers with proper Passover certification)
Melt into the margarine with 3/4 package chocolate chips
Let cool 5 -10 min
In the mixer beat 
2 eggs
1.5 cups sugar
Add margarine/chocolate
Add 1 pkgs ground walnuts (6 oz) and 1/4 cup cake meal* 
Bake in a 9 x 12 pan at 350 for 30 min. Test with a toothpick.
When they are dry, let them cool down then freeze for 30 min before cutting. Or just eat them.

Happy Holidays, friends.


*Cake meal is very finely ground matzah, a truly humbling baking substitute for the fine flour we use all year round. 

Friday, April 04, 2014

Ivan Lopez: Could this have been prevented?

Ivan Lopez screenshot Facebook
Ivan Lopez shot 19 people yesterday, killing three at Fort Hood, Killeen, Texas. Five years ago, same army base, Nidal Hasan, an army physician, killed 13, wounded 33. Hasan has been sentenced to death.

Lopez served 4 months in Iraq in 2011 driving a truck, served in the Sinai Peninsula, too, and the National Guard. He's not been injured, officially, in combat. In fact the army claims he didn't serve in combat.

He either requested or was ordered a mental health evaluation, hence the transfer to Fort Hood from another base, according to one report.. His mother died of a heart attack in November last year, and the army gave him a hard time about going to Puerto Rico for the funeral. Granted a one day leave, he complained, was granted two. (Not much of a grief allowance, but typical in the military). The psychiatrist considered him nonviolent, prescribed Ambien for sleep. Follow-up in a month.

Perhaps Lopez forgot to tell the doctor. Somebody is going to pay for this. I need to be with my family.

One news bureau suggests that not only Ambien, but a variety of other psychotropic prescriptions were prescribed as well. Nothing unusual about that, to be expected, even, but one of those drugs could have been an SSRI, from a family of drugs that has saved millions, but is associated with suicide and bad decision-making.

Quick story:  About a month ago a new patient, referred by a physician, called me very depressed. In his fifties, I saw him the next day, and as is usually the case, he had a pocket list of the medications he's taking. One, an SSRI. Short list of those:

fluvoxamine maleate(Luvox),
paroxetine hydrochloride (Paxil)
citalopram (Celexa)
escitalopram (Lexapro),
fluoxetine (Prozac)
and Sertraline hydrochloride (Zoloft). 

Hearing his suicidal thoughts, I scheduled him for the next day, and then again the day after that. That or refer the patient directly to an emergency room for evaluation and hospitalization. My new patient wasn't ready for that but it is always Plan A.

Not being a medical doctor, when he told me about the SSRI, I thought nothing of it, assumed that perhaps he just needed more. I was going to call the referring physician, when FD popped into the room (a family doctor, happens to live with me). I picked his brain first, described a man in his fifties, suicidal thoughts, an SSRI. Could we up it?

He quickly replied, "Not the best choice, that family of drugs, for someone with suicidal thoughts. Can make suicidal people disinhibited."

What does that mean, disinhibited? I understand what it means in other contexts, but how does disinhibited manifest under prescription meds?

"Oh, they'll do things they might not ordinarily do. A person with suicidal or homicidal thoughts might be more inclined to act upon them on those drugs. That's why we keep them away, generally, from suicidal teenagers. They're already unpredictable."

Which leads me to an entirely different explanation, why Ivan Lopez gunned down innocent people at Fort Hood. His neighbors describe an amiable, friendly man, married to a friendly woman. Armed, as soldiers usually are, he acts upon impulses that seem out of character for friendly people. He is disinhibited, and this is what disinhibited people sometimes do.

The only other real consideration is his self-diagnosed traumatic brain injury. Brain trauma can change character, too, turns loving personalities into angry, violent people. But they are always angry and irritable and Lopez wasn't.

We can blame the meds, perhaps, but perhaps not. He had a Facebook page, an alias Ivan Slipknot. On that page he wrote in Spanish:

“The people shouldn’t fear the government — the government should fear the people.”

So perhaps it wasn't out of character, after all.

We might be wonder why the psychiatrist didn't make a followup for Lopez sooner. He had a month between visits.

I would venture to say that the facilities at Fort Hood are mobbed with psychiatric patients coming home from Iraq and that professionals are working night and day treating post traumatic stress. Suicide in the military is at an all-time high. It is likely that Spc. Lopez didn't express violent thoughts or plans, his dirty little secret. His knew what he was doing. But he felt lousy, so he asked for legitimate help, medication for sleep.

It has been five years since the last massacre on an army base, one that had the makings of a terrorist attack. We worry incessantly over those. Time to worry about our soldiers. Vet them a little more carefully in those evaluations.