When A Patient Gets Political

JenniferLeave a comment

Disclaimer: This blog post reflects the author’s present recollection over time. Characters and dialogue have been recreated and rearranged. Events have been fictionalized and any resemblance to actual persons, living or dead, is purely coincidental.

A well-groomed, middle-age woman walked into my office and said, “Doctor, my anxiety is shooting through the roof!”

I expressed dismay and asked her what has changed since our last visit.

“It’s this damn fake election!” she exclaimed. “The Democrats are going to undo all the great things that Trump has done for this country. I can’t stand seeing these BLM rioters and Muslim invaders and Antifa terrorists on television. And now they’ve stolen our democracy! It’s terrible! And so many businesses are still shut down because of this stupid Chinese virus. I felt safer with Trump as president.”

Okay. I felt my heart pounding. I heard a low buzz in my ears. My body was entering fight-or-flight mode. I repressed the urge to stand and leave the room.

This puzzled me. Why was I feeling so afraid?

It made no sense. My patient was sitting in a non-threatening posture and more than six feet away, the result of social distancing precautions. She spoke at a moderate pace in a mildly anxious tone. She was even smiling at me as if she expected me to agree with her.

In my role as a psychiatrist, I take care of people who are intoxicated, delirious, and emotionally labile. This happens, especially in an emergent setting. Many of my patients had been brought to the hospital against their will, and they are usually afraid. Fear leads to irrationality, irrationality leads to unpredictability, and unpredictability leads to violence. I have tolerated a lot of verbal abuse from patients. I’ve endured misogynistic comments and racial slurs. I am trained in verbal de-escalation. I have talked many, many people down from screaming at me to thanking me. Despite these measures, I’ve had several patients attempt to physically assault me. One actually did.

Any front-line healthcare worker understands. As a group, we are remarkably prone to encountering verbal and physical abuse. Nationwide, 78% of emergency department physicians reported being targets of workplace violence (Behnam 2011). 82% of US nurses have been assaulted at least once during their careers, and 73% believe that assault was just part of their job (Speroni 2014). Verbal aggression is just as serious. In a 2016 review article, Phillips writes, “The importance of recognizing verbal assault as a form of workplace violence cannot be overlooked, since verbal assault has been shown to be a risk factor for battery. When verbal abuse and low-level battery are tolerated, more serious forms of violence are invited.” Verbal violence affects not only the victimized individual but also the entire health care system. Verbal violence can lead to demotivation, poor job satisfaction, early burnout and compassion fatigue. Overall, workplace violence affects the delivery of health care, decreasing quality and accessibility (Watson 2020).

I can handle that. But this smiling woman in my office was different. This felt new, in a strange, subtle, gut-twisting way. Maybe it was because this patient was not intoxicated or psychotically delusional and was speaking with a linear thought process. Maybe it was because this took place in the ostensibly safe space of my office. Maybe it was the inflection in which the word “Chinese” is said – with an elongated and emphasized sound of “chai” followed by the derisive sneer of “neez”. Maybe it was because I never expected this type of hate speech from this particular patient, who I had formerly thought of as a friendly, pleasant lady. Or maybe it was because I was vividly reminded of past hurts, of the childhood peers who would smile to my face and then make fun of my “chinky” eyes behind my back.

I took a slow breath. She seemed to sense my emotional turbulence. We looked at each other silently. I wondered what she saw.

My physical presentation is as a petite, Asian-American female. Would she think of me differently if she knew that I was not born in the United States? That despite my adopted American accent and soft southern drawl, my mother tongue is Mandarin Chinese. Or would she tell me that, oh no I’m not racist, you’re one of the good ones, without thought of how that implies the opposite – that in order for me to be different, the rest of my peer group must share common negative traits.

As a rule, I don’t bring up politics with patients. But what do I do, when a patient gets political?

“I don’t agree. I feel less safe,” I said. “You know, it has been really difficult being an Asian person in this pandemic.”

To my relief, she offered an olive branch.

“I’m sorry for talking about politics,” she said. “I don’t mean to bring all that negative energy in here.”

And we talked about it. I told her that I want my office to be a safe place where she can bring her worries. That I wanted to hear about the triggers for her anxiety, so that I could better understand her and be a better doctor for her. At the same time, I told her that her words can be hurtful. That although she was certainly not responsible for my feelings, perhaps she could be a little more mindful and understanding about what she says and how she says it – because I am a person, too.

Then we moved on to discuss her medical care.

Although it may be uncomfortable, I think that it is important to think about how race and politics can color interactions between health care providers and patients. As we seek to understand each other, these conversations need to be ongoing and authentic. NBA player Jeremy Lin spoke out earlier this week as a guest on “Race in America: A Candid Conversation.”

“I feel bad for somebody who harbours hate for somebody else, who they’ve never met, just based on skin colour,” he said. “That makes me want to do something. It makes me want to educate people… speak out and find ways to make a difference. Honestly, it goes from anger to just heartbreak.”

He also posted on his Instagram: “Being an Asian American doesn’t mean we don’t experience poverty and racism. Being a 9 year NBA veteran doesn’t protect me from being called ‘coronavirus’ on the court. Being a man of faith doesn’t mean I don’t fight for justice, for myself and for others.” (Didion 2021)

There has also been a rise in hate crimes against people of Asian descent. Recent data released in major cities show a shocking growth in the number of racially-motivated attacks (Wells 2021, Sturla 2021). As I discussed above, serious physical assault does not occur in a vacuum; it is frequently preceded by verbal abuse and low-level battery. I strongly suspect that there are numerous unreported events of verbal abuse and microaggressions. Knowing this, I can begin to understand why I felt the way I did. My feelings of danger have root in truth.

What happens out in the world gets brought into doctors’ offices. And when this happens again – when, not if, because problems of hate and intolerance do not simply fade away – then I can be better prepared for it.

More Information

Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. J Emerg Med 2011;40:565-579

Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228. doi:10.1016/J.JEN.2013.05.014

Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. PMID: 27119238.

Watson A, Jafari M, Seifi A. The persistent pandemic of violence against health care workers. Am J Manag Care. 2020 Dec 1;26(12):e377-e379. doi: 10.37765/ajmc.2020.88543. PMID: 33315330.

Didion, A. Warriors’ Jeremy Lin Reveals He Has Been Called ‘Coronavirus’ on Court. NBC Sports Bay Area. February 26, 2021. Accessed February 27, 2021. Link: Warriors’ Jeremy Lin Reveals He Has Been Called ‘Coronavirus’ on Court – NBC Bay Area

Wells, N. Anti-Asian Hate Crimes Are Up 717% In Vancouver. Canadian Press. February 18, 2021. Accessed February 27, 2021. Link: Anti-Asian Hate Crimes Are Up 717% In Vancouver | HuffPost Canada (huffingtonpost.ca)

Sturla, A, et al. Anti-Asian attacks are on the rise in NYC. The city is pushing to combat it. CNN. February 27, 2021. Accessed February 27, 2021. Link: Anti-Asian attacks are on the rise in NYC. The city is pushing to combat it. – CNN

Inside Asylum Walls

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“Nobody will ever convince me that the splendor of individual courage cannot triumph over all the fates. Neither family death, nor personal illness, nor “hard times,” nor heavy responsibility solely borne, nor hazards met without warning can defeat one man standing alone who refuses to relinquish his courage. I knew such a man. He was my father.”


– Dorothy Powers, In Tribute to My Dad.

About a year ago, I visited a small bookshop in Spokane, Washingon. As an independent book store for nearly four decades, 2nd Look Books was full of second-hand treasures and local history. A bright red book caught my eye. Boldly titled: “Dorothy: POWERS TO THE PEOPLE”, it contained a collection of columns written by journalist Dorothy Rochon Powers for the pages of The Spokesman-Review.

The inside cover had a hand-written note from the author dated September 16, 1989. It was addressed to a dedicated reader, perhaps the author’s friend. “I wish you many happy memories in these pages. Thank you for reading my column! – DRP”

As per my usual habit, I flipped open the book to a random page. To my surprise, the book fell open to an article titled, “Inside Asylum Walls: The Patient’s View.” It must be fated for this book to land in the hands of a psychiatrist, I thought, and so of course I purchased the book.

Published in December 1957, the article by Powers reported on conditions at Eastern Washington State Hospital. As part of her research, Powers repeatedly visited the institution and conducted interviews with members of the staff. Then with the assistance of officials, she got herself “committed” and spent time there disguised as a patient.

What she found was disturbing. The institution was overcrowded and understaffed. “To a state mental hospital with 2,064 patients — and facilities for 1,861; to a staff of 13 doctors, where the American Psychiatric Association standards show 28 are needed; to an institution with 20 nurses instead of 166,” Powers wrote (pg 99). This was shocking. In comparison, the institution where I am currently training as a resident physician can provide services for up to 99 patients, with four attending psychiatrists on-site every workday and a half-dozen resident psychiatrists serving as helping hands. The physicians are supported by a robust staff of nurses, techs, and social workers.

In 1957, there were too few hands on deck at the Eastern Washington State Hospital. Members of the staff did their best, but the amount of work was overwhelming. Not only were they outnumbered, but they also cared for some of the most severely mentally ill people in the state. There would have been people who were diagnosed with debilitating illnesses such as chronic schizophrenia or catatonia. Some would be so paralyzed by their minds that they depended entirely on caretakers for basic functions, such as eating, bathing, and toileting. Powers described their despair. “‘It’s all we can do to keep them clean,’ sighs an attendant, ‘much less spend any time working with them'” (pg 101).

Remember, this was before the advent of psychopharmacology, before antipsychotic medication such as chlorpromazine and haloperidol and clozapine revolutionized psychiatric medicine. This was before the 1960s, when the social movement for deinstitutionalization of the chronically mentally ill gained momentum and lead to the replacement of long-stay psychiatric hospitals with an outpatient care-focused model and the goal of reintegrating patients into the their community. Powers’ article, among many others across the nation, helped instigate change. Today, Eastern Washington State Hospital has a patient capacity of just over 280 beds, according to Wikipedia. The changes over the years are reflective of our society’s evolving attitudes and growing understanding towards mental health.

The picture that Powers’ paints may seem foreign and strange, as the landscape of behavioral healthcare has transformed so drastically. But some things remain familiar. As I read, I was vividly reminded of people I have met in my current work in psychiatric wards. The 1950s were not so long ago – some of these patients may still require care today. Powers provided powerful quotes: “‘You keep wondering why you’re different, what the people at home are saying. Right now, I worry whether the neighbors will still let their children come see me, when I get home… if I get home'” (pg 100).

People in the past as they do today still yearn for home, fear rejection, and desire healing. They have hopes and fears and dreams that, though clouded with their illness, remain deeply, unconditionally, and essentially human.

The remainder of the book is a fascinating documentary of life in the eastern side of Washington State. Powers captured the highs and lows of the human experience. She flew in a giant Air Force refueling jet at 40,000 feet in the air at 600 miles an hour. She mingled with inmates in Washington State Penitentiary. She climbed a 15-story bare steel scaffolding. She reported on the thunderous eruption of Mount St. Helens. Throughout it all, she described people with understanding and compassion.

When I travel, I love these pieces of local history. Upon my next visit to Spokane, I plan to return the book where I found it so that someone else can also discover its treasures. May the next lucky person also find inspiration in Powers’ stories!

More Information

Powers, DR. Dorothy: Powers To The People. Cowles Publishing Company. 1988. Print.

Let’s Learn Psychopharmacology A to Z: Bupropion

JenniferLeave a comment

“Happiness is not something you have to achieve. You can still be happy during the process of achieving something. So if you change your perspective a bit, although many of you may be going through tough times right now, this could also be the most beautiful moment of our lives.”


– Kim Nam-joon, 2015. “The Most Beautiful Moment In Life Concert” Seoul, South Korea

Welcome to another post in the “Let’s Learn Psychopharmacology A to Z” series! This series is dedicated to discussing some of the most highly-cited, landmark articles in psychopharmacology.

Disclaimer: This discussion is intended to briefly and superficially review the medical literature that describes the use of a medication. As new studies are published every day, information presented here may be obsolete. Ultimately, selecting a medication remains a decision between a patient and their doctor. Doctors recommending and patients using these medications are strongly advised to consult information provided by the manufacturer.

Today’s topic is bupropion (brand names: Wellbutrin, Aplenzin, Zyban [branded for smoking cessation]).

First, let’s have some background. Bupropion is a norepinephrine and dopamine reuptake inhibitor. Since dopamine is inactivated by norepinephrine reuptake in the frontal cortex, which largely lacks dopamine transporters, bupropion can increase dopamine neurotransmission in this part of the brain (Stahl 2017). Bupropion is FDA-approved for major depressive disorder, seasonal affective disorder, and nicotine addiction. It is also used off-label for bipolar depression, ADHD, and sexual dysfunction. Bupropion decreases depression relapse and also extends time to relapse for depression (Weihs et al 2002). Studies comparing bupropion and SSRIs have all shown comparable efficacy (Clayton 2007).

Bupropion is offered in three formulations: immediate release (IR), sustained release (SR), and extended release (XL). Both SR and XL formulations are FDA approved for major depressive disorder. Only the SR formulation is FDA approved for nicotine addiction. Bupropion can be used with SSRIs (such as citalopram or sertraline) to treat partial responders or to improve SSRI-induced apathy and SSRI-induced sexual dysfunction. Bupropion is also used as an augmenting agent to mood stabilizers and/or atypical antipsychotics (such as lithium or olanzapine) in bipolar depression. 

This brings me to today’s discussion, which I am titling, “Bupropion Mythbusters.” As I reviewed literature for this post, I was surprised that a number of oft-repeated “truths” by my colleagues and mentors were, in fact, not so firmly set in stone. Some may be controversial, or perhaps the data simply isn’t conclusive. In any case, I have selected three which impressed me the most and presented them below.

!!! Bupropion Mythbusters !!!

Myth #1: More is Better

Guidelines allow for use of up to a total of bupropion 450 mg daily for the treatment of depression, with most patients taking a 300 mg daily dose. But there is little to no evidence of a clear dose-response effect. One 8-week multicenter study of bupropion SR showed no difference between 150 and 300 mg daily doses measured on depression rating scales (Reimherr et al 1998). A possible explanation for this is presented in an early study that demonstrated a potential inverted curvilinear plasma concentration-response curve for bupropion, meaning that concentrations above or below the maximum response range may correlate with a poor response for depression (Preskorn 1983). 

This finding may not be absolute. In contrast, there is a positive linear dose- and concentration-response observed for smoking cessation with bupropion. Johnston et al showed that higher daily doses of bupropion were correlated with increased likelihood of smoking cessation, up to 300 mg daily. 

In practice, I would still support increasing doses of bupropion for depression, as it may help some patients reach the maximum response range. However, my expectations for symptom reduction would be guarded. 

Myth #2: Bupropion will make anxiety worse

Hypothetically, bupropion may increase anxiety due to its stimulant properties. However, this theory has remained unproven. A randomized, parallel-group, double blind, multicenter trial compared anxiety response between sertraline (n=126) and bupropion SR (n=122) in people with major depressive disorder. No difference in anxiolytic efficacy or time-to-treat effect was observed between the two groups. Furthermore, there was no evidence for worsening of anxiety with bupropion over the course of the 16-week trial (Rush et al 2001). In a review article, Foley et al state that in their experience, anxiety is an occasional self-reported cause of intolerance, yet bupropion also appears to lower anxiety in the majority of psychiatric patients. These findings suggest that bupropion is not anxiogenic.

Myth #3: Stop bupropion for smoking cessation if there isn’t an intent to quit smoking

Bupropion is useful in improving both initial and long-term abstinence rates and at preventing relapse (Ferry 2003). Its principal mode of action seems to be the alleviation of withdrawal symptoms following smoking cessation. A randomized, double-blind trial comparing bupropion versus placebo showed that bupropion may be used long-term in people who are unwilling to quit or who perceive themselves as being unable to quit smoking. Fourteen percent in the bupropion group sustained a 4-week continuous abstinence period versus 8% in the placebo group. The researchers also showed that the number of cigarettes smoked per day and the time until the next cessation attempt were decreased during bupropion treatment (Hatsukami 2004). Therefore, bupropion can provide a positive benefit even in the absence of intent to stop or cut down tobacco use. The effects are not sustained after bupropion is discontinued. 

In conclusion, bupropion has been widely studied for a variety of uses and has been proven to be safe and effective. Its unique mechanism of action relative to other SSRIs and SNRIs make it a valuable option in antidepressant treatment.

References

Stahl, Stephen M, and Meghan M. Grady. Stahl’s Essential Psychopharmacology: Prescriber’s Guide. 2017. Print.

Weihs KL, Houser TL, Batey SR et al. Continuation phase treatment with bupropion SR effectively decreases the risk for relapse of depression. Biol. Psychiatry 51(9), 753–761 (2002).

Clayton AH . Extended-release bupropion: an antidepressant with a broad spectrum of therapeutic activity? Expert Opin Pharmacother 2007 ; 8 (4): 457 –66. 

Reimherr FW, Cunningham LA, Batey SR et al. A multicenter evaluation of the efficacy and safety of 150 and 300 mg/d sustained-release bupropion tablets versus placebo in depressed outpatients Clin. Ther. 20(3), 505–516 (1998). 

Preskorn SH. Antidepressant response and plasma concentrations of bupropion. J. Clin. Psychiatry 44(5 Pt 2), 137–139 (1983).

Johnston JA, Fiedler-Kelly J, Glover ED et al. Relationship between drug exposure and the efficacy and safety of bupropion sustained release for smoking cessation. Nicotine Tob. Res. 3(2), 131–140 (2001).

Rush AJ, Trivedi MH, Carmody TJ et al. Response in relation to baseline anxiety levels in major depressive disorder treated with bupropion sustained release or sertraline. Neuropsychopharmacology 25(1), 131–138 (2001).

Foley KF , DeSanty KP , Kast RE . Bupropion: pharmacology and therapeutic applications . Expert Rev Neurother 2006 ; 6 (9): 1249 –65. 

Ferry L , Johnston JA . Efficacy and safety of bupropion SR for smoking cessation: data from clinical trials and five years of postmarketing experience . Int J Clin Pract 2003 ; 57 (3): 224 –30. 

Hatsukami DK, Rennard S, Patel MK et al. Effects of sustained-release bupropion among persons interested in reducing but not quitting smoking. Am. J. Med. 116(3), 151–157 (2004).

A Fear of Words

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“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.”

– Dune, Frank Herbert

Writing is scary because words on paper are meant to be read. When I write, my writing is not meant to be hidden in a private journal. I yearn to communicate to others. I want my words to reach out to the outside world and say, “I exist.” 

But for me, there is also a terrifying push-pull between the desire to be heard and the fear of being judged. To write, I need to have something to say. And behind that comes with a whole host of fears. Is what I have to say worth saying? Is my writing worth reading? I feel afraid of being judged and found wanting. 

Sometimes I fear that my writing will become devoid of emotion because in my day-to-day work, my writing is mostly scientific and technical. This happens in my daily interactions as well. I have conversations all day, often about very similar topics. Although each individual person and interaction is unique and different, there are inevitable similarities which develop into pattern recognition. When I am asked the same question for the thirtieth time in a week, I frequently begin to speak from rote memory. I worry that my words are robotic. The thing is, connection with another human being evokes an emotional response. I don’t want my words to be meaningless.

Sometimes I fear being wrong. Or more exactly, I fear inconsistency. Even after I leave training and become a board-certified, licensed psychiatrist, I am only human and I know that I can be wrong. When confronted with opposing evidence, I gladly revise my opinions. Minds change. But words on the Internet do not. I want to write words that I can stand behind, that I can look back upon proudly even years later. But I cannot predict the future. I cannot predict what new scientific revelations may change the medical and scientific communities. I cannot see how society’s values may change. I can only look at the information I have now and write from my current experiences.

Sometimes I fear being attacked. There are people who disregard scientific evidence. There are people who ignore medical authority. There are people who disparage psychiatrists and the field of psychiatry. When hidden behind the anonymity of a computer screen, keyboard warriors can be vicious. I am afraid of the emotional pain, or even the potential physical threats. Even if I do everything right, there may be people who hate me not because of who I am, but because of what I represent.

A part of me wants to suppress these fears. But it is difficult, perhaps even harmful, to ignore them. I think that these fears are quite reasonable, and furthermore, they serve a purpose. They motivate me to examine my choices, to research my ideas, to truly push towards bettering myself. They help me keep watch, temper my expression, and protect myself. It doesn’t mean that the fear is irrelevant, or that it can’t be prohibitive. Sometimes, I wish that I could work less carefully and more quickly, and be more tolerant of mistakes.

We all carry within us a secret inner world, hidden from others’ eyes. Writing is a way for our inner selves to reach out to the outside and attempt to connect with others. Writing is a form of communication. Writing is a form of vulnerability.

In the end, like many things in life, I need to write for myself. And I need to keep writing, despite my fears. 

Because even worse than being afraid is being silenced.

Cultural Competence in Clinical Psychiatry: A book review

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I’ve always found cultural considerations in psychiatry to be a fascinating but difficult topic to understand. Perhaps this is because the topic is so broad; lessons from one culture may not necessarily be applicable to others. Or perhaps it is because in formal education and exam prep books, there is a lot of focus on abstract, theoretical and conceptual issues. Many questions quiz on specific culture-bound syndromes such as “koro,” “hwabyung,” and “ataque de nervios.” The theme, if any, is usually some variation of: “People have many different viewpoints. Treat all of them with respect.” But usually, big questions remain: How do cultural differences affect, in a concrete, tangible way, the relationship between a psychiatrist and their patient? How does this impact management decisions and outcomes? And how exactly can physicians best communicate with patients who hold views, beliefs, values, and attitudes different from their own?

Well, this book answers those questions.

I recently borrowed this book from one of my attendings. Published by the American Psychiatric Association in 2004, a dozen psychiatrists contributed to the book and illustrated the impact of cultural differences in psychiatrists in different clinical settings with an emphasis on clinical applications.

My favorite part of this book were the clinical vignettes. Each chapter was neatly separated by clinical setting or subspecialty, and included up to 5 clinical vignettes. Memorable examples include a teenage Hispanic female with psychosis; a 6-year-old boy being evaluated for ADHD; a Samoan schoolteacher with psychogenic weakness of the legs. I won’t spoil the conclusions to the cases, but I will reveal that they had numerous twists and turns and that I found them fascinating. Within the book, each case’s cultural components were carefully analyzed and discussed.

I especially liked that the clinical vignettes provided an easily accessible means for classroom discussion. After an initial description of the presenting problem, students could be asked for their ideas in formulating a differential diagnosis. Then the instructor can guide students towards a final diagnosis and provide education. Each case presentation can conclude with a classroom discussion on treatment, management, and communication with the patient in a culturally appropriate manner.

My criticism of the book stems from a personal dislike of repetition. Because the chapters are divided by clinical setting or subspecialty, the same themes are reinforced again, and again, and again. By the sixth chapter or so, I began to tire of seeing the same idea presented in yet another new sentence, and would skim it quickly just until I found another clinical vignette. Please don’t misunderstand me – there were certainly sections of the discussion between cases that were novel and different among the chapters. It was only the sections that were similar that I would not miss.

Would I read the entire book again? Probably not. But would I use it as a reference material for an instructional series? Absolutely.

More Information

Tseng, WS, Streltzer, J. Cultural Competence in Clinical Psychiatry. American Psychiatric Publishing, 2004. Print.

Let’s Learn Psychopharmacology A to Z: Acamprosate

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“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”


– Better: A Surgeon’s Notes on Performance, Atul Gawande

Welcome to the first post to start the “Let’s Learn Psychopharmacology A to Z” series! Through this series, I will discuss some of the most highly-cited, landmark articles in psychopharmacology. A lot of this knowledge is relatively new. Medications were introduced into the practice of psychiatry in the 1950’s starting with the use of chlorpromazine and lithium. Since then, the list of psychotropic medication has exploded. There are 143 drugs described in Stahl’s Essential Psychopharmacology, Prescriber’s Guide, Sixth Edition (which is a highly recommended reference material decorating many psychiatrists’ offices) and more are being developed in pharmaceutical pipelines.

Disclaimer: This discussion is intended to briefly and superficially review the medical literature that describes the use of a medication. As new studies are published every day, information presented here may be obsolete. Ultimately, selecting a medication remains a decision between a patient and their doctor. Doctors recommending and patients using these medications are strongly advised to consult information provided by the manufacturer.

Today’s topic is acamprosate (brand name: Campral).

Let’s start with basic facts. Acamprosate is an amino acid derivative of taurine that acts as a modulator of GABA neurotransmission. It is FDA-approved for maintenance of alcohol abstinence. Theoretically, it reduces excitatory glutamate neurotransmission and increases inhibitory GABA neurotransmission. Because alcohol withdrawal can lead to excessive glutamate activity and deficient GABA activity, acamprosate can act as “artificial alcohol” to mitigate these effects.

"How Acamprosate Works" © Jennifer Hsu
“How Acamprosate Works” © Jennifer Hsu

Acamprosate appears to work best for individuals who have already abstained from alcohol. Other medications used frequently for alcohol use disorder include naltrexone and disulfiram.

In 2004, Bouza and colleagues published a meta-analysis of 13 acamprosate studies with 4000 total participants. The major findings confirmed that acamprosate improved the continuous abstinence rate with a number needed to treat of 10, and also significantly improved cumulative abstinence. Unfortunately, this study also showed that the rate of adherence to prescribed medication was a problem. Compliance varied widely among the studies, ranging between 40% to 90%. Overall, only about half of the people receiving acamprosate continued to take it throughout the assigned treatment period. The reasons for drop-out are unclear, though a minority reported discontinuation of medication due to adverse side effects, with gastrointestinal issues affecting approximately 17% of patients assigned to take acamprosate.

Next up is a randomized controlled trial – the COMBINE study, which was published in JAMA in 2006.

The COMBINE study is one of the largest studies on acamprosate. It was a randomized controlled trial that studied medication management (MM) and combined behavioral intervention (CBI) for the treatment of alcohol use disorder. Medications used include acamprosate and naltrexone. Primary outcome measures were 1) percent days abstinent and 2) time to first heavy drinking day. A heavy drinking day was defined as ≥ 4 drinks per day for women and ≥ 5 drinks per day for men

Participants were first divided into three groups: 1) MM only, 2) MM+CBI, and 3) CBI only. Within the groups that received medication management (MM), participants were further divided into four groups: acamprosate only, naltrexone only, both acamprosate + naltrexone, and placebo. This resulted in nine total groups.

Surprisingly, the COMBINE study showed that acamprosate had no significant effect on drinking versus placebo, either by itself or with any combination of naltrexone, CBI, or both. This result was different from the prior studies. The authors hypothesize that the negative result is perhaps because the COMBINE trial required only 4 days of abstinence before participants could join the trial, versus a longer pretreatment abstinence period.

A meta-analysis published in 2008 stated that acamprosate is efficacious, but in different ways than naltrexone. Rösner and colleagues write that acamprosate improves continuous abstinence rates over placebo with a number needed to treat of 8. However, acamprosate did not influence alcohol consumption after the first drink (i.e. reducing the amount consumed or risk of a lapse becoming a relapse.) Naltrexone reduced relapse rates, time to relapse, and also reduced heavy drinking in a subgroup of non-abstinent patients. From this, acamprosate appears to be the treatment of choice if the goal is complete abstinence, whereas naltrexone is preferred if choosing a harm-reduction strategy to prevent excessive drinking in non-abstinent patients.

“Individually allocating patients to treatments according to their motivational status could further enhance the effectiveness of treatments of alcohol dependence.”


– Rösner and colleagues 2008, citation below

The final article presented here was published in 2008 by Kranzler and colleagues. This report contributed to the United States Food and Drug Administration (FDA) approval of acamprosate for use in conjunction with psychosocial support in the maintenance of abstinence in alcohol-dependent patients. Kranzler et al re-analyzed three European pivotal trials, which were published in 1995, 1996, and 1997. These trials took place in France, Belgium, and Germany and examined a total of 623 patients.

Krazler et al applied a more rigorous definition of abstinence than the initial studies; for example, patients with missing data or with unknown status were also considered non-abstinent. With a more restrictive definition of abstinence, the calculated rates of abstinence were lower than the rates previously published, but remained significantly higher for patients treated with acamprosate than placebo. Rates of complete abstinence for placebo ranged between 9-13%, while rates for acamprosate ranged from 16-38%. Secondary outcomes for percent days abstinent and time to first drink also showed efficacy favoring acamprosate.

Overall, acamprosate is a well-studied, safe, and effective medication. There is also some evidence to show that the benefits of acamprosate in maintaining sobriety can extend for at least up to 12 months after drug discontinuation. Acamprosate has some limitations in its use. For example, it is most likely to be successful in people who have already maintained a period of sobriety. However, it can still be a valuable treatment option for many people.

References

Bouza C, Angeles M, Muñoz A, Amate JM. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction. 2004 Jul;99(7):811-28. doi: 10.1111/j.1360-0443.2004.00763.x. Erratum in: Addiction. 2005 Apr;100(4):573. Magro, Angeles [corrected to Angeles, Magro]. PMID: 15200577.

Anton RF, O’Malley SS, Ciraulo DA, Cisler RA, Couper D, Donovan DM, Gastfriend DR, Hosking JD, Johnson BA, LoCastro JS, Longabaugh R, Mason BJ, Mattson ME, Miller WR, Pettinati HM, Randall CL, Swift R, Weiss RD, Williams LD, Zweben A; COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006 May 3;295(17):2003-17. doi: 10.1001/jama.295.17.2003. PMID: 16670409.

Rösner S, Leucht S, Lehert P, Soyka M. Acamprosate supports abstinence, naltrexone prevents excessive drinking: evidence from a meta-analysis with unreported outcomes. J Psychopharmacol. 2008 Jan;22(1):11-23. doi: 10.1177/0269881107078308. PMID: 18187529.

Kranzler HR, Gage A. Acamprosate efficacy in alcohol-dependent patients: summary of results from three pivotal trials. Am J Addict. 2008 Jan-Feb;17(1):70-6. doi: 10.1080/10550490701756120. PMID: 18214726.

A Brief Discussion on the International Pilot Study of Schizophrenia

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I’ve been trying to make a renewed and dedicated effort to both read and write more. I’ve realized that waiting for the inspiration to strike doesn’t happen. If I want to read and write more, then I need to set aside time to cultivate the skill. It has been more difficult that I thought.

Still, this is part of that effort. And so today, I decided to review and write about my thoughts on a very important psychiatric article – The International Pilot Study of Schizophrenia: five-year follow-up findings.

Published in 1992, this article is an “oldie but goodie.” It is best known for its provocative finding that people with schizophrenia have better clinical and social outcomes in developing countries when compared with developed countries. In other words, a person with schizophrenia in Agra (India) or Ibadan (Nigeria) was significantly less ill and suffered less occupational and social impairment than someone with the same diagnosis in London (United Kingdom) or Washington, DC (United States).

As discussed in the article, one suggested explanation for this finding is incompleteness of follow-up at the sites in developing countries. However, when they further examined the data, they found that this was an unsatisfactory explanation for the results. A second suggested explanation was if a greater proportion of patients in developing countries had an acute, rapidly resolving psychosis with an inherently better prognosis. This explanation, too, was not supported upon further data modeling.

A third proposed explanation involved greater tolerance and acceptance of the behaviors displayed by people with schizophrenia by their families. This hypothesis had partial support, as a sub-study related to this project showed that patients in Chandigarh (India) who had families with low levels of Expressed Emotion had better clinical outcomes.

Low levels of Expressed Emotions are favorable; alternatively, families with high Expressed Emotion interact more frequently with negative and intense verbal exchanges. Relationships are oppositional or conflictual in nature, and interaction patterns are rigid. Conversations are marked by increased criticism, hostility, and emotional overinvolvement. As described by Amaresha & Venkatasubramanian in a 2012 article, “Researchers have positioned Expressed Emotion within the diathesis-stress model of psychopathology, characterizing it as an environmental stressor that can potentially precipitate/cause relapse of psychosis among people with a genetic vulnerability.”

However, the study concluded with a statement that an exact definition of the elements of culture and society that improve outcomes remains unclear.

There have been additional follow-up studies to this impactful article. In 2000, Hopper and Wanderling revisited this question and hypothesized that cultural factors promoting recovery may include: 1) supportive kin, 2) auspicious or alternative beliefs, 3) flexibly configured work, 4) forgiving domestic space, and 5) more socially integrated subjectivities. They also point out that, subtracting Hong Kong, the remaining sites in the “developing” group are all located within India, which simplifies the question of culture.

“The extraordinary engagement of Indian families in the course of treatment – from the initial decision to seek help, to attending to basic needs and medication adherence during hospitalization, to support afterward, including monitoring medications and functioning – is surely one of the signature features of psychiatry in that country.”


Hopper & Wanderling 2000, “Revisiting the Developed Versus Developing Country Distinction in Course and Outcome in Schizophrenia.”

I can further appreciate this finding while I was reading The Quiet Room by Lori Schiller. The Quiet Room is a biography describing one woman’s experience with schizophrenia. About midway into the book, Lori’s mother realizes that she had seen her own mother, Lori’s grandmother, display the eccentric and psychotic behaviors that Lori appeared to be experiencing. Lori underwent multiple psychiatric hospitalizations and trials of medications. Meanwhile, Lori’s grandmother, who was the daughter of a wealthy man and a housewife, did not. As a quote from the book describes, “My mother [Lori’s grandmother] was rich, and so she was allowed to be eccentric.” (Schiller & Bennett 1994, pg 82)

Lori, who faced the pressures of being a high-achieving, upper-middle class young adult, newly graduated from college, suffered greatly not just from the symptoms of psychosis but also from the loss of her place in society.

“I have lost many things: the career I might have pursued, the husband I might have married, the children I might have had.  During the years when my friends were marrying, having their babies and moving into the houses I once dreamed of living in, I have been behind locked doors.”


Schiller & Bennet 1994, The Quiet Room, pg 5

It brings to mind the pressures that society may place on its members to conform. Of course, conforming is not necessarily bad. Conforming to social norms regulates our social interactions, reduces anxiety, brings us closer to one another, and helps us feel safe. But perhaps there is a price for conformity – a price that is paid by the marginalized among us.

References

Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med. 1992 Feb;22(1):131-45.

Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. Schizophr Bull. 2000;26(4):835-46.

Amaresha AC, Venkatasubramanian G. Expressed emotion in schizophrenia: an overview. Indian J Psychol Med. 2012;34(1):12-20.

Schiller, L., & Bennett, A. The Quiet Room: A Journey Out of the Torment of Madness. New York: Warner Books. 1994.

Golden Gate Survivors

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This article contains discussion of a topic which some readers may find disturbing. The discussion is not graphic, but may still be upsetting. Please err on the side of protecting yourself if this is a sensitive topic for you.

Trigger warning: self-harm, suicide.

I have only ever been to San Francisco once. At the time, I was a first-year medical student exploring different medical specialties, and I traveled there to attend a conference for obstetrics and gynecology.

It was an incredibly motivating experience. Those of you who have gone to conferences probably know what I’m talking about. The excitement! The hubbub! What could be better than a bunch of people who all love to talk about something that you’re interested in, too? There were workshops for medical students on suturing, delivering babies, robotic laproscopy, a Q&A by current residents and practicing ob/gyns, and more. I was busy morning till night. There was no lack of things to see, people to meet, and places to explore.

Strangely, my most vivid memory is of the protestors who stood outside the convention center with picket signs. I might have expected some anti-abortion groups to show up, but no, not at all! Instead, these were anti-circumcision groups for male newborns. I viewed the protestors with curious amusement, because ob/gyns did not perform circumcisions at the hospital that I rotated through and, well, I have never known an ob/gyn to treat very many patients with male genitalia. Perhaps other places have different practices, but anyways, this topic is not my expertise and I digress.

I was in the city for two days. However, to my regret (and I don’t remember the reason anymore), I didn’t visit the Golden Gate Bridge, one of the “Wonders of the Modern World.”

Golden Gate Bridge as seen from Marshall’s Beach
Golden Gate Bridge as seen from Marshall’s Beach © Frank Schulenburg via Wikipedia.Org

The bridge is renowned for its visual beauty and suspension design. It is famous for one more thing: it is the second-most common suicide site in the world.

In 1975, David H. Rosen, MD published a study of persons who survived jumping from either the Golden Gate or the San Francisco-Oakland Bay bridge. He interviewed seven of ten known survivors. In his publication, he states that, “Each person was made aware that he or she could refuse to answer any of the questions during the interview, and assured that anonymity would be preserved. . . . [T]heir participation was entirely voluntary.” (Rosen, 1975)

In his interviews, Dr. Rosen asked several questions. Why the choice of the bridge? What did they experience during the fall and upon impact? Did they lose consciousness? What has been the long-term impact of this event on their lives?

Dr. Rosen also discusses several psychological aspects of near-death experiences, including the three phases of resistance, life review, and transcendence as described by Russell Noyes, MD, and the phenomenon of ego-death/rebirth. As a survivor said, after his jump, he was “refilled with a new hope and purpose in being alive. . . . I appreciate the miracle of life – like watching a bird fly – everything is more meaningful when you come close to losing it.”

It has been over forty years since this publication. Since then, suicide rates have continued to increase. In this context, there are three points from Dr. Rosen’s article that I would like to discuss. First, the survivors report that they got the idea of jumping from press coverage. Second, the survivors chose the bridge because it symbolized something to them, and if it had not been available, they would not have used any other method of suicide. Third, all survivors interviewed recommended a barrier to prevent others from attempting suicide.

1. Press Coverage

The effect of press coverage on suicide rates has been well documented. Named the “Werther effect” after a character of the novel The Sorrows of Young Werther, who dies by suicide, it is thought that exposure to the idea of solving problems through suicide can send troubled people over the edge. This observation is echoed in Dr. Rosen’s interviews. One survivor said, “Newspaper editors should voluntarily stop all press coverage of the Golden Gate Bridge suicides – extensive press coverage put the idea into my mind.”

In response to this effect, the World Health Organization released a booklet in 1999, titled “Preventing suicide: a resource for media professionals.” The booklet has since been updated twice (most recently in 2017) to accommodate for changes in technology such as social media. It provides evidence of media impacts on suicidal behavior and guidelines for the responsible reporting of suicide. I think that it is a valuable read for anyone working in the media and giving information about suicide.

2. A Symbolic Choice

Second, the bridge was an important, symbolic choice for all of the interviewed survivors. Dr. Rosen reports that “four of the six [survivors] said they would not have used any other method if the Golden Gate Bridge had not been available… Often this was related in a symbolic way to the association of the Golden Gate Bridge with death, grace, and beauty.”

Symbolism plays a large role in our understanding of the world, and this holds true for the concept of suicide. People use symbols to communicate with others, guide our behavior, and inspire our actions. Symbolism is also apparent in suicide prevention, for example Project Semicolon, a non-profit organization dedicated to suicide prevention. A quote from their website: “Instead of ending a sentence, a writer can use a semicolon to continue on, and so too can an individual choose not to end his or her life, but continue on living.”

When discussing methods of suicide completion with people who present to the psychiatric emergency room, my level of concern increases when the plan clearly has symbolic meaning to the person. I become further alarmed when the person appears to view death as romantic or desirable. These statements are important to my evaluation, as they give valuable insight into the person’s psychological state.

Although an individual suicidal action is unpredictable, there can be certainty that an event may or may not occur in some places. If a place holds meaning to a community, then further events will likely occur. Places of symbolic significance, like the Golden Gate Bridge, should be monitored.

3. The Aftermath

Third, all the survivors recommend a suicide barrier. This is related to an area of suicide prevention called means reduction, in which lethal means are made less available or deadly. Although there may be some displacement to other methods, the overall suicide rate decreases.

In 2013, a barrier was installed at a bridge in Canada. The study showed that suicide rates at this site decreased, which persisted even when attempts at other bridges or jumping sites were studied. Little to no displacement to other jumping sites occurred. (Perron, 2013)

This holds true for other methods of suicide, including the famous coal gas story. Prior to the 1950s, most households in the United Kingdom used coal-derived gas, which contained about 10-20% carbon monoxide. As time progressed, more people began to use natural gas, which releases much less carbon monoxide. This resulted in a sustained decrease in overall suicide. (Kreitman, 1976)

Currently, the installation of netting at the Golden Gate bridge is scheduled to be completed in 2021 at an estimated project cost of $221 million. (San Francisco Chronicle)

Suicide prevention is a complicated topic that encompasses much more than the aspects presented in this brief discussion. As a young physician, this article is especially memorable, as the idea of approaching survivors of suicide and broaching a sensitive topic takes a certain type of courage. I am thankful that Dr. Rosen wrote this article, as there are important lessons to be learned from his discussions with these survivors. I hope these lessons can save future lives.

You can find the publication on PubMed Central here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1129714/

More Information

Rosen, D.H. Suicide survivors: A follow-up study of persons who survived jumping from the Golden Gate and San Francisco-Oakland Bay bridges. Western Journal of Medicine 122: 289-294, Apr 1975.

World Health Organization. Preventing suicide: A resource for media professionals. Geneva, Switzerland: Author. 2017. http://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/

Perron S, Burrows S, Fournier M, Perron PA, Ouellet F. Installation of a bridge barrier as a suicide prevention strategy in Montréal, Québec, Canada. American Journal of Public Health. 2013 Jul;103(7):1235-9.

Kreitman N. The coal gas story. United Kingdom suicide rates, 1960-71. Br J Prev Soc Med. 1976;30(2):86-93.

If you or someone you know is suicidal, please seek help.

International Resources

United States

Please let me know if any of these links are out of date.

Hiroshima

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In April, I went to Japan for three weeks for vacation. I chose a handful of cities to visit and spent few days in each. One of these was Hiroshima, where I visited the Peace Memorial dedicated to the people who were killed in the atomic bombing on August 6, 1945.

Before I went to the memorial, I don’t think that I understood the devastation of nuclear weapons. I knew that the bombs released enormous amounts of heat and radiation, and that the aftereffects of radiation exposure such as cancer were horrible. Knowing wasn’t the same as seeing photographs of the sick and dying, or the ragged, blood-stained uniforms the schoolchildren had worn, or hearing the stories narrated by survivors, most of whom had been children and are now old men and women.

The exhibit is constantly changing, especially as society changes and living memory fades. At the time, the main museum was undergoing renovation, but there were others nearby, including a special exhibit titled “The Twinkling Stars Know Everything,” after a collection of stories by the mothers and fathers of first-year students of Hiroshima Itchu Junior High School. The school was located only a kilometer away from the hypocenter of the bomb, and nearly the entire class died. They were only thirteen years old.

I learned about another collection of stories at the memorial and decided to read it: Hiroshima, by John Hersey. Originally published in The New Yorker, this book follows the lives of six people who were present in the bombing.

Genbaku “A-bomb” Dome © Jennifer Hsu

Of the six, the individual who most caught my interest was Dr. Terufumi Sasaki, a 25-year-old surgeon who had just completed his training at the Eastern Medical University in China. I felt great empathy with this young physician, as I am similar in age and stage of training. Dr. Sasaki was working in the Red Cross Hospital in Hiroshima. When the bomb fell, he found himself to be one of the few uninjured physicians on staff, and soon he and the other physicians were overwhelmed by the thousands of injured who came to the hospital for help.

Quote from the book:

“By three o’clock the next morning, after nineteen straight hours of his gruesome work, Dr. Sasaki was incapable of dressing another wound. He and some other survivors of the hospital staff got straw mats and went outdoors — thousands of patients and hundreds of dead were in the yard and on the driveway — and hurried around behind the hospital and lay down in hiding to snatch some sleep. But within an hour wounded people had found them; a complaining circle formed around them: “Doctors! Help us! How can you sleep?” Dr. Sasaki got up again and went back to work. Early in the day, he thought for the first time of his mother, at their country home in Mukaihara, thirty miles from town. He usually went home every night. He was afraid she would think he was dead.” – Hersey, J. Page 25

I can hardly imagine how exhausted and terrified he must have been.

Hiroshima is one of the most striking and terrifying proofs of the horrors of war. But my visit there also showed me the greatness of the human spirit and the possibility of forgiveness and healing. At the memorial, I stopped to listen to a student choir – one of many which take place throughout the year, dedicated to the children killed in the bombing – when a Japanese man turned to me and attempted to give me a pamphlet. When I indicated that I could not read Japanese, he used broken English to tell me about why the students were singing. Then he asked where I came from. When I said that I came from America, he smiled broadly and said that he loved Americans, and that he hoped to travel across the world to visit our country one day, too.

More Information

Hersey, J. Hiroshima. Vintage Books, NY. Reprint edition, 1989.

Ikegami, N. The Twinkling Stars Know Everything. First English Edition edition, 1984.

I Am Not Sick, I Don’t Need Help

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Have you ever been in denial?

Recently I have been pinching myself in disbelief. Am I really graduated from medical school? Are people actually going to start calling me “doctor?” Wow! It is terrifying, yet exciting. As a fresh graduate, I know that I still have a long road ahead of me before becoming a board-certified physician, but right now I have been feeling so incredibly blessed.

This period of time between graduation and the beginning of residency has been incredibly relaxing. I spent most of it vacationing. In April, I traveled throughout Japan for three blissful weeks. Then, I went on a scenic car trip from Texas and all the way up through New Mexico, Nevada, and Idaho to Washington State. Beautiful, isn’t it?

Driving by the Sierra Nevada © Jennifer Hsu

During these trips, I also read several books. One of these is “I Am Not Sick, I Don’t Need Help” by Xavier Amador, Ph.D., a clinical psychologist. I found it to be a quick, pleasurable read, because of the author’s concise and clear writing style. He also does a spectacular job of evoking empathy and understanding through clinical vignettes and personal stories.

If you know somebody with serious mental illness who is in “denial” and refuses to seek treatment or take medication, then this book is for you.

Dr. Amador divides this book into five parts. The first part provides information about mental illness, particularly schizophrenia. The second part describes the LEAP (listen, empathize, agree, partner) methodology that Dr. Amador developed, which has shown positive results in his work with patients and their families. The third part focuses on the feelings of betrayal and guilt that a patient and their family may feel when the patient is taken against their will to the hospital, and how to re-build trust. The fourth part discusses the value of assessing a person’s awareness of their illness and its purpose in formulating a cooperative treatment plan.

The fifth section is the most memorable of all. In it, Dr. Amador tells us about his brother Henry, who was diagnosed with schizophrenia. I could feel the love and care between the brothers, nearly palpable from the page, and I admired that he shared his brother’s story with us. It is a poignant reminder that every patient, no matter how “crazy” or psychotic, is loved by somebody. I admit that I shed some tears reading Henry’s story.

I highly recommend this book for anyone with a family member with mental illness. It is also a wonderful read for any health professionals.

Key Takeaways
  • “Denial” is the wrong term for poor insight in a person with mental illness. In patients with schizophrenia, the executive (frontal) part of the brain is often dysfunctional, resulting in a symptom called anosognosia, which is the condition in which a person with a disability seems unaware of its existence.
  • Reflective listening is listening with only one goal: to understand. It is not commenting, disagreeing, judging, or reacting in any way.
  • It is not necessary for the patient to believe that they have a mental illness. But, it is necessary for the patient and their support network (family, health provider) to work together for success. Prioritize finding common ground and collaboration, not arguing over who is “right.”
Quotes

“I can’t guarantee that LEAP will definitely eliminate medication and service refusal in the person you’re trying to help, but I can promise that if you faithfully follow the guidelines I give, they will help lower tension, increase trust, and greatly increase the likelihood that the person you are trying to help will follow your advice.” – Amador, X. Page 3.

“I have never talked anyone out of a delusion and, to my knowledge, I have never talked anyone into one either. The point is, when you’re facing someone who rigidly holds irrational beliefs, you gain nothing by disagreeing.” – Amador, X. Page 84.

“I loved Henry, and when someone you love is in pain, it is hard not to empathize. Learning to listen lead to empathy. And my empathy ultimately resulted in my brother showing a real interest in my thoughts about the illness he felt he did not have and the medications he was sure he did not need.” – Amador, X. Page 113.

More Information

Amador, X. I Am Not Sick I Don’t Need Help! How to Help Someone with Mental Illness Accept Treatment. Vida Press. Kindle Edition. 2012.

“LEAP®”; “L.E.A.P.®“;“Listen-Empathize-Agree-Partner®”; “Listen, Empathize, Agree, Partner®” and all similarly punctuated versions are registered trademarks of the LEAP Institute, are protected under the laws of the United States Patent and Trademark Office (USPTO), and may not be used without express license of the LEAP Institute.

Learn more at https://leapinstitute.org