Archive for the PSYCHIATRY Category

Psychiatric Ethics & the Goldwater Rule

Posted in MEDICOPOLITICS, ONLINE DEBATE, PERSONAL, PRACTICE, PSYCHIATRY, U.S. POLITICS with tags , , , , , , , , , , , , , , , on January 11, 2018 by drjgelb

The desperation of the Democrats, still baying at the moon over a year since their terrible candidate lost the election, despite her seditious, criminal actions to subvert the will of the American People, is astonishing. We have witnessed a complete refusal by the Democrats and their supporters to allow a smooth and peaceful transition of power. Instead, as each attempt to oust President Trump falls flat on its face, the derangement of his enemies escalates & now we have the absurd scene of highly trained medical specialists attempting to misuse their skills in order to achieve what their compatriots have been unable to pull off. Let me make it very clear to all my colleagues, friends and readers, opining on someone that one has not clinically evaluated, that one has never met, without taking a thorough psychiatric and medical history, conducting a Mental State Examination, including an assessment of Cognitive Function, obtaining a collaborative history from family, friends, involved medical practitioners and allied health and obtaining appropriate special investigations such as blood tests and medical imaging, is MALPRACTICE or put formally, Professional Misconduct. The actions of the psychiatrists supporting the outrageous 25th Amendment Coup attempt are a despicable display of partisan abuse of psychiatry reminiscent of the Soviet Union’s fabrication of the diagnosis of “Slowly Progressive Schizophrenia” used to incarcerate & stupefy hundreds of thousands of political dissidents and enemies of the state. So egregious was the USSR’s behaviour considered that the nation was expelled from the World Psychiatric Association and the psychiatrists that colluded with the regime were ostracised for life. I consider attempts to use our specialty as a political weapon makes the perpetrators the equivalent of War Criminals. At the very least, they don’t give a damn about President Trump’s Human Rights. They bring psychiatry into shameful disrepute and I sincerely hope that those engaged in this shameful, cowardly attack are formally reported to their State Medical Board for ethical investigation and censure. Below are some of the official APA statements regarding this ongoing debacle. You can see that the APA leadership has had to repeat its warning to members more than a few times and has had to head off at the pass several attempts to introduce confounding side issues to the debate.

APA Calls for End to ‘Armchair’ Psychiatry

WASHINGTON, D.C. — Today, the American Psychiatric Association (APA) reiterates its continued and unwavering commitment to the ethical principle known as “The Goldwater Rule.” We at the APA call for an end to psychiatrists providing professional opinions in the media about public figures whom they have not examined, whether it be on cable news appearances, books, or in social media. Armchair psychiatry or the use of psychiatry as a political tool is the misuse of psychiatry and is unacceptable and unethical.

The ethical principle, in place since 1973, guides physician members of the APA to refrain from publicly issuing professional medical opinions about individuals that they have not personally evaluated in a professional setting or context. Doing otherwise undermines the credibility and integrity of the profession and the physician-patient relationship. Although APA’s ethical guidelines can only be enforced against APA members, we urge all psychiatrists, regardless of membership, to abide by this guidance in respect of our patients and our profession.

A proper psychiatric evaluation requires more than a review of television appearances, tweets, and public comments. Psychiatrists are medical doctors; evaluating mental illness is no less thorough than diagnosing diabetes or heart disease. The standards in our profession require review of medical and psychiatric history and records and a complete examination of mental status. Often collateral information from family members or individuals who know the person well is included, with permission from the patient.

“The Goldwater Rule embodies these concepts and makes it unethical for a psychiatrist to render a professional opinion to the media about a public figure unless the psychiatrist has examined the person and has proper authorization to provide the statement,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “APA stands behind this rule.”

The President is about to undergo his annual physical examination, and APA has confidence that his physician will follow the standard of care in examining all systems, which includes an age-appropriate medical and mental health evaluation. If mental health concerns are raised, the standard of care would result in the examining physician seeking consultation from an experienced psychiatrist who would approach the consultation with objectivity and within the physician-patient confidential relationship.

APA is ready to make recommendations from among our 37,000 psychiatrist members, physicians who have the knowledge, training, expertise, discretion, and objectivity to perform a thorough and apolitical evaluation. Using psychiatry for political or self-aggrandizing purposes is stigmatizing for our patients and negatively impacts our profession.

 

 

Goldwater Rule

by Aaron Levin

Restraint of psychiatrists’ comments on political candidates is grounded in APA’s response to an attempt to question Barry Goldwater’s mental health during the 1964 campaign for President.

“Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” the editors of Fact magazine asked 12,356 psychiatrists during the 1964 presidential campaign between Goldwater and Lyndon Johnson.

The responses set off a wave of reaction that resonated again most recently after media speculation about the mental status of the current Republican presidential candidate.

Fact published numerous comments questioning Sen. Barry Goldwater’s psychological capacity for office, which ultimately led to the creation of APA’s “Goldwater Rule” in 1973.

A look at the original episode reveals as much about psychiatry’s changes over the last half century as it does about politics then or now.

The harshly negative responses by people who had never even met Goldwater seem astonishing by today’s standards, as a sampling suggests:

“I believe Goldwater to be suffering from a chronic psychosis,” wrote one.

“A megalomaniacal, grandiose omnipotence appears to pervade Mr. Goldwater’s personality giving further evidence of his denial and lack of recognition of his own feelings of insecurity and ineffectiveness,” wrote another.

“From his published statements I get the impression that Goldwater is basically a paranoid schizophrenic who decompensates from time to time. … He resembles Mao Tse-tung,” said a third.

Not wanting to exclude other relevant 20th-century tyrants, another claimed, “I believe Goldwater has the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders.”

Others pushed back. In reality, Goldwater had worked in his family’s business, then served as a transport pilot in World War II, and retained a commission in the Air Force Reserve for many years. He was twice elected senator before the 1964 presidential race and would be again in 1968, 1974, and 1980.

It was difficult, said one psychiatrist quoted in Fact, to believe that a man who was “psychotic” or “schizophrenic” would have managed all that.

“I served as a flight surgeon in the USAF,” wrote Wilbert Lyons, M.D., of Sellersville, Pa. “I speak with authority when I say that Sen. Goldwater could not be a jet pilot if he were emotionally unstable.”

Goldwater certainly held very conservative political views and expressed them forcefully. Many of the respondents who declared him “unfit” were likely expressing their own political biases in psychiatric terms. Tellingly, many of them asked that their names be withheld from publication, perhaps hinting at some guilt feelings over their cavalier, remote diagnoses of the candidate.

Nevertheless, many other respondents understood immediately the greater implications of the question for psychiatry’s purported role in the electoral process.

“Your inquiry for a professional opinion regarding Sen. Barry Goldwater’s general mental stability is an insult to me,” wrote Thomas Stach, M.D., in 1964. “An inquiry of this type regarding any individual can only be based on ignorance of the field of psychiatry.”

Stach demanded an apology from the editors to all the psychiatrists who had received the survey.

“It was astounding to me when the survey first came out,” Stach, now retired in Willowbrook, Ill., told Psychiatric News. “It was impossible for a psychiatrist to come to a conclusion like that without a personal examination. The psychiatrists who were baited into giving responses were imprudent.”

Some offered a nuanced statement of their own positions.

“Politically, I heartily disapprove of Goldwater,” wrote Joseph Schachter, M.D., Ph.D., in 1964. “In fact, I find him somewhat frightening. Yet I do not feel I can honestly say he is psychologically unfit to serve as president.”

“I still think that’s a plausible view of the Goldwater situation,” said Schachter, now retired and living in New York City, in a recent interview. “Psychiatrists and psychoanalysts have the right as citizens to comment on elections and candidates and are free to do that, but without selecting a psychiatric diagnosis.”

“Vetting a candidate should be based on his or her position on the issues,” agreed Stach. “The survey betrayed the ignorance of the questioner.”

APA’s initial reaction to the Fact magazine article came swiftly.

“[S]hould you decide to publish the results of a purported ‘survey’ of psychiatric opinion on the question you have posed, the Association will take all possible measures to disavow its validity,” wrote APA Medical Director Walter Barton, M.D., in a letter to the magazine’s editors on October 1, 1964.

APA President Daniel Blain, M.D., denounced the compilation as “a hodge-podge of the personal political opinions of selected psychiatrists speaking as individuals. … [T]he replies to the question have no scientific or medical validity whatsoever.”

Tying political partisanship to the psychiatric profession, continued Blain, “has, in effect, administered a low blow to all who would work to advance the treatment and care of the mentally ill of America.”

APA’s formal response came in 1973 with the adoption of Section 7.3 in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, which became known as the Goldwater Rule.

The rule applies to public figures and states: “It is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement” (see below).

The episode and the subsequent adoption of Section 7.3 appear to have dampened the enthusiasm of most APA members for a repeat performance, leaving psychiatric diagnosis to the media.

Text of APA’s Ethics Annotation Known as ‘Goldwater Rule’

7. 3. On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

 

APA’s Goldwater Rule Remains a Guiding Principle for Physician Members

ARLINGTON, Va. — The American Psychiatric Association (APA) today released the following statement regarding The Goldwater Rule:

“In the past year and a half, there have been numerous news articles and commentaries on The Goldwater Rule. The Goldwater Rule is an ethics principle that guides our physician members not to provide professional opinions in the media about the mental health of someone they have not personally examined and without patient consent or other legal authority. A personal examination includes ruling out physical causes of or other reasons for a behavior. Nothing about the Goldwater Rule discourages psychiatrists from providing education to the public about mental illnesses; in fact, APA encourages psychiatrists to educate the public about the causes, symptoms, and treatment of mental illnesses and substance use disorders.

The APA would also like to dispel a common misconception about the so-called “Duty to Warn.” The duty to warn is a legal concept which varies from state to state, but which generally requires psychiatrists to breach the confidentiality of the therapeutic session when a risk of danger to others becomes known during treatment of the patient. It does not apply if there is no physician-patient relationship.”

 

APA Reaffirms Support for Goldwater Rule

ARLINGTON, Va. March 16, 2017 — The American Psychiatric Association (APA) today reaffirmed its support behind the ethics guideline commonly known as “The Goldwater Rule,” which asserts that member psychiatrists should not give professional opinions about the mental state of someone they have not personally evaluated.

The APA’s Ethics Committee issued an opinion that clarifies the ethical principle and answers questions that have been posed recently.

Since 1973, the American Psychiatric Association and its members have abided by a principle commonly known as “the Goldwater Rule.” The ethics principle is so named because of its association with an incident that took place during the 1964 presidential election. (See APA Blog on Goldwater Rule.) During that election, Fact magazine published a survey in which it queried some 12,356 psychiatrists on whether candidate Sen. Barry Goldwater, the GOP nominee, was psychologically fit to be president. A total of 2,417 of those queried responded, with 1,189 saying that Goldwater was unfit to assume the presidency. Goldwater would later sue the magazine, which was found liable for damages.

“It was unethical and irresponsible back in 1964 to offer professional opinions on people who were not properly evaluated and it is unethical and irresponsible today,” said APA President Maria A. Oquendo, M.D., Ph.D. “In the past year, we have received numerous inquiries from member psychiatrists, the press and the public about the Goldwater Rule. We decided to clarify the ethical underpinnings of the principle and answer some of the common questions raised by our members. APA continues to support these ethical principles.”

In reaffirming the existing policy, the Ethics Committee explained the rationale behind the rule. For example, offering a professional opinion or a diagnosis of someone they have not thoroughly examined compromises the integrity of the doctor and the profession and it has the potential to stigmatize those with mental illness. Furthermore, when a physician publicly gives a professional opinion on a public figure without consent, it violates the principle that a psychiatric evaluation must occur with consent or authorization.

 

The Goldwater Rule: Why breaking it is Unethical and Irresponsible

August 3rd 2016    

Every four years, the United States goes through a protracted elections process for the highest office in the land. This year, the election seems like anything but a normal contest, that has at times devolved into outright vitriol. The unique atmosphere of this year’s election cycle may lead some to want to psychoanalyze the candidates, but to do so would not only be unethical, it would be irresponsible.

Simply put, breaking the Goldwater Rule is irresponsible, potentially stigmatizing, and definitely unethical.

Maria A. Oquendo, M.D.

Since 1973, the American Psychiatric Association and its members have abided by a principle commonly known as “the Goldwater Rule,” which prohibits psychiatrists from offering opinions on someone they have not personally evaluated. The rule is so named because of its association with an incident that took place during the 1964 presidential election. During that election, Fact magazine published a survey in which they queried some 12,356 psychiatrists on whether candidate Sen. Barry Goldwater, the GOP nominee, was psychologically fit to be president. A total of 2,417 of those queried responded, with 1,189 saying that Goldwater was unfit to assume the presidency.

While there was no formal policy in place at the time that survey was published, the ethical implications of the Goldwater survey, in which some responding doctors even issued specific diagnoses without ever having examined him personally, became immediately clear. This large, very public ethical misstep by a significant number of psychiatrists violated the spirit of the ethical code that we live by as physicians, and could very well have eroded public confidence in psychiatry.

We live in an age where information on a given individual is easier to access and more abundant than ever before, particularly if that person happens to be a public figure. With that in mind, I can understand the desire to get inside the mind of a Presidential candidate. I can also understand how a patient might feel if they saw their doctor offering an uninformed medical opinion on someone they have never examined. A patient who sees that might lose confidence in their doctor, and would likely feel stigmatized by language painting a candidate with a mental disorder (real or perceived) as “unfit” or “unworthy” to assume the Presidency.

Simply put, breaking the Goldwater Rule is irresponsible, potentially stigmatizing, and definitely unethical.

The Goldwater Rule is published as an annotation in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. I encourage you all to read the full text of the rule below, and keep it in mind during this election cycle, and other events of similarly intense public interest.

 

 

The Ethical Psychiatrist’s Role in Public Elections

April 7th 2016

Presidential elections are intense and may lead some observers to speculate about the mental health of the candidates. People are curious about psychiatrists’ diagnostic opinions of politicians and other public figures. This is a sufficiently common phenomenon that APA added an annotation to the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry in 1973, commonly referred to as the Goldwater Rule, prohibiting psychiatrists from offering public opinions about people they have not personally evaluated.

Section 7, Article 3, of the Principles states, “On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

Why is it called the Goldwater Rule? During the 1964 presidential election, Fact magazine published the results of a survey it had mailed to 12,356 psychiatrists. Of the 2,417 respondents, 1,189 replied that Sen. Barry Goldwater was not psychologically fit to be president. For a detailed account of the responses, see Henry Pinsker, M.D.’s “Goldwater Rule History” in Psychiatric News. Sen. Goldwater successfully sued Fact for libel and was awarded $75,000 in punitive damages.

APA responded to this very public ethical misstep by a large number of psychiatrists with the annotation above, and periodically the Goldwater Rule is recapped in APA publications (“Ethics Reminder Offered About Goldwater Rule on Talking to the Media,” and in the national media (“Should Therapists Analyze Presidential Candidates?).

Beyond a reminder about the rule, it may be helpful to understand some of the ethical concepts behind it. Virtue ethics emphasizes the personal characteristics that society expects physicians to embody. Among these virtues are respect for others, humility, and adherence to diagnostic processes according to the standards of our field. If we venture a diagnostic impression about a person we have not examined, we trample upon these virtues.

In addition to inviting a lawsuit for libel or slander, a potential consequence of psychiatrists breaching these virtues is a diminution of public confidence in psychiatrists. If we will speak to the media about the possible psychiatric diagnosis of a person we have not evaluated, will we also reveal the identities and diagnoses of our patients? We must guard against undermining the protective cloak of confidentiality, without which people may refrain from seeking mental health treatment.

Political campaigns are brutal. Even a psychologically healthy person needs extra support if engaged as a candidate in an election. Because of stigma, that candidate needs to be assured of the utmost privacy and confidentiality if he or she is to enter treatment. If we are hazarding guesses about politicians’ diagnoses in the media, we will lose the opportunity to provide treatment to our political leaders, which is perhaps one of the most effective ways to ensure a mentally healthy leadership while simultaneously eroding the stigma attached to our field.

Psychiatrists can play an important role in elections, but it is mostly silent. 

 

 

There are many other similar statements, warnings, reminders and guidelines that have been issued on a regular basis since 1973, as each election cycle strained adherence to the Goldwater Rule but have no doubt, EVERY PSYCHIATRIST IS FULLY AWARE OF THEIR ETHICAL RESPONSIBILITIES IN THESE MATTERS and the public has the right to expect better of its key Mental Health Professionals. 

 

 

 

 

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How to Spot a Psychopath

Posted in Cultural Marxism, ONLINE DEBATE, PSYCHIATRY, U.S. POLITICS with tags , , , on July 24, 2017 by drjgelb

How to Spot a Psychopath

 

Richard Fidler’s “Conversations” program on ABC Radio National (Australia) today interviewed David Gillespie, author of a new book on how to spot a psychopath at work & at home. Unfortunately, the last five minutes of the program consisted of branding President Trump a psychopath, a disturbing and invalid characterisation. I made the following comment on the show’s Facebook Page:

 

 

“Excellent program let down by mischaracterisation of Donald Trump as a psychopath based on 2nd & 3rd hand, biased reporting & an absence of inclusion of numerous examples of behaviour completely inconsistent with psychopathy. Mainstream media has failed to report the numerous unheralded examples of great generosity displayed by Trump throughout his life. Research will reveal instances of Trump contacting people affected by serious misfortune & providing enormous help anonymously. Several instances have been revealed years later, despite Trump’s wishes to remain anonymous.
Secondly, he has loyal and diverse friendships with people from all walks of life, many whom have complained that the goodness they have witnessed from Trump does not interest the press & is ignored.
Thirdly, psychopaths rarely have successful, confident children, rather they control their kids mercilessly, demand loyalty without reciprocating & suffer inevitable rejection & abandonment by their adult children.
Fourthly, the comments suggesting Trump is a compulsive liar neglects to place this opinion in the proper context of the bottomless pit of lies told by his rival, Hillary Clinton, whose remorseless blame-shifting & dishonesty regarding her private email server, details of the Benghazi attack, destruction of mobile devices and so much more, is much more indicative of psychopathy. Her calling the parents of the murdered Benghazi defenders “liars” after she blamed the attack on an anti-Islamic video when she knew categorically that this was untrue, was one of the lowest & despicable actions of the entire campaign & was much more characteristic of a psychopath. Her laughing comments re winning a case for a rapist of a 13yr old girl were similarly despicable, as was her “we came, we saw, he died” laughter following Gaddafi’s unnecessary removal. Her actions related to arms sales to ISIS were totally reprehensible & her hypocrisy re the sale of 20% of U.S. Uranium to Russia & the acceptance of a $130 million donation to the Clinton Foundation for doing so, was astounding. Failure to mention her husband, psychopath & serial rapist, Bill Clinton, demonstrated the bias that infected the show today.
Lastly, regardless of experience, no diagnostic labels are valid in the absence of a clinician personally interviewing a patient, preferably face to face and supplementing the assessment with a thorough search for corroborative information & 3rd party interviews with relevant informants who have personal knowledge of the subjects life & behaviour. Armchair psychiatrists who provide the press with definitive diagnoses re Trump without such an examination may actually be in breach of their Code of Conduct and various U.S. State Medical Boards have indicated that such practitioners may face investigation and censure.”

ANZAC DAY IS 25TH APRIL 2016

Posted in GUN CONTROL, CRIMINAL JUSTICE & THE HORRORS OF THE ADVERSARIAL SYSTEM!, PERSONAL, PRACTICE, PSYCHIATRY with tags , , , on April 6, 2016 by drjgelb

Anzac Day, 25th April 2016, is a difficult day for many if not most Veterans, especially those whose mental health has been damaged by their military service. Current ADF members whose deployment has caused damage to their mental health may also suffer on or around Anzac Day, even among those not yet diagnosed with a mental health condition. It’s important to know that the day itself is not the only day of increased risk for mental distress, worsened symptoms of mental health disorders & suicide. Many Veterans have reported feeling rising tension & increased unease from the beginning of April or earlier that last until well after Anzac day is over. The “Anzac Day Effect”, as I call it, is actually an example of the well known “Anniversary Reaction”, a peak of distress that commonly occurs on important days such as birthdays, Christmas & wedding anniversaries in the bereaved. In other words, it is normal & expected to be common. What is different, is that this common effect is made more likely and more severe in those Veterans already suffering from a mental disorder like PTSD, where reminders of military service have a more severe impact. Regardless of whether or not you have been diagnosed with a mental disorder, be aware that you and/or your Veteran mates are entering a potentially difficult period and keep an eye out for each other. If you’re worried about yourself or a mate, don’t keep quiet & hope it just passes. Ask yourself or your mate if they’re travelling ok, start a conversation about what you are feeling or about what you’ve read about the tough time that many Veterans go through around Anzac Day. The best medicine for distress around Anzac Day isn’t Alcohol, it’s airing these feelings with trusted people…….Veterans, family, friends or your doctor. Suicide results from hopelessness & involves alcohol 75% of the time. Observing Anzac Day with either no alcohol or by limiting your alcohol intake, together with a willingness to talk and awareness of the increased Anzac Day risks amongst the entire Veteran community, will, not might, save lives. To all Veterans, I wish you a solemn and special Day of remembrance, nostalgia and celebration of our national heroes, past, present & future.

VITAMIN D – DANGEROUSLY DEFICIENT!

Posted in PSYCHIATRY with tags , , , on October 21, 2013 by drjgelb

VITAMIN D DEFICIENCY IS THE UNDESIRABLE NEW NORM IN THE DIGITAL AGE, WITH DEVASTATING INCREASES IN EARLY ONSET OSTEOPOROSIS AND BONE FRACTURES AND LIKELY INVOLVEMENT IN DEPRESSION, DEMENTIA AND CANCER. MUCH WORK REMAINS TO BE DONE BUT THERE IS NO DOUBT THAT IF YOU WORK INDOORS, IT IS IMPOSSIBLE AND UNSAFE TO LIVE IN Melbourne AND GET SUFFICIENT UNPROTECTED MIDDLE OF THE DAY SUNLIGHT TO MAINTAIN VIT.D STORES WITHOUT SUPPLEMENTATION. AN INCREASING INCIDENCE OF RICKETTS IN CHIDREN OF DARK SKINNED MIGRANTS AND RATES OF DEFICIENCY IN PREGNANT VEILED WOMEN EXCEEDING 80%, MUST RING ALARM BELLS FOR HEALTH AUTHORITIES. PERHAPS IT’s TIME TO FINESSE THE SLIP, SLOP, SLAP MESSAGE WITH A SOFTER MESSAGE ABOUT SUN EXPOSURE OUTSIDE THE DANGEROUS 4-6hr MIDDLE OF THE DAY WINDOW. eg. Exposure until 10am and after 3pm requires less aggressive use of sun protection strategies

OR ARE PEOPLE TOO EASILY CONFUSED TO RISK IT?

ANYWAY, HERE ARE THE FACTS FYI:

VITAMIN D DEFICIENCY – WIDESPREAD AND MORE SERIOUS THAN PREVIOUSLY KNOWN!

The major function of Vitamin D in humans is to maintain appropriate serum calcium concentrations by enhancing the ability of the small intestine to absorb calcium from the diet. Vitamin D also plays a role in enhancing absorption of phosphorus from the diet, but the blood concentration of phosphorus is not well regulated and varies according to supply and the renal excretory threshold.

Vitamin D maintains the blood calcium at supersaturating levels such that it is deposited in the bone as calcium hydroxyapatite. When dietary calcium is inadequate for the body’s needs, 1,25-dihydroxyvitamin D [1,25(OH)2D or calcitriol] – the active form of vitamin D – together with parathyroid hormone, can mobilise stem cells in bone marrow to become mature osteoclasts which in turn increase the mobilisation of calcium stores from bone. However, there is a limited capacity to mobilise sufficient calcium from bone to have a significant effect on blood calcium levels.

Vitamin D occurs in two forms. One is produced by the action of sunlight on skin (D3 or cholecalciferol) and the other is found in a limited range of foods (D2 or ergocalciferol). With current food supplies and patterns of eating, it is almost impossible to obtain sufficient vitamin D from the diet alone (Fuller & Casparian 2001). Vitamin D in foods is fat soluble and is biologically less active. Its metabolite, 1.25-dihydroxyvitamin D (1,25(OH2)D, or calcitriol) is the biologically active hormone responsible for its physiological actions. In the circulation, vitamin D appears as 25-hydroxyvitamin D (25(OH)D) which is five times more potent than cholecalciferol.

Vitamin D status is generally maintained in the population by exposure to sunlight (Glerup et al 2000, Holick 1996, Rasmussen et al 2000). If sunlight exposure is adequate, dietary vitamin D can be considered unnecessary (Holick 2001). In skin, 7-dehydrocholesterol is converted to pre-vitamin D3 by a narrow band of solar ultraviolet radiation (290-320 nm) which undergoes isomerisation in a temperature-dependent manner to vitamin D3.

Thus, vitamin D is not a nutrient in the usual sense, since under normal conditions it is supplied mainly by the skin. In addition, its physiological actions are attributable to the active metabolite, 1,25-dihydroxyvitamin D which, because it is synthesised in the kidneys and acts elsewhere, is often called a hormone.

1 µg cholecalciferol is equal to 0.2 µg 25(OH)D. Vitamin D is also sometimes expressed in International Units where 1 IU equals 0.025 µg cholecalciferol or 0.005 µg 25(OH)D.

Seasonal changes have been shown to have a significant effect on the cutaneous production of cholecalciferol (Pettifor et al 1996, Webb et al 1990). In the winter months in temperate latitudes, solar UV light in the wavelength range of 290-320 nm is absorbed by the atmosphere. People also spend less time outdoors and wear more clothing. For this reason, vitamin D deficiency is more common in the winter months (Holick 1995).

Despite the sunny climate, a seasonal variation in vitamin D levels also occurs in Australia. In the Geelong Osteoporosis Study, the mean vitamin D levels for winter were 58 nmol/L compared with 70 nmol/L in summer (Pasco et al 2001). However, after regular sun exposure, people under the age of 50 can produce and store approximately 6 months’ worth of vitamin D, so vitamin D stored in the body is available during the winter when production is minimal (Holick 1996). However, in older people, the efficiency of cutaneous synthesis of vitamin D is significantly less than that in younger people (Holick et al 1989, Need et al 1993).

Other environmental factors such as the angle of the sun, distance from the equator, the amount of cloud cover and the amount of particulate matter in the atmosphere (Holick 1995, Kimlin et al 2003, Madronich et al 1998) can affect the amount of vitamin D produced. Comparative data indicate that Northern and Southern latitudes are not equivalent. It has been estimated that ultraviolet levels in summer are up to 40% higher in New Zealand than in the equivalent Northern latitudes (Madronich et al 1998).

Deficiency of Vitamin D results in inadequate mineralisation or demineralisation of the skeleton. This can lead to rickets in young children, causing bowed legs and knocked knees., A study in China showed that vitamin D given as a supplement over 2 years increased both total body bone mineral content and bone mineral density in older children (Du et al 2004). In adults, deficiency can lead to increased bone turnover and osteoporosis and less commonly to osteomalacia for which the associated secondary hyperparathyroidism enhances mobilisation of calcium from the skeleton, resulting in porotic bone. Vitamin D may also affect fracture rates via mechanisms other than its influence on bone mass. Bischoff-Ferrari et al (2004) showed that on the basis of five RCTs involving 1,237 participants, vitamin D reduced the number of falls by 22% compared with patients receiving calcium or placebo.

Vitamin D is also thought to play a role in maintaining the immune system (Brown et al1999, DeLuca 1998) and helping maintain healthy skin (DeLuca 1998, Jones et al 1998) and muscle strength (Brown et al 1999).

There is increasing recognition that a significant number of Australians and New Zealanders may have less than optimal 25(OH)D status, however limited published information of the prevalence of vitamin D deficiency in Australia is available, other than from relatively small subpopulations (Nowson & Margerison 2002, Pasco et al 2004). Some information is available currently in unpublished form, from the national surveys of 1997 and 2002 in New Zealand (Green et al 2004a,b). Recent analyses of blood samples from these surveys showed that 31% of New Zealand children aged 5-14years whose bloods were sampled in 2002 had a serum 25(OH)D concentration indicative of vitamin D insufficiency. Between 0% (for 5-6 year olds of European background) and 14% (for girls aged 11-14 years of Pacific Island backgrounds) had vitamin D deficiency. For adolescents at or above 15 years and adults whose bloods were sampled in 1997, the prevalence of deficiency, defined as <17.5 nmol/L, was 2.8%, but the prevalence of insufficiency, defined as 70 yr 15.0 µg /day
Women
19-30 yr 5.0 µg /day
31-50 yr 5.0 µg /day
51-70 yr 10.0 µg /day
>70 yr 15.0 µg /day
Rationale: The AI for younger adults (19-50 years) is based on the amount of vitamin D required to maintain serum 25(OH)D at a level of at least 27.5 nmol/L with minimal exposure to sunlight. One study of US women of this age (Kinyamu et al 1997) showed that an average intake of 3.3-3.4 µg/day resulted in serum 25(OH)D of greater than 30 nmol/L. A study of females in Australia undertaken across both the summer and winter months at latitude 38o (Pasco et al 2001), assessed median intakes to be only 1.3 µg/day (much lower than other estimates for Australia and New Zealand), but had only 7% of subjects with serum 25(OH)D below 28 nmol/L in summer and 11% in winter. A vitamin D intake of 2.5 µg/day was seen as prudent for this age group. There are no data on men on which to set a figure except from one study of submariners not exposed to sunlight, whose status was assessed with or without a 15 µg/day supplement (Holick, 1994). However, the effects of lower doses were not assessed in this study. It is therefore assumed that requirements for men will be the same as those for women.

To cover the needs of all adults in the age range of 19-50 years, regardless of exposure to sunlight and in recognition of the fact that the available data were collected in women, a figure of 5 µg/day was set as the AI for younger adults. The AI was raised to 10 µg/day for adults aged 51-70 years to account for the reduced capacity for the skin to produce vitamin D with ageing (Holick et al 1989, Need et al 1993). Data on bone loss and vitamin D supplementation in women were also taken into consideration (Dawson-Hughes et al 1991, 1995). For adults over 70 years, the AI was raised to 15 µg/day. Studies of elderly people with intakes of 9.6 µg, 7.1 µg or 5.2 µg vitamin D/day showed that 8, 14 and 45%, respectively had low levels of serum 25(OH)D (Gloth et al 1995, Kinyamu et al 1997, O’Dowd et al 1993). A value of 7.5 µg/day was considered prudent for those with limited sun exposure and was doubled to 15 µg/day to cover the needs of all adults of this age, regardless of sun exposure or body stores.

It should be noted that the effect of increasing the dietary intake of vitamin D on 25(OH)D concentration in blood varies according to the existing vitamin D status of the individual. The status of those with low 25(OH)D levels in plasma will be improved to a more significant degree than of those with pre-existing high status (eg plasma levels above about 50 nmol/L) who may benefit little from the additional dietary intake.

Role of sunlight exposure: There is evidence from selected subpopulations that about 4-8% of adults in Australia have serum 25(OH)D levels below 28 nmol/L and about 30% have levels below 50 nmol/L. (Pasco et al 2001, MacGrath et al 2001, Vasikaran et al 2000). National surveys in New Zealand have indicated that some 2.8% of adults have levels of less than 17.5 nmol/L and 27.6% have levels below 37.5 nmol/L. Both sunlight and diet play an essential role in vitamin D status in younger adults. Kimlin et al (2003) estimated that for an older woman with fair skin, exposure of 6% of the body surface (face, hands, forearm) to sunlight for 15-30 minutes, 2-3 times per week would provide the equivalent of 15 µg vitamin D/day. Because of reduced cutaneous production, young adults (19-50 years) who live in southern latitudes such as Tasmania and the southern island of New Zealand are particularly at risk of becoming vitamin D deficient during the winter months.

For dark-skinned peoples such as indigenous Australians and New Zealanders and certain migrant groups and veiled women, there is evidence in Australia of high rates of vitamin D deficiency. Grover et al (2001) found that 80% of pregnant dark-skinned, veiled women attending one antenatal clinic in a large teaching hospital had vitamin D levels of less than 22 nmol/L. For people with little access to sunlight a supplement of 10 µg/day would not be excessive.

Institutionalised elderly: Several studies in Australia and New Zealand have shown high rates of deficiency in very elderly people with restricted access to sunlight, many of whom live in institutions. Estimates of deficiency range from 15-52% in Australia (Bruce et al 1999, Flicker et al 2003, Inderjeeth et al 2000, Stein 1996). Ley et al (1999) found that 49% of older New Zealand subjects in winter and 33% in summer had low serum 25(OH)D while McAuley et al (1997) reported 69% of subjects in Dunedin having low levels in winter, but only 26% in summer. Data from the National Nutrition Survey of New Zealand (Green et al 2004b) showed that 1.6% of males over 65 years and 5.8% of females had blood levels below 17.5 nmol/L for serum 25(OH)D and that 20.5% of men and 39.6% of women had levels below 37.5 nmol/L. This survey did not include institutionalised people. The recommendation of 15 µg/day for those over 70 years relates to the general population over 70 years. A number of recent studies demonstrate protection from falls and fractures with supplemental intakes of vitamin D in the elderly.

For institutionalised or bed-bound elderly who have very restricted exposure to sunlight often accompanied by reduced food intake, supplementation with vitamin D in the order of 10-25 µg/day may be necessary (Brazier et al 1995, Byrne et al 1995, Chapuy et al 1992, Egsmose et al 1987, Fardellone et al 1995, Kamel et al 1996, McKenna 1992, Sebert et al 1995, Sorva et al 1991).

Pregnancy

Age AI
14-18 yr 5.0 µg/day
19-30 yr 5.0 µg/day
31-50 yr 5.0 µg/day
Rationale: Although there is placental transfer of vitamin D and its metabolites from mother to foetus, the amounts are too small to affect the mother’s vitamin D requirement, particularly as there is a rise in serum calcitriol (probably of placental origin) and a rise in calcium absorption in late pregnancy (Paunier et al 1978, Specker 2004). However, maternal deficiency of vitamin D can affect the foetus and needs to be prevented. Pregnant women who receive regular exposure to sunlight do not require supplementation. However, at intakes of less than 3.8 µg/day, pregnant women in winter months at high latitudes have been shown to have low serum 25(OH)D (Paunier et al 1978). For women who have little access to sunlight, a supplement of 10 µg/day prenatally would not be excessive. In the last trimester of pregnancy there is quite a large transfer of 25(OH)D across the placenta.

Vitamin D

Background

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The major function of Vitamin D in humans is to maintain appropriate serum calcium concentrations by enhancing the ability of the small intestine to absorb calcium from the diet. Vitamin D also plays a role in enhancing absorption of phosphorus from the diet, but the blood concentration of phosphorus is not well regulated and varies according to supply and the renal excretory threshold.

Vitamin D maintains the blood calcium at supersaturating levels such that it is deposited in the bone as calcium hydroxyapatite. When dietary calcium is inadequate for the body’s needs, 1,25-dihydroxyvitamin D [1,25(OH)2D or calcitriol] – the active form of vitamin D – together with parathyroid hormone, can mobilise stem cells in bone marrow to become mature osteoclasts which in turn increase the mobilisation of calcium stores from bone. However, there is a limited capacity to mobilise sufficient calcium from bone to have a significant effect on blood calcium levels.

Vitamin D occurs in two forms. One is produced by the action of sunlight on skin (D3 or cholecalciferol) and the other is found in a limited range of foods (D2 or ergocalciferol). With current food supplies and patterns of eating, it is almost impossible to obtain sufficient vitamin D from the diet alone (Fuller & Casparian 2001). Vitamin D in foods is fat soluble and is biologically less active. Its metabolite, 1.25-dihydroxyvitamin D (1,25(OH2)D, or calcitriol) is the biologically active hormone responsible for its physiological actions. In the circulation, vitamin D appears as 25-hydroxyvitamin D (25(OH)D) which is five times more potent than cholecalciferol.

Vitamin D status is generally maintained in the population by exposure to sunlight (Glerup et al 2000, Holick 1996, Rasmussen et al 2000). If sunlight exposure is adequate, dietary vitamin D can be considered unnecessary (Holick 2001). In skin, 7-dehydrocholesterol is converted to pre-vitamin D3 by a narrow band of solar ultraviolet radiation (290-320 nm) which undergoes isomerisation in a temperature-dependent manner to vitamin D3.

Thus, vitamin D is not a nutrient in the usual sense, since under normal conditions it is supplied mainly by the skin. In addition, its physiological actions are attributable to the active metabolite, 1,25-dihydroxyvitamin D which, because it is synthesised in the kidneys and acts elsewhere, is often called a hormone.

1 µg cholecalciferol is equal to 0.2 µg 25(OH)D. Vitamin D is also sometimes expressed in International Units where 1 IU equals 0.025 µg cholecalciferol or 0.005 µg 25(OH)D.

Seasonal changes have been shown to have a significant effect on the cutaneous production of cholecalciferol (Pettifor et al 1996, Webb et al 1990). In the winter months in temperate latitudes, solar UV light in the wavelength range of 290-320 nm is absorbed by the atmosphere. People also spend less time outdoors and wear more clothing. For this reason, vitamin D deficiency is more common in the winter months (Holick 1995).

Despite the sunny climate, a seasonal variation in vitamin D levels also occurs in Australia. In the Geelong Osteoporosis Study, the mean vitamin D levels for winter were 58 nmol/L compared with 70 nmol/L in summer (Pasco et al 2001). However, after regular sun exposure, people under the age of 50 can produce and store approximately 6 months’ worth of vitamin D, so vitamin D stored in the body is available during the winter when production is minimal (Holick 1996). However, in older people, the efficiency of cutaneous synthesis of vitamin D is significantly less than that in younger people (Holick et al 1989, Need et al 1993).

Other environmental factors such as the angle of the sun, distance from the equator, the amount of cloud cover and the amount of particulate matter in the atmosphere (Holick 1995, Kimlin et al 2003, Madronich et al 1998) can affect the amount of vitamin D produced. Comparative data indicate that Northern and Southern latitudes are not equivalent. It has been estimated that ultraviolet levels in summer are up to 40% higher in New Zealand than in the equivalent Northern latitudes (Madronich et al 1998).

Deficiency of Vitamin D results in inadequate mineralisation or demineralisation of the skeleton. This can lead to rickets in young children, causing bowed legs and knocked knees., A study in China showed that vitamin D given as a supplement over 2 years increased both total body bone mineral content and bone mineral density in older children (Du et al 2004). In adults, deficiency can lead to increased bone turnover and osteoporosis and less commonly to osteomalacia for which the associated secondary hyperparathyroidism enhances mobilisation of calcium from the skeleton, resulting in porotic bone. Vitamin D may also affect fracture rates via mechanisms other than its influence on bone mass. Bischoff-Ferrari et al (2004) showed that on the basis of five RCTs involving 1,237 participants, vitamin D reduced the number of falls by 22% compared with patients receiving calcium or placebo.

Vitamin D is also thought to play a role in maintaining the immune system (Brown et al1999, DeLuca 1998) and helping maintain healthy skin (DeLuca 1998, Jones et al 1998) and muscle strength (Brown et al 1999).

There is increasing recognition that a significant number of Australians and New Zealanders may have less than optimal 25(OH)D status, however limited published information of the prevalence of vitamin D deficiency in Australia is available, other than from relatively small subpopulations (Nowson & Margerison 2002, Pasco et al 2004). Some information is available currently in unpublished form, from the national surveys of 1997 and 2002 in New Zealand (Green et al 2004a,b). Recent analyses of blood samples from these surveys showed that 31% of New Zealand children aged 5-14years whose bloods were sampled in 2002 had a serum 25(OH)D concentration indicative of vitamin D insufficiency. Between 0% (for 5-6 year olds of European background) and 14% (for girls aged 11-14 years of Pacific Island backgrounds) had vitamin D deficiency. For adolescents at or above 15 years and adults whose bloods were sampled in 1997, the prevalence of deficiency, defined as <17.5 nmol/L, was 2.8%, but the prevalence of insufficiency, defined as 70 yr 15.0 µg /day
Women
19-30 yr 5.0 µg /day
31-50 yr 5.0 µg /day
51-70 yr 10.0 µg /day
>70 yr 15.0 µg /day
Rationale: The AI for younger adults (19-50 years) is based on the amount of vitamin D required to maintain serum 25(OH)D at a level of at least 27.5 nmol/L with minimal exposure to sunlight. One study of US women of this age (Kinyamu et al 1997) showed that an average intake of 3.3-3.4 µg/day resulted in serum 25(OH)D of greater than 30 nmol/L. A study of females in Australia undertaken across both the summer and winter months at latitude 38o (Pasco et al 2001), assessed median intakes to be only 1.3 µg/day (much lower than other estimates for Australia and New Zealand), but had only 7% of subjects with serum 25(OH)D below 28 nmol/L in summer and 11% in winter. A vitamin D intake of 2.5 µg/day was seen as prudent for this age group. There are no data on men on which to set a figure except from one study of submariners not exposed to sunlight, whose status was assessed with or without a 15 µg/day supplement (Holick, 1994). However, the effects of lower doses were not assessed in this study. It is therefore assumed that requirements for men will be the same as those for women.

To cover the needs of all adults in the age range of 19-50 years, regardless of exposure to sunlight and in recognition of the fact that the available data were collected in women, a figure of 5 µg/day was set as the AI for younger adults. The AI was raised to 10 µg/day for adults aged 51-70 years to account for the reduced capacity for the skin to produce vitamin D with ageing (Holick et al 1989, Need et al 1993). Data on bone loss and vitamin D supplementation in women were also taken into consideration (Dawson-Hughes et al 1991, 1995). For adults over 70 years, the AI was raised to 15 µg/day. Studies of elderly people with intakes of 9.6 µg, 7.1 µg or 5.2 µg vitamin D/day showed that 8, 14 and 45%, respectively had low levels of serum 25(OH)D (Gloth et al 1995, Kinyamu et al 1997, O’Dowd et al 1993). A value of 7.5 µg/day was considered prudent for those with limited sun exposure and was doubled to 15 µg/day to cover the needs of all adults of this age, regardless of sun exposure or body stores.

It should be noted that the effect of increasing the dietary intake of vitamin D on 25(OH)D concentration in blood varies according to the existing vitamin D status of the individual. The status of those with low 25(OH)D levels in plasma will be improved to a more significant degree than of those with pre-existing high status (eg plasma levels above about 50 nmol/L) who may benefit little from the additional dietary intake.

Role of sunlight exposure: There is evidence from selected subpopulations that about 4-8% of adults in Australia have serum 25(OH)D levels below 28 nmol/L and about 30% have levels below 50 nmol/L. (Pasco et al 2001, MacGrath et al 2001, Vasikaran et al 2000). National surveys in New Zealand have indicated that some 2.8% of adults have levels of less than 17.5 nmol/L and 27.6% have levels below 37.5 nmol/L. Both sunlight and diet play an essential role in vitamin D status in younger adults. Kimlin et al (2003) estimated that for an older woman with fair skin, exposure of 6% of the body surface (face, hands, forearm) to sunlight for 15-30 minutes, 2-3 times per week would provide the equivalent of 15 µg vitamin D/day. Because of reduced cutaneous production, young adults (19-50 years) who live in southern latitudes such as Tasmania and the southern island of New Zealand are particularly at risk of becoming vitamin D deficient during the winter months.

For dark-skinned peoples such as indigenous Australians and New Zealanders and certain migrant groups and veiled women, there is evidence in Australia of high rates of vitamin D deficiency. Grover et al (2001) found that 80% of pregnant dark-skinned, veiled women attending one antenatal clinic in a large teaching hospital had vitamin D levels of less than 22 nmol/L. For people with little access to sunlight a supplement of 10 µg/day would not be excessive.

Institutionalised elderly: Several studies in Australia and New Zealand have shown high rates of deficiency in very elderly people with restricted access to sunlight, many of whom live in institutions. Estimates of deficiency range from 15-52% in Australia (Bruce et al 1999, Flicker et al 2003, Inderjeeth et al 2000, Stein 1996). Ley et al (1999) found that 49% of older New Zealand subjects in winter and 33% in summer had low serum 25(OH)D while McAuley et al (1997) reported 69% of subjects in Dunedin having low levels in winter, but only 26% in summer. Data from the National Nutrition Survey of New Zealand (Green et al 2004b) showed that 1.6% of males over 65 years and 5.8% of females had blood levels below 17.5 nmol/L for serum 25(OH)D and that 20.5% of men and 39.6% of women had levels below 37.5 nmol/L. This survey did not include institutionalised people. The recommendation of 15 µg/day for those over 70 years relates to the general population over 70 years. A number of recent studies demonstrate protection from falls and fractures with supplemental intakes of vitamin D in the elderly.

For institutionalised or bed-bound elderly who have very restricted exposure to sunlight often accompanied by reduced food intake, supplementation with vitamin D in the order of 10-25 µg/day may be necessary (Brazier et al 1995, Byrne et al 1995, Chapuy et al 1992, Egsmose et al 1987, Fardellone et al 1995, Kamel et al 1996, McKenna 1992, Sebert et al 1995, Sorva et al 1991).

Pregnancy

Age AI
14-18 yr 5.0 µg/day
19-30 yr 5.0 µg/day
31-50 yr 5.0 µg/day
Rationale: Although there is placental transfer of vitamin D and its metabolites from mother to foetus, the amounts are too small to affect the mother’s vitamin D requirement, particularly as there is a rise in serum calcitriol (probably of placental origin) and a rise in calcium absorption in late pregnancy (Paunier et al 1978, Specker 2004). However, maternal deficiency of vitamin D can affect the foetus and needs to be prevented. Pregnant women who receive regular exposure to sunlight do not require supplementation. However, at intakes of less than 3.8 µg/day, pregnant women in winter months at high latitudes have been shown to have low serum 25(OH)D (Paunier et al 1978). For women who have little access to sunlight, a supplement of 10 µg/day prenatally would not be excessive. In the last trimester of pregnancy there is quite a large transfer of 25(OH)D across the placenta.

Lactation

Age AI
14-18 yr 5.0 µg/day
19-30 yr 5.0 µg/day
31-50 yr 5.0 µg/day
Rationale: There is no evidence that lactation increases the AI of the mother for vitamin D. Thus, if sunlight is inadequate, an AI of 5 µg/day is needed. As noted above, the infants of dark-skinned and/or veiled women may be at higher risk of developing rickets partly because of marginal or frank vitamin D deficiency in the mother. For mothers and their babies with limited exposure to sunlight, a supplemental intake during lactation of 10 µg/day would not be excessive.

Upper Level of Intake

Age UL
Infants
0-12 months 25 µg /day
Children and adolescents
1-3 yr 80 µg/day
4-8 yr 80 µg/day
9-13 yr 80 µg/day
14-18 yr 80 µg/day
Adults 19+ yr
Men 80 µg/day
Women 80 µg/day
Pregnancy
14-18 yr 80 µg/day
19-50 yr 80 µg/day
Lactation
14-18 yr 80 µg/day
19-50 yr 80 µg/day
Rationale: The UL for infants was set on the basis of a NOAEL of 45 µg/day (Fomon et al 1966, Jeans & Stearns 1938) together with a UF of 1.8 (FNB:IOM 1997) because of the small sample sizes and insensitivity of the endpoint used (linear growth). For children and adolescents, there are little available data, so the recommendation for adults was adopted.

The UL for adults was based on studies assessing the effect of vitamin D on serum calcium in humans (Honkanen et al 1990, Johnson et al 1980, Narang et al 1984, Vieth et al 2001). Johnson et al (1980) and Honkanen et al (1990) conducted studies with supplementation at 50 µg/day or 45 µg/day for several months and saw no adverse effects. Narang et al (1984), using dosages of 60 µg and 95 µg/day over several months in a non-randomised trial that included 30 normal controls, saw increases above 2.75 mmol/L in serum calcium levels a level considered as defining hypercalcaemia, at 95 µg/day but not at 60 µg/day. However, a recent, well-designed, RCT by Vieth et al (2001) saw no adverse effect of dosages of 25 µg/day or 100 µg/day over six months in 30 subjects. This finding was confirmed in a later randomised study (Vieth et al 2004) of inpatients with subclinical or marginal deficiency. Vieth et al (2001) felt that the earlier data of Narang et al (1984) may have been erroneous in dosage, citing concerns about lack of independent confirmation of the actual amount of vitamin D administered (there were no measures of serum 25(OH)D). There is also some animal evidence of oral vitamin D causing non-calcified atherosclerosis of large arteries (Taura et al 1979, Toda et al 1985), suggesting that a cautious approach should be taken to high dose vitamin D in people other than the elderly.

Taking all of this into account, the figure of 100 µg/day from Vieth’s studies was adopted as the NOAEL and a UF of 1.2 was applied because of the inconsistencies in the studies and they were performed on relatively small number of subjects with pre-existing marginal vitamin D status. Vieth et al (2001) have themselves cautioned about the relatively small numbers in their studies.

The available data for pregnancy and lactation are inadequate to derive a figure different from that of other adults. There appears to be no increased sensitivity during these physiological states.

It should be noted that the intake of vitamin D via food would add to the vitamin D formed by exposure to sunlight.

( References provided upon Request from Jerry )

ALCOHOL (1) PUBLIC GOOD (0)

Posted in PSYCHIATRY with tags , , , on July 22, 2013 by drjgelb

NSW goes soft on Alcohol Regulation………again!

My comment to the Minister concerned, Mr Andrew Stoner:

“Dear Minister,

As a psychiatrist with 29yrs experience, it depresses and angers me to see that today’s politicians are as cowardly, ignorant and beholden to the alcohol cartels as your predecessors, although with far more evidence of the death and damage caused by alcohol now available, folding to the alcohol industry’s generosity and lying to protect “self-regulation” of advertising and promotional standards, will blight your legacy for generations to come. Young men and women will die because of your government’s self-interested caving in to an industry responsible for hundreds of thousands of Australian deaths & injuries. International evidence is unequivocal, decreased access to alcohol by decreased advertising, restricted hours of availability, higher pricing and many more simple measures, are as effective as similar anti-smoking measures have been. You and the industry can deny it to the electorate and to yourselves but not to professionals at the coalface. When the next shocking alcohol related public tragedy occurs in NSW, I’ll distribute this letter to every media outlet in your State and to all your political rivals. Your casual indifference to the death and crippling of our children will come back to haunt you.

Yours Sincerely,

DR JEROME L GELB
Consultant Psychiatrist”

COGNITIVE BEHAVIOURAL THERAPY

Posted in PSYCHIATRY on July 17, 2013 by drjgelb

20130717-183301.jpg

ACCEPTANCE COMMITMENT THERAPY MISSING THE POINT?

Posted in PSYCHIATRY with tags , , , , , , , on July 17, 2013 by drjgelb

Today’s “Australian Doctor” online newsletter, highlighted an article by Amanda Shepeared
http://www.australiandoctor.com.au/author/Amanda%20Sheppeard
about former Melbourne GP, Dr Russ Harris, an ardent supporter of Acceptance Commitment Therapy, a form of therapy that has been in existence for several decades. This form of therapy was never once mentioned during my 5yrs of intense Psychiatric training, neither was it among the numerous therapies we looked at as part of our study of the history of Psychiatry. If decades old, it must have survived in relative obscurity until recently revived by Dr Harris.

Here is the article, followed by the comment that I submitted to Australian Doctor.

Stop chasing happiness, author says:

Society’s focus on positive thinking is unsustainable and potentially problematic, believes Melbourne GP Dr Russ Harris, who advocates acceptance commitment therapy.

Dr Russ Harris is feeling anxious. On a scale of one to 10, the former Melbourne GP — widely recognised as a pioneer of a form of psychotherapy called acceptance commitment therapy — rates his current anxiety level about a six. It’s a pretty surprising admission. After all, Dr Harris has spent most of the past decade travelling the country, speaking publicly about acceptance commitment therapy, running workshops for GPs, appearing on television and at international conferences, not to mention helping everyday people conquer their own inner demons. So why is he feeling so anxious at the moment? The feeling has been prompted by talking to Australian Doctor on the phone. “I suffer from social anxiety. About 40% of the population experience significant social anxiety,” he says. “An easy interview like this puts my anxiety about a six. But that’s okay. Anxiety is only a problem if you keep fighting it.” He says he has learned to accept that social anxiety is part of his make-up. “When I am giving public talks, I go around and show people how my hands are dripping with sweat.”

Acceptance commitment therapy (ACT, pronounced ‘act’) is founded in learning to accept that life has both negative and positive experiences. A form of psychological therapy that has been around for several decades as an alternative to cognitive behavioural therapy and more traditional forms of therapy, it has gained the acceptance of the American Psychological Society. Dr Harris says people can become stuck in a cycle that places an intense focus on the pursuit and preservation of ‘happiness’, which establishes an unrealistically high bar for an average person’s mood. We are not, says Dr Harris, designed to be constantly happy.

Aiming for happiness at all costs, people may avoid or try to shut out negative aspects of their life, he says. This escapism can take many forms, including avoidance, but can have serious implications when it involves the use of drugs, alcohol or other addictive behaviours. For Dr Harris, it’s no surprise that we chase happiness. “We all enjoy happy feelings … however, like all other feelings, feelings of happiness don’t last. No matter how hard we try to hold on to them, they slip away every time.” The ephemeral nature of happiness means a life spent in pursuit of those feelings is unsatisfying, he says. “In fact, the harder we pursue pleasurable feelings, the more we are likely to suffer from anxiety and depression.”

He speaks from experience, having had his own battles with depression and anxiety. Dr Harris qualified as a doctor in 1989, at the University of Newcastle-Upon-Tyne in the UK, before migrating to Australia in 1991, where he set up a general practice in Melbourne. “I was very miserable in my mid-20s,” he reveals. “I had a great job, status, income, but I had a very harsh inner critic and a lot of social anxiety.” In his quest to understand his own depression, he became increasingly interested in the psychological side of health, and less interested in his general practice. “As I started exploring, I found out that about 90% of my patients were suffering [psychologically] in some way or another,” he says. “I gradually started doing less and less general practice shifts and more counselling, and it evolved from there.” Dr Harris says he researched many different forms of therapy, from Buddhism to CBT, and found middle ground in ACT. “It seemed to have the best of both worlds,” he says.

This led him to pen his first book The Happiness Trap. He pitched it to every publisher in Australia but was rejected everywhere he went. It was finally picked up by New Zealand-based company Exisle Publishing, and, in 2007, his book hit the shelves. It has become a bestseller, with more than 150,000 copies sold, and has been translated into 22 different languages. Dr Harris says the publisher couldn’t be happier as the book is their best selling title. In fact the publisher laughingly calls it the company’s Harry Potter. “It’s not quite up there with Harry Potter, but it’s been a big success,” he says.

.Exisle Publishing’s Benny Thomas describes the book as a “true winner” that has sold all over the world. “We get a lot of unsolicited manuscripts at Exisle but there was something about Russ’ proposal that grabbed my attention immediately,” he says. “It seriously was the best self-help book I had ever read, as the message was clear and practical but also gentle and kind.” Dr Harris has trained in the US with Steve Hayes, Kelly Wilson and Kirk Strosahl — the creators of ACT — and now focuses his time on training Australian health professionals and spreading the message about the therapy. He has already trained more than 14,000 people and hopes to reach many thousands more before he is finished. Aside from his resounding success with The Happiness Trap, Dr Harris has written a swag of other books. And next month, he’ll release an illustrated version of his most successful work, produced with author and illustrator Bev Aisbett. This latest offering, The Happiness Trap Pocketbook, takes a different approach to most other self-help books, using quirky illustrations instead of pages of text. As he explains to Australian Doctor, he hopes this version of the book will capture more audiences who could benefit from ACT. These include teenagers, and people who are time-poor or have difficulty reading. “People who are very depressed or stressed can also find it hard to focus and concentrate on a large book with lots of text,” he says. “There’s nobody on this planet — with the exception of the Dalai Lama perhaps — who wouldn’t benefit from this book.” If ever there was a need to understand why he wants to widen his net, look no further than page 12 of the new book, which lists some “sobering statistics”, including:

One in 10 people has clinical depression.
One in five is depressed at some time.
One in four has or has had an addiction.
Thirty per cent of the adult population has a recognised psychological disorder.
Dr Harris believes that society’s views on happiness need to change.

“It’s the whole culture really. If you’re not feeling good and positive, there’s something wrong with you and of course that trickles down to children as well,” he says. He is particularly concerned with how these attitudes translate to children, especially the idea that children are being raised to believe they are “all winners”, and there are no losers or failures in life. He describes it as a David and Goliath battle that will need radical change to be successful. But he isn’t giving up. “Our culture doesn’t really teach us to accept the normal pain of human existence,” he says. “Children have to learn that disappointment is a normal human emotion, along with failure and even boredom. When my seven-year-old says he’s bored, I say ‘good’. We need to accept that these feelings are normal, and not automatically a sign that something is wrong.”

Dr Harris concedes it has taken some time for the medical profession to accept ACT as a legitimate form of psychological therapy. But he says there are now more than 70 randomised control led trials that demonstrate its efficacy. “ACT has been around for about 30 years, but it has only really started becoming popular in the last six or seven years,” he says. “Everyone is so focused on positive thinking and being happy, happy, happy, but it’s not sustainable and creates more problems. “Anyone who is interested in happiness had better get used to accepting pain.”
Has he managed to conquer his own demons? “I didn’t conquer them; I just made peace with them.”

In a paper published in the journal Psychotherapy in Australia a few years ago, he described the way he would summarise ACT on a T-shirt. “It would read: ‘Embrace your demons, and follow your heart’.”

References
Psychotherapy in Australia 2006; 12:70-76.
Australian Family Physician 2012; 41:672-76.

My Comment:

There’s a big difference between positive thinking and rational thinking and Cognitive Behavioural Therapy (CBT), originally named Rational Emotive Therapy by Albert Ellis, teaches the latter, not the former. The mischaracterisation of CBT as a treatment that falsely & simply uses positive affirmations in the face of harsh realities, is harmful to the reputation for excellent results achieved by this psychotherapeutic method. CBT calls for reconstruction of catastrophic thinking, commonly called “stinking thinking”, which carries a high risk of triggering, deepening or perpetuating a depressed mood, into rational thoughts that are consistent with the available evidence. The thoughts achieved may still be unwelcome but their power to cause mood to plummet, is greatly reduced or eliminated. Acceptance without a search for evidence for what one is trying to accept, is likely to frequently be unsupported by evidence and may involve dismissing or failure to consider novel strategies that may greatly alter the status quo. ACT runs the real risk of paralysing corrective and innovative thinking by shutting such thoughts off in light of a problem prematurely labelled resolved.

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