for appoint please call 352-265-HELP(4357)

The University of Florida (UF) Department of Psychiatry offers programs for patients of all ages with depression, complex mood disorders and dual disorders.  We treat patients from physicians from all over Florida and the nation.  Depressed patients are evaluated by double and triple boarded experts in psychiatry, neurosurgery and internal mediince.  UF’s depression experts are all practicing academic psychiatrists treating patient and teaching psychiatry to to the UF medical students, residents and fellows.  They bring over 150 years of experience in the evaluation and treatment of depression.  As the state’s leading academic medical center patients with difficult to treat or treatment resistant depression have the opportunity to be evaluated by leaders in medicine, neurology, endocrinology and other medical specialties with access to UF’s advanced imaging and diagnostic testing.  UF pioneered TMS and also operates the largest ECT center in the state.  Drs. Solomon, Holbert and Khurshid have the most ECT-TMS experience in the state of Florida.  UF is a leader in pharmacutical and non-pharmacutical treatments of depression.  To schedule an appointment to our depression clinic please call 352-265-HELP(4357).

Depression Experts:

Hebert Ward, M.D. 

Co-chairman of the Department of Psychiatry

Psychiatry

Internal Medicine

Richard Shriner, M.D.

Psychiatry

Internal Medicine

Kimberly White, M.D. 

Adult Psychiatry

Child and Adolescent Psychiatry

Addiction Medicine

Louis Solomon, M.D. 

Psychiatry

Neurosurgery

Richard Holbert, M.D. 

Psychaitry

Khurshid A. Khurshid, M.D. 

Psychiatry

Internal Medicine

Sleep Medicine

Locations:

UF Psychiatric Hosital

Inpatient Psychiatric Hospital

Shands Medical Plaza

Out-Patient Psychiatry

Psychiatry at Springhill

Out-Patient Psychiatry and TMS

President, RHL Consulting, LLC

BioPharmaceutical CNS Drug Discovery and Development

Professor of Pharmacology and Clinical Neurosciences

University of New England, College of Medicine

Q:   Over the last 30 years how have you seen drug development evolve?

A:    Over the past 30 years, the discovery of new chemical entities and bringing them to the market place has significantly decreased.  In fact, if you look over the past 50 years, the number of new chemical entities that have come to the market versus the dollars spent has halved every nine years over that period. So there really is a crisis occurring in the pharmaceutical industry, in terms of our ability to develop new drugs and in particular, within the central nervous system and in psychiatry. However, there are ways that are going to be developing over the next several years that should try to stem this process.

Q:   What do you see in the near future, for better or worse, in drug development and research?

A:    Well, I think that several things have occurred. The most difficult part of the process has been the inordinate amount of time it takes to do the preclinical discovery. In many cases the preclinical discovery, while it gets done, does not produce compounds and drugs that are eventually validated within the clinic, for the clinical indication. So much of the industry, right now, is beginning to focus on the short-term strategy of repurposing old drugs for new indications, and the assessment of compounds that have been tested for one reason or another, within the clinic and found to be either not efficacious, or the program has been stopped, or not able to get safely into the human. So there are potentially ways for us to begin to have the drug tested in humans where many of the diseases, particularly in psychiatry, are really fully phenotypically expressed. This would avoid the deficits within the current models that are being used. So, I would say, there is promise in our ability to alter the regulatory process that may make this a bit easier.

Q:   What specific role(s) does industry, the NIH, Private Philanthropy, FDA play in the future of drug development?

A:    The fact of the matter is drug discovery is best done by people that are focused in the area of drug discovery. It really needs the support of a team of investigators ranging from medicinal chemists to pharmacokineticists, looking at PKPD relationships, looking at metabolism, and ultimately looking at safety and toxicity, so there is a rationale for the pharmaceutical industry. The issue is, at what point are they most effective? I would say they are most effective in diseases in which we can identify a clear target, and I would have the industry put the full brunt of force that they have in medicinal chemistry, virtual screening, high-throughput screening, and com matura chemistry; bringing that to bear on targets that have shown some validation.

This will be particularly evident over the next several years, as it is this year, particularly in oncology where we can do that kind of thing. To what extent we will be able to do this in the future, in neurobehavioral disorders, will really depend upon the basic science that is expended within academia to better understand the pathophysiology, systems and circuits that are involved with these particular diseases.

Finally, I think it’s also important to recognize that the FDA needs to understand that many of the drugs that are coming out will need exposure to a greater population of patients, to begin to understand more fully their impact both in terms of efficacy and safety.  While we can certainly demand that prior to a drug being marketed, the drug have significant efficacy for the disease indication, it seems unattainable to guarantee that a drug is 100 percent safe. The FDA really needs to move from a cross-sectional approval to a longitudinal approval, and look at it as an approval process that basically looks first at initial approval and phase 4 studies and then looks over time at patient safety data while monitoring closely the exposure of the drug to the populations we are treating. This will then assure that we optimize our ability to get drugs to the patients that need them rapidly, while also assuring the best safety measures we can.

Edgardo J. Menvielle, MD

Associate Professor of Psychiatry and Child Health & Development

George Washington University

The Center for Neuroscience and Behavioral Medicine

Children’s National Medical Center

Q:   Dr. Bussing: Dr. Menvielle, what should a parent do if they feel like their child is acting too much like the opposite sex?

A:    Dr. Menvielle: Well, first we would look at the age. We would say if it’s a young child, (say 4 or 5 or 6) talk to their pediatrician and get some input from the pediatrician.  Parents should also understand that it’s not abnormal for children to like things that are not considered typical for their gender and it’s likely to evolve over time, but differently for different people. The bottom line is that it’s not something the parents should consider as abnormal or punish or try to suppress. They should give the child some space and if the child needs to be private then it should be private, but there should be some space within the home where they can feel free to play how they like and choose the toys they want to choose.

Q:   Dr. Bussing: What if parents are wondering what the difference is between children being gay, transgender, or being gender non-conforming?

A:    Dr. Menvielle:  Well, both children that are going to grow up to be gay and/or transgender could be gender non-conforming when they are children, meaning that they are different than the average child in terms of their gender interest and expression, but the difference of course is something that we cannot tell for sure while the child is young. What we do know is the statistics show that most children who are gender non-conforming are going to likely be gay or lesbian. Although some girls can also be heterosexual, where as transgender outcomes are rarer, but could also happen. The only issue is the parents are not going to know that for sure, until the child goes into puberty or beyond.

Q:   Dr. Bussing: Now what should parents do if they are concerned, but the adolescent doesn’t want to talk to them about their thoughts or feelings regarding gender and sexuality?

A:    Dr. Menvielle: What the parents need to do is to demonstrate to the child that they would be ok with whatever the child is experiencing, so for example, if the parents are suspecting that their daughter might be a lesbian or their son might be transgender they should not ask the questions in a negative way and should convey the message that they are interested in knowing because they want to be helpful; they want to be loving and they are going to love the child no matter what. They will make it more likely that the child will open up.

Q:   Dr. Bussing: What if the child is getting bullied at school about their gender variant behavior what’s the best thing for a parent to do about that?

A:    Dr. Menvielle: The best thing for the parent to do is talk to the schools, be active in their involvement with the schools, so that the school understands these parents are not going away until something is done about the problem. Sometimes it can happen the schools do the bare minimum and that might not be enough, or they don’t do anything. If the schools are not held accountable then bullying could go on and then the parents need to be in the school talking to people, asking for interventions to be made so their children can go to school and feel safe while they are there.

Q:   Dr. Bussing: Are there some examples of things schools could do for a child in that situation?

A:    Dr. Menvielle: They can identify the particular bullies and they can sanction them, give consequences to them and put them on notice and let them know that this is not going be allowed; they could do a lot of things if they wanted to.

Gary Geffken, Ph.D.

Associate Professor

University of Florida

Joseph McNamara, Ph.D.

Assistant Professor

University of Florida

Is OCD onset more common in childhood or adolescence?

Dr. McNamara: The research really shows that OCD for most people really gets started in childhood and earlier childhood is likely to be male and in adolescents females catch up and then by the time people reach adulthood the gender splits about even between people suffering from the disorder between males and females.

Dr. Geffken: But the smallest estimate is probably 20% have onset in adulthood and maybe as high as half or a little above that otherwise starts before adulthood.

What are the most basic behavioral elements for Cognitive Behavioral Therapy for OCD?

Dr. Geffken: Well the most basic elements are exposure, which means facing the fear and that involves presenting the patient with something that is going to make them anxious and raise their anxiety and trigger one of their obsessions and the other most basic element is response to or ritual prevention. Which involves having them reduce repetitive actions that they engage in to reduce their anxiety in most cases that’s an overt behavior or a compulsion or ritual that anybody could see in come cases though you don’t see that and probably as recent as 30 years ago not a lot of OCD people recognized that people were engaging in mental or covert rituals like counting or praying but some people are doing that to try and fend off their anxiety not to suggest there is something inherently pathological about praying it’s just if you’re spending two or three hours and it’s preventing you from doing things.

Dr. McNamara: Right and rigidity with prayers might be the case as well, so I have to say the prayer just right or I have to say it exactly this way, so very often you’ll see that. Exactly like what Dr. Geffken was saying if someone is afraid of this magazine for whatever reason the key thing would be the exposure aspect would be keeping the magazine there and then challenging them in their response prevention part of not leaving the room, not withdrawing from it and saying so right now I’m this far away from it I’m going to stay that distance and that’s engaging the response prevention part and then as the person progresses thought the treatment moving them closer and closer to the magazine and having them touch the magazine, hold the magazine or whatever it might be that is creating the anxiety in particular.

What is not an uncommon comorbity in adults with OCD?

Dr. MaNamara: Well really there are so many different comorbidities associated with OCD from other anxiety disorders, major depressive disorder, in children disruptive behavior disorders especially ODD (Oppositional Defiant Disorder) we know can be really problematic. Fortunately people still respond very effectively to the treatment which is a great thing that people still respond effectively to the treatment but the treatment response is not as robust as when it’s only OCD alone not when it’s comorbid along with something else.

Dr. Geffken: And so depression is often comorbid with OCD and often if you just target the OCD, depression will decrease as the OCD decreases. Sometimes when it’s more severe than the depression you’ll have to treat the depression before you try behavioral or cognitive behavioral therapy (CBT) because it’s pretty effortful and really depressed people don’t seem to have enough energy or effort to exert to do the CBT

Dr. McNamara: Well one of the things that so often happens with OCD after struggling with it for a long period of time people seem to very much lose hope which certainly feeds into this part of depression and so it can be very hard to work up the fortitude it takes to be able to attack the different anxieties.

What is an example of accommodation in children with OCD?

Dr. Geffken: I think an example of an accommodation we talked about was reassurance seeking, children often will ask their parents do you love me? Am I ok? Am I sick? And they want some reassurance that they are ok or loved and while that would seem to be a reasonable thing for a parent to do and it would help keep the peace what it does in the long run is it keep their anxieties and worries going because it temporarily reduces their anxiety after they ask that question and so they are more likely to ask it again to reduce their anxiety. If the parents can stop answering that question the kids will stop asking that question and stop reassurance seeking which if it’s done too much can get to be pretty bothersome.

Dr. McNamara: I had a case a number of years ago where a child was really concerned that something bad was going to be happening to mom. She was very young maybe second or third grade, and after she had been at school for about an hour would get permission from the teacher to go up to the office and she would call mom’s cell phone and say “just checking in mom to make sure you’re ok” and mom would say yes and then she’d go back to class and then about every hour on the hour this girl was leaving class to go check and make sure her mom was ok. Mom would always make sure to answer the phone because if she didn’t answer the phone the child would just start crying hysterically in the main office so we had a combination there of the teacher letting the child out of class to make that phone call, the office staff that was allowing the child to make these calls and a combination on mom’s end because she would answer these calls providing the information. So we first started by targeting and working with mom to reduce the combination of if she calls within an hour and half of the last time she called mom wouldn’t answer and then gradually expanding that. Then mom got the teacher and the office staff on board with that and eventually the child stopped calling and she would stay in the class all day and do well and not be distressed by this intrusive thought about something horrible was happening to mom.

How common is OCD?

Dr. Geffken: OCD is one of the most disabling disorders as rated by the World Health Organization it has a 2% lifetime prevalence, one out 50 people, over the course of their lifetime will show OCD. When I was in graduate school in the late 70s the estimate was one out of 10,000. It’s not really that OCD has become that much more common but it’s become much more readily identified just in the course of 30 years, OCD has had a lot of progress in terms of being recognized and treated.

Dr. McNamara: Absolutely, one of the things that is just really striking, and one of the things I talk to the potential patients that are calling our clinic with the different concerns, they think well I don’t have OCD because it’s not washing, it’s not hoarding, I’m counting all the time or it’s ok if things are asymmetrical or not perfectly neat  my struggle is that I keep thinking something horrible will happen to someone I love and the thought just keeps coming and coming so there are a lot of cases I think where people aren’t recognizing that this is actually OCD but they are certainly very distressed by this recurrent thought and then engaging in some type of behavior to reduce that anxiety the key thing is that behavior actually serves to reinforce the anxiety and makes it worse in the long run.

Dr. Geffken: I think OCD is a term that a lot of people use in everyday life and I think a lot of us have obsessive compulsive characteristics but we don’t necessarily have the disorder. It becomes a disorder when it’s too time consuming, distressing or interfering with your life. There are some rituals that are healthly and good, like brushing your teeth in the morning. We general assume that’s a good thing. Putting your keys in the same place when you come in the house, putting your glasses in the same place so you don’t have to look for them. Those are good rituals, it’s ones that take up time, interfere and cause distress.

Dr. McNamara: And with those rituals, how ridge are they? I have to start by brushing the teeth on the left or can start on the left one day or can I start at the top or the bottom. Or there are five rungs on the place where I hang my keys, I have to hang it on the far left one and if there is already a key there I have to move it somewhere else so my key can go on the far left rung. So really looking for that sort of rigidity as apposed to well these is generally where I hang my keys or brush my teeth in the morning.

Can OCD be cured?

Dr. Geffken: I think for most people, they describe OCD as waxing and waning so while there can be dramatic improvements in OCD it’s… and we’ve treated a lot of children over the years  where it did seem to remit or almost go away entirely but in so many people it goes up and down and up and down and so many people just don’t get treated.

Dr. McNamara: Just in the population of people that aren’t struggling with OCD there’s just random intrusive thoughts pop into our head for all different types of reasons, it might be something we see on the news, it might be someone walks by wearing a perfume that makes us think of an old friend so there are any number of different things that can trigger thoughts the key thing is would I consider this an intrusive thought, a distressing thought and very often the people who have been struggling with OCD the thoughts that might get triggered at one point or another it may or may not have been intrusive or distressing the key thing is that if they are noticing, oh that thought is bothering me a little we know the distinction and if they use the strategies they’ve learned through CBT they’ll be able to knock those anxiety symptoms back down very quickly. While it’s something that might be there for really long periods of time you can get down to the point where the intrusive thoughts while they occur, they don’t actually cause that much distress and its not really even taking minutes out of your life. Maybe a minute here and there occasionally and you think there’s that thought that really used to bother me.

Dr. Geffken: I think that’s a really good point, I wouldn’t want to leave the impression that there’s a hopelessness about it. I wanted to leave the impression that it may recurring and you may have to deal with it but I think some people can get a handle on it and keep a handle on it

Dr. McNamara: And the research on remission in kids does show that children are much more likely to reach and maintain remission than adults and particularly adults about 25 and older they’ll have a higher frequency of intrusive thoughts as they get older but again if they have the strategies and the tools they can be successful, provided they are successfully implementing those there is every reason to believe they will be able to work through those periods very effectively

World-renowned experts are invited to address a wide spectrum of specialties and subspecialties and often introduce new and interesting developments. The objective of the program is to update physicians and healthcare personnel on developing trends and techniques in medicine.