Interpersonal Chemistry with Physicians and Therapists – Free Page

Interpersonal Chemistry with Physicians and Therapists

an elderly male physician with white hair, wearing rimless glasses slid down his nose, with a white clinical coat, a stethoscope around his neck, and an expensive gold watch on his wrist
Photo by granderboy

A Trip That Leads to a Trip to the Doctor

A young woman is walking through a parking lot with her friends, heading back to the car after the ball game. She trips over one of those cement wheel stops and twists her ankle. Her friends help her up and she continues on to the car. It seems relatively okay, but the next morning her ankle is swollen and blue and she can’t walk on it. So off to Urgent Car, where the physician takes x-rays, determines that no bones are broken, and puts on one of those big walking boots to stabilize a sprained ankle. On the way out of Urgent Care she bursts into tears right in the waiting room.

Welcome to the Neuroscience Research and Development Consultancy website. If you would like more information about any of the topics we cover on our site, or if you have a question. a comment, or a critique, please send it to us at: Comment@NeuroSciRandD.com

Oh, God, Tell Me This Isn’t Happening!

It’s completely embarrassing but she can’t help it.  She slumps down in one of the uncomfortable chairs and can’t stop the tears. The nurse/receptionist asks if she’s okay. Clearly she’s not. Between sobs she confesses to the nurse that she’s been depressed for the past few months and she doesn’t know why. And this ankle sprain and ankle boot are just too much. it put her over the top. The nurse disappears for a few minutes and comes back with a referral from the Urgent Care physician. It’s a referral to a psychotherapist

A 1940s physician, wearing a white clinical coat, sits in his office at a simple desk writing on a pad. There's a lamp and a telephone on the desk. Outside the windows behind him are tall evergreen trees with snow.
Photo by Michel van der Vegt

One of our Readers in Los Angeles, California wrote to us about a therapist she didn’t like:

I just stopped therapy. I didn’t know what else to do. I was referred to her for my depression but I really didn’t like her. I couldn’t keep going so I just stopped going. What’s a person supposed to do if you can’t stand the therapist you were referred to?

This reader’s email prompted us to write this page. It’s a common dilemma. There’s this thing, this essence, that everyone knows about and talks about but that’s hard to define. It’s “interpersonal chemistry”, that gut-level impression when two individuals meet each other and begin a conversation, if it even gets as far as a conversation.  The discussions usually comes up in romantic contexts, like dating situations, but it’s there whenever any person meets another person. And meeting a new therapist is definitely a situation where chemistry is important. On the one hand you did the right thing to stop going, but, on the other hand you cheated yourself if you stopped therapy. Therapy is about healing. You need to heal. So, for yourself, for your own benefit, you need to find a therapist with whom you have good chemistry. Start the search and don’t stop until you find one.

It’s For The Best, This Seeing a Therapist, or Is It?

Back to our young women in tears in the Urgent Care waiting room with a slip of paper in her hand referring her to a therapist. She’s embarrassed but she knows the doctor and the nurse are right. She’s been depressed and it’s been getting worse. She needs help and she definitely doesn’t want some stupid drug the doctor might give her. So she goes home, thinks about it for a week, gets her nerve up, and calls the number on the piece of paper. She makes an appointment for the next week, after work, at 5:30. The time comes, she goes to the therapist’s office and they have a session. And she leaves feeling really in trouble. She absolutely doesn’t like the person. She can’t see herself, can’t make herself go back. Now what?

Attractive young woman physician in a form-fitting white clinical coat stands in a medical exam room and faces and smiles at the camera, stethoscope around her neck and hands on her hips.
Photo by Daniel Dan outsideclick

The Struggle Inside Has Begun

Maybe it’s just me. Maybe she rubs me the wrong way because of me. Maybe she’s an okay therapist but she just reminds me of someone I don’t like. She just seemed like a “know-it-all” when she really just met me. And the way she was dressed, I just don’t think we’re a good match. But I’m always awkward with new people, especially new important people, so maybe it really is just me. I think she reminds me of that damn girl in high school, the mean one, that I never liked. Oh, God, I don’t know what it is, but I’m not going back. So, once again, now what?

Stop The Struggle and Let Yourself Be Correct, Let Yourself Choose

The relationship you have with your therapist should be something special. It’s a relationship that lives on a delicate boundary, more inside your head than almost anyone else. But not a love relationship, not a friend, not a romance, not close like that. So you have to feel comfortable from almost the beginning. Because how eventually successful the whole course of therapy will  be depends on the quality of this relationship. So, if you have that first session with the therapist and, as you leave the office, feel, “Yes, this will work,” that’s good. But if that “struggle inside” starts, it’s not important why it’s a poor fit. It’s only important that it is a poor fit. (Maybe, if you want to, you can eventually understand the “why” as you work with the right therapist.) So, go find a good-fit therapist. Really. Don’t worry about it, just do it.

Friendly, smiling woman nutritionist wearing fashionable large white-framed glasses. She has on a white clinical lab coat with a doctor's stethoscope around her neck. She holds an attractive clear glass bowl filled with whole fruits in front of her.
Photo by Sebastián García

There Are Lots of Therapists and Lots of Styles of Therapy

So let’s leave our depressed young woman with the sprained ankle, the big walking boot on one foot, and let her find the right therapist. Because this discussion applies to everybody. And, it’s not just therapists, it applies equally to physicians. These medical relationships need to work for you. Finding doctors, including therapists, with the right personal chemistry for you does sort of feel like dating. If you dump a doctor for another one, if the dumped doctor is good and well trained, the doctor won’t mind. They know, or at least should know, what you’re seeking, what you need for yourself to get well, and want you to find the right clinical person. It’s not personal, and they shouldn’t feel offended.

An Awkward Relationship with a Clinician Can Keep You Sick

It’s true, an awkward relationship with a clinician can keep you sick. This question has actually been studied a lot. Of course, the academic people studying such relationships can make understanding their results seem complicated. They talk about statistics, effect sizes, and repairing therapeutic ruptures (which sounds pretty awful). But the bottom line of all the research jargon is that a good relationship with your doctor increases your chances of getting well. And an awkward, uncomfortable relationship makes it more likely that you’ll stay sick. So, there’s too much riding on the quality of the interaction to accept mediocre. A great relationship would be wonderful, but it has to be at least good. And, good is good enough. There’s nothing wrong with “good”.

Attractive, tall, smiling woman physician with long, dark hair stands looking at the camera, stethoscope around her neck and wearing a short-style white clinical lab coat, arms loosely crossed.
Photo by RADHIKA86

Diving Into Why the Therapeutic Relationship Is So Important

The patient-therapist (or client-therapist) is a relationship. But that’s not really the heart of the matter. Therapy is a learning, an education. There’s a step one followed by a step two. It’s a process. And your therapist knows this. They need to guide your way forward to talk about what’s hard to talk about. They come to realize what you’re up against in life. And almost certainly they’ve seen that dilemma before. The more you can “let it all hang out,” the more authentic the therapy will become. The therapist is your guide to help you on a path that scares you, that causes you embarrassment, that can seem awful. But by walking the path with the right therapist you come out the other side with your burden lessened. It has to start in the right place for you to get to where you need to go.

A Comment Thought About Those “Therapeutic Ruptures”

We mentioned this phrase above but need to return to it because it’s one important reason why you have to start with a good therapeutic relationship. Human beings don’t have personal connections that go smoothly forever. There are bumps in the road. You’re working to learn more about yourself and about your family and friends. You’ll discover some things that are wonderful. And, some things that you don’t want to know. That’s hard. And, your therapist “did it”. Maybe argument time, maybe confrontation. So we have a therapeutic rupture. Do you withdraw, storm out, and never go back? Do you emotionally withdraw, clam up, and stop the progress? Does anger boil out? Will it ruin everything? As with any committed relationship (like a marriage), the stronger it starts and the better it builds over time the more likely that a rupture can be fixed as part of the process.

Friendly woman psychologist with long dark hair smiles at the camera while leaning on a chair. Her attractive and pleasant office is a bit out of focus in the background.
Photo by Clayton – cvpericias

Back to Interpersonal Chemistry with Physicians and Therapists

It’s apples and oranges to compare a personal union (dating or marriage) with a professional medical healing relationship. A good spouse can “save your life” from you being less than you could be. A good doctor can save your life from illness and death. But there are parallels. And chemistry is one of these parallels. If you go on a blind date you usually know pretty quickly if it’s not going to work. And, it might take a few dates to tell if it will work. Same with a therapist or physician. You know pretty quickly if it’s not going to work. It you feel that, trust your gut, and get out, exit stage right. As with dating, the longer you hang in there with a poor connection the more you delay finding a better one.

Brain Damaged Killers – Free Page

Brain Damaged Killers

Legal-Copyright 949187124 21Dec2020Brain Damage That Creates a Mass Murderer

Especially when we first hear a news story about an especially horrible set of murders we want that killer brought to justice. And any mention that brain damage might have caused the criminal’s behavior sounds like a flimsy excuse to get away with murder. This seems true because we’ve heard of people who’ve had strokes, or head injuries, or brain tumors, and none of them killed anyone. It is unusual. Criminal behavior occurs in less than ten percent of patients who’ve suffered a traumatic brain injury. So people with brain damage, even brain damage in just the specific correct brain circuits, don’t become crooks. But what about the people in that “less than ten percent”. That is, there are people who have brain damage that hits just the right place, that disrupts just the right brain nerve circuit, who then have a higher risk of committing criminal behavior.

Welcome to the Neuroscience Research and Development Consultancy website. If you would like more information about any of the topics we cover on our site, or if you have a question. a comment, or a critique, please send it to us at: Comment@NeuroSciRandD.com

One of our Readers in Stillwater, Oklahoma wrote to us with this comment:

There was a guy in the 1960s who shot a lot of people from a tower at UT Austin who they said had a brain tumor that made him do it. Is this true?

It’s partly true, though most people would not agree that his brain tumor made him kill people. His name was Charles Whitman. The events seem to be that he stabbed to death his mother and his wife, then went to the clock tower at the University of Texas at Austin and shot at people from the 28th floor observation deck. He shot 42 people, and 11 of them died. This reckless, killing behavior was especially odd because when he was teenager he had been an Eagle Scout in the Boy Scouts of America, then in his early 20s he was a decorated Marine in the U.S. military. It’s definitely true that at autopsy he was found to have a brain tumor.

On the one hand his brain tumor was said to be the size of a pecan nut. This might seem too small to cause a problem, but the size of the brain region it was pushing against was the size of an almond, that is, about the same size. This brain area is called the amygdala and it’s remarkably important in how a person behaves. It’s a major communication hub for emotions, and links emotions with memories, learning, and the senses. Charles Whitman’s brain tumor was pressing on his amygdala, his center for emotion and behavioral control. We at the Neuroscience Research and Development Consultancy don’t feel that the tumor made him kill people, but we do opine that it confused his thinking in a way that he really didn’t understand the implications of what he was doing when he took the lives of others.

sagittal non-contrast cephalic MRI scan image with a blue colorization of the brain
Photo by Kalhh

The Unpredictable Nature of Disrupting a Complex System like the Brain

One cannot smash just the right spot in someone’s brain and turn them into a killer. Even a specific lesion can’t automatically be the only cause of criminal behavior. Many people with no known brain damage are outrageous crooks. But given the right set of other personal facts and then damage their brain and one can get an awful personality change. Genetic makeup and what they were like before the brain damage might be important. The cause of the damage and their age when it happened might also be factors. in addition, after the injury, the quality of their social support system and their social environment might change the final outcome. But whatever the specific mix that’s needed, it does happen. As one Scientific American article put it regarding Charles Whitman, what turns a twenty-five year old former Eagle Scout and decorated Marine into a deadly shooter?

It Can Be Either a Location or a Nerve Circuit

A study by Ryan Darby at Vanderbilt (reference below) is a remarkable piece of work in this area. He and his collaborators completed a mapping of lesion locations in twenty-three cases where new criminal behavior began after a brain-damaging event. They looked both at the location of the lesions and within what brain nerve circuits the lesions were. The research team identified seventeen people with a time-based link between the brain damage and the criminal behavior. Twelve of the seventeen cases involved violent crimes like assault, rape, and murder. The other five were “white collar” crimes like fraud and theft. In fifteen of the cases there was no criminal behavior before the brain damage, and two other cases the cimininal behavior went away after the damage was treated.

The Four Important Findings of Dr. Darby and His Research Group

In discussing their findings, Dr. Darby’s group laid out four specific important findings from their research.

  • First, while it was true that the damaged areas in the brains that led to the criminal behavior were in different brain areas in different people, the lesions all sat within one brain nerve network. Brain damage in brain areas not in this network do not cause criminal behavior.
  • Second, this network circuit where lesions cause criminal behavior connect to brain regions involved in moral decision making don’t connect to areas related to empathy or cognitive control.
  • Third, lesions time-linked with criminal behavior show connectivity opposite the connectivity of brain regions activated by weighing moral choices. This predicts the bias toward criminal behavior seen in these patients.
  • And finally, fourth, when they took what they learned and applied the evaluation process to a different set of people they got the same result. That is, their research was reproducible from one set of people to another.
photo of head MRI scan images mounted on a view box in a dark room like radiologists use
Head MRI scan images – photo by Dmitriy Gutarev

The Case of Jordan Rice and her Frontal Lobe Meningioma

Though I’m a neuroscientist and psychiatrist, every time one of these cases hits the news I’m upset. Read our page “Your Mind & Your Brain” to understand why. Let me mention this one case. Jordan Rice is the mother of three and wife of Robert Rice, who’s in the U.S. Marines. Sometime in 2016 or 2017 a tumor, a cancer, began to grow in the covering of her brain right next to her brain’s frontal lobe. As it  grew and began pressing on her brain she became apathetic, not caring about anything. And, no one was there to notice. On May 24, 2018, Mrs. Rice called 911. Her 13-month-old daughter had died. When the police came it appeared that the little girls died of neglect. She was emaciated, in an unchanged diaper, and weighed only ten pounds. Mrs. Rice was arrested. No one knew about the brain tumor.

Jordan Rice in Jail Had To Go Blind In Both Eyes for Someone to Notice

After eight months in jail she was complaining of crushing headaches and then went blind in both eyes. (She’s never regained her sight.) Finally an MRI was done and it showed a brain cancer the size of a baseball. She was rushed to surgery and the tumor was removed. It was a a type called a meningioma. Despite being brain damaged and having no way to function she was still held accountable for the “crime” of her daughter’s death. At the time when their 13-month-old daughter, Violet, died, Jordan’s husband Robert was working in Florida as a military contractor. Jordan’s attorney has made a motion to the court to dismiss the case. Her usual previous personality, bright, aware, active, and concerned, had slowly returned after the baseball-size cancer was removed from her brain.

Concerned and upset young military man in uniform fatigues in female doctor's office. They're both seated, facing each other, and her hand is on his shoulder.The Tumor and the Legal System Have Made a Mess of Everything

Jordon Rice’s two older children are in foster care. Both grandparents have been denied access to them since 2018. Jordon’s husband Robert maintained visits with his surviving children after his wife’s arrest. But after a year the prosecutors arrested him for “child abuse and reckless manslaughter”. He took a plea deal in the manslaughter case and is currently incarcerated in Baldwin County. And don’t forget, Jordon Rice is now permanently blind.

Jordon Rice Needed Medical Care When Her Personality Changed

As people look back and piece together what happened, they realize that there was a huge change in her personality and behavior during the months before her daughter Violet died. That’s when she needed an MRI and the surgery, when the tumor was growing and pressing on her brain’s frontal lobe. Ryan Darby, MD, whom we mentioned above, has said that tumors that grow near the front of the brain often cause the biggest changes in values and decision-making. Jordon is now totally blind, her two children are in foster care, her husband’s in jail, she had a baseball-size cancer removed from her brain, and the prosecuting attorneys still want to prosecute her. Good grief. It’s true that attorneys don’t go to medical school, but in this instance they seem stupid (or heartless) beyond that deficiency.

EEG Testing for Epilepsy. Alzheimer's, Schizophrenia, Bipolar Disorder, Etc.Yes It’s Rare But When the Key Fits the Lock…

We think we can imagine your complaints and disagreements bubbling up. But… But… But… It’s true that there are about 700,000 people living with brain tumors in the U.S. And the known and documented cases of brain tumors perhaps leading to criminal behavior are maybe a few dozen. So it’s not as though a brain cancer makes a person a criminal, and just having a brain tumor is not an automatic defense against criminal activity. As we point out on our page “Your Mind & Your Brain”. our brains are complicated! A tumor doesn’t automatically make a person a criminal. But a brain tumor that damages just the right brain nerve circuits can change a person so dramatically that their behavior can fall of the cliff. Bad behavior, bad brain.

Reference

Ryan Darbya, Andreas Hornb, Fiery Cushmang, Michael D. Fox. Lesion network localization of criminal behavior. Proceedings of the National Academy of Sciences, Vol. 115 No. 3, December 18, 2017, pp. 601 – 606. Edited by Kent A. Kiehl, The Mind Research Network, Albuquerque, NM, and accepted by Editorial Board Member Michael S. Gazzaniga November 20, 2017 (received for review April 25, 2017)

Helpful links:

Proceedings of the National Academy of Science on Lesion Network Localization of Criminal Behavior

Scientific American on Killers with Brain Damage

Amy Yurkanin. The brain tumor defense: Did an Alabama mother mean to kill her toddler? AL.com. September 20, 2021.

Can’t Find a Doctor – Free Page

Attractive young woman physician in a form-fitting white clinical coat stands in a medical exam room and faces and smiles at the camera, stethoscope around her neck and hands on her hips.
Photo by Daniel Dan outsideclick

No One Can Ever Find a Doctor

One of our Readers in Hartlepool, England wrote to us with this comment:

On your site keep saying to go see your doctor, to go ask your physician, to be sure to check with your health care provider, and so on. That’s wrong! Most of us don’t have a doctor we can just go see, or that we can just ask. It takes weeks or months to get an appointment. Sometimes there’s no doctor to see no matter how long you wait. There’s no “answer your question” phone line to a real doctor. If you’re sick now and need help now you’re out of luck almost everywhere in the world. Unless you’re so sick, so near death, that the UEC [Urgent and Emergency Care] in some hospital will see you. That might work if you live in a country that has hospitals with emergency care.

Yes, it’s true, this reader correctly states the case. While there was this idea of one’s personal physician or treating physician, it usually was more for the few who could afford such personalized care. Now, with huge public health systems, the fantasy of seeing your own doctor still lingers but, especially when you’re just “kind of sick”, there’s no doctor to be found. Some people are lucky to have an identified physician for a chronic medical problem, but if you’re healthy and suddenly fall ill, it’s hard to find care. With the situation of too few fully trained physicians there has developed a proliferation of nurse practitioners and physician’s assistants to try to meet people’s needs. Given the reality that our reader brought this to our attention, we thought we’d spend a few paragraphs describing what people actually do to get help when there is no one to help.

A young attractive brunette woman doctor wearing a white clinical coat and a dark blue blouse is looking at the camera and starting to drape her stethoscope around her neck.
Photo by Yerson Retamal

Are You Crazy – There Are No Doctors To Just “Go See”

We have to admit that we’ve fallen into the common jargon of “your physician”, “your personal doctor”, and similar terms as though you have a medical person who knows you that you can just go see as needed. For many, many people it might be more realistic to say go to your nearest urgent care clinic, or to call a nurse hot line if there is one. But good quality free nurse help lines are also rare. And going to an urgent care clinic can cost a fortune even if one has reasonable health insurance. And, an urgent care “visit” is going to take hours and hours of your time. Hours that someone working a job and now sick often does not have. And hospital emergency departments? Forget it. They’re so expensive and time consuming they make urgent care clinics look quick and cheap. So, what to do?

Welcome to the Neuroscience Research and Development Consultancy website. Have a question or a comment? Send it to us at: Comment@NeuroSciRandD.com

When There Is No Personal Physician to Just Go See

What people actually do when they fall ill is try to access what information they can and do the best they can. Many go onto the Internet with Google searches and YouTube videos to diagnose themselves and find a treatment. This practice is hard to criticize if there’s no other help, but it’s a risky path to take. There’s more false information, really bad, dangerous false information, on the world wide web than good medical information. There are, of course, many reputable sites, but they usually say what they might do if you came to see them for care. They rarely tell you what to do to diagnose and treat yourself. And the sites that do come right out and tell you how to diagnose and treat yourself are most often the disreputable sites that will steer you in the wrong direction.

Your Friend as Your Doctor

Another path that is often chosen as a reasonable way to go is to talk to a few close friends about your problem and see what they think. Perhaps they had the same elbow pain last year or had the same flu bug last month. What worked and didn’t work for them? Depending on the situation they might even have some left over medication that they’ll give you to take. Now ask any physician, any nurse practitioner, any physician’s assistant, any health care provider about this idea and they’ll tell you it’s a horrible way to go, fraught with danger. This is true. But is it more dangerous than being sick and doing nothing. Well, maybe. But nonetheless it’s what many people do when they get sick and can’t get care.

Your Neighbor as Your Doctor

This access route to help is similar to consulting your friends as though they were physicians, except that neighbors are closer, as least distance-wise closer. If you’ve fallen and hoping someone will notice that you’ve not come outside in a while, it’s one of your neighbors who might rescue you, or who might call social services for a wellness check on you. The hope here is that one of your neighbors is, if not a real friend, at least friendly enough to help. Another hope is that someone is nosey enough to kind of keep track of people in the neighborhood, the patterns of coming and going, in case something is out of place. And just as with friends as doctors, with your neighbor, ask some advice, borrow some medication, incur the distain of all the real health care providers, and hope you live through it.

There Are Those Who Don’t Trust Doctors Anyway

We’ve again approached this situation from a narrow point of view. There are people, and if the pandemic is any indication, there are many, many people, who don’t even want to see a doctor because they don’t trust doctors. They are right in the groove of friend as their physician, neighbor as their physician, “best-buddy healer” person as their doctor. The list of neighborhood helper people is long with lots of titles, such as faith healers, some but not all acupuncturists, astrologers, some but not all chiropractors, fortune tellers, homeopathic “doctors”, witches, or sorcerers. While most would view these individuals as charlatans, there are many who seek them out as the most trustworthy source. They might incur the rath, not only of all the real health care providers but of everyone else who doesn’t believe. We can’t offer any advice here. We just hope they live.

an elderly male physician with white hair, wearing rimless glasses slid down his nose, with a white clinical coat, a stethoscope around his neck, and an expensive gold watch on his wrist
Photo by granderboy

Rule to Follow in Borrowing a Medication

Part of the journey through having a friend or neighbor or non-traditional healer as your doctor is getting a medication for your illness. This particular aspect is of especial concern because, while bad advice can cause you trouble, bad medicine can kill you. Ethical pharmaceuticals at least actually have in the pill what it says on the bottle. This is not true for most “natural” medicines or herbal remedies. An exception is that for brands that display a “USP Verified Mark”, what’s on the label is what’s in the bottle. One fortunate circumstance is that most “natural” medicines or herbal remedies, though ineffective, are harmless. The biggest risk category is drugs made to look exactly like a pharmaceutical medication but that are fake, made by the drug cartels and backroom chemists. The paragraph below addresses this aspect of staying alive when your friend is your doctor.

Only From a Pharmacy in the Country Where You Live

The nightly national news and the Internet are filled with regular stories of a teenage who took “Valium” to calm down, and died. The name of the real medication does not matter. Many ethical pharmaceutical medications have been knocked-off by backroom chemists and drug cartels. Here’s the problem. Even if these amateurs could make the actual medication, which they usually can’t, it’s harder to make and more expensive to make than fentanyl. A plain old aspirin has 325 mg of aspirin in it. For fentanyl, 325 mg could kill 81 people. Fentanyl is a factor in 53% of overdose deaths, 42,700 deaths in 2020. So if you’re borrowing your friend’s medication, only take it if it’s in a real pharmacy or pharmaceutical company container and if it came from a pharmacy in the country in which you live. Otherwise you might wind up treating your headache by killing yourself.

Not Too Far Out of Date

This is an often asked question. I can’t sleep at night and my neighbor lent me some of his doxepin to take at bedtime, but the label says it expired two months ago. Is it safe to take? Yes, probably. This whole “out-of-date” concern has been blown way out of proportion. Consult The Medical Letter on Drugs and Therapeutics, Vol. 62 Issue 1603, July 27, 2020, pp. 117-119. The Medical Letter says that when no suitable alternative is available, outdated drugs may be effective. “Many solid dosage formulations stored under reasonable conditions in their original unopened containers retain ≥90% of their potency for at least 5 years after the expiration date on the label, and sometimes much longer. Solutions and suspensions are generally less stable. There are no published reports of toxicity from degradation products of currently available drugs.” So, the expiration date is not the biggest problem.

Tan oblong medication tablets, round white pills, brown softgels, and translucent yellow softgels lie on a gray background.
Photo by Garak01

Absolutely No Street Drugs

This is part of the topic of avoiding fake drugs except that these are super-fake drugs often offered as safe. Don’t do it, don’t trust it. It’s one thing to “borrow” a pharmacy-bottled pharmaceutical medication from your friend or a neighbor. It quite different to buy something from the guy on the corner. The chance of getting something safe and effective from the drug dealer on the corner is near zero. We don’t like to preach, but in this case, just don’t do it.

Reference:

Drugs Past Their Expiration Date. The Medical Letter on Drugs and Therapeutics, Vol. 62 Issue 1603, July 27, 2020, pp. 117-119

Helpful links:

Harvard Medical School’s Harvard Health on Supplements: A Scorecard

National Center for Complementary and Integrative Health on Using Dietary Supplements Wisely

The British Medical Journal on Health Effects of Vitamin and Mineral Supplements

New Zealand Psychiatric Care – Free Page

The Good News About Treating ADHD

Attention deficit / hyperactivity disorder is now less a stigmatizing mystery and more a treatable neurologic condition. Now, when treating children and adults with ADHD, it’s great to see the change. A child moves from an initial position of, “I want to do it but I just can’t get it done.” A while later life is in a better place. Children come to learn that they have more control over themselves and their daily activities. This isn’t changing a devil into an angel. It’s evolving a mischievous rascal into putting energy into becoming a true competitor in life. The medical names used for this developmental brain disorder of children have changed over time. These obsolete labels included minimal brain damage, minimal brain dysfunction, learning / behavioral disabilities, hyperactivity, hyperkinetic reaction of childhood, and attention-deficit disorder. We’ve come a long way in understanding.

photo of the Auckland Port skyline in the rising sun - photo by Scout 58
Auckland Port Skyline – photo by Scout58

New Zealand Psychiatric Care

We’re including this article because readers have pointed out this dilemma faced by some psychiatrists in New Zealand who treat ADHD. They can’t use amphetamine-based medications. If the person, child or adult, responds to some other type of medication, such as the methylphenidates or non-stimulants, all can be well. If not, and amphetamine might be the best choice, it’s New Zealand Schedule 8 and they can’t use it.

We’ve Asked The Royal Australian and New Zealand College of Psychiatrists

We sent this question to The Royal Australian and New Zealand College of Psychiatrists: If a psychiatrist in New Zealand decides that it would be in the patient’s best interest to initiate a trial of dexamphetamine, is there a pathway forward to allow use? We are awaiting their reply and will post it here as soon as we hear from them.

Are Psychiatrists in New Zealand and Australia Taking Sides?

Treating ADHD is an area of medical practice that through the decades has been fraught with uncertainty and at times conflict. Over time, at the level of international consensus, clarification of aspects of this developmental brain disorder have been resolved. For example, it is now widely recognized that children with ADHD can grow to adulthood continuing to have ADHD. While there are still debates about adult ADHD, it is not debated that if a child had ADHD and that the signs and symptoms of that condition continue through adolescence and into adulthood, the adult person does have ADHD. It’s also widely agreed that the medications most often helpful are the stimulants. And, they can help quickly and permanently. With appropriate medical supervision they can be taken as needed all of one’s life.

What’s This All About? Where Did This Topic Come From? We’re responding to a reader who wrote to us:

On reading our article on ADHD Treatment (a free page), a reader in New Zealand told us of a dilemma in ADHD treatment there. The doctors can’t use any of the amphetamine-based medications, like Dexedrine or Adderall. The only “stimulants” they can use are the methylphenidate-based medications like Ritalin and Concerta. As a result, there are amphetamine-only-responder patients who cannot be appropriately treated. They pointed out that it’s interesting, however, that dexamphetamine is available to children with ADHD in Australia, but not in New Zealand.

Who Says Stimulants Are the Best Treatment?

The (U.S.) Centers for Disease Control and Prevention page on the Treatment of ADHD says, “Stimulants are the best-known and most widely used ADHD medications. Between 70-80% of children with ADHD have fewer ADHD symptoms when taking these fast-acting medications.” The (U.S.) National Institute of Mental Health web page on ADHD says, “Stimulants. The most common type of medication used for treating ADHD is called a “stimulant. Although it may seem unusual to treat ADHD with a medication that is considered a stimulant, it works by increasing the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention. Under medical supervision, stimulant medications are considered safe. However, like all medications, they can have side effects, especially when misused or taken in excess of the prescribed dose, and require an individual’s health care provider to monitor how they may be reacting to the medication.”

More Expert Medical Opinion on Stimulants in ADHD

The Medical Letter on Drugs and Therapeutics is a highly respected medical information source. It’s completely unbiased because it’s independent of the pharmaceutical industry, supported only by subscriptions and donations, accepts no advertising, and has a strict policy that no reprints will be sold to the pharmaceutical industry. In the June 28 2021 issue The Medical Letter reviewed the latest FDA-approved non-stimulant. The Medical Letter’s conclusion ends with the statement, “Stimulants are preferred for most patients.” The American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents says, “For elementary school-aged students, the evidence is particularly strong for stimulant medications…” The Guideline also states, “Most studies comparing behavior therapy to stimulants indicate that stimulants have a stronger immediate effect on the 18 core symptoms of ADHD.”

The United Kingdom’s National Health Service on Amphetamine in ADHD

The United Kingdom’s National Institute for Health Research says, “Amphetamines probably the best first-choice treatment for adults with ADHD.” The site describes further evidence that amphetamines might be the most effective medication to treat adults with ADHD. A systematic review of adults had 10,296 people from 52 randomized, double-blind, controlled trials. The analysis compared several drugs for ADHD either with each other or with placebo. At 12 weeks clinicians rated core ADHD symptoms using several scales. The result: amphetamines greatly improved symptoms. Moderate improvements were seen for methylphenidate and atomoxetine. The was uncertain moderate improvement with bupropion, and modafinil was no better than placebo. Amphetamines were the only drugs that were more acceptable than placebo, as measured by the proportion of participants who left the study for any reason. The drugs were equally tolerated based on people who left a study because of side-effects.

What the UK’S National Institute for Health and Care Excellence Says

NICE (the UK’S National Institute for Health and Care Excellence) has a guidance on the diagnosis and management of ADHD that was most recently updated in March 2018. NICE’S guidance recommends lisdexamfetamine or methylphenidate as the first-line medications for the treatment of ADHD in adults. It would stay with one of these two medications for up to twelve weeks. That is, if a medicine trial of one of these two medications has not shown enough benefit by six weeks, NICE suggests switching and trying the other of the two next. Lisdexamfetamine, taken once daily, is broken down slowly in the body to dexamfetamine. If it works but has effects that last for too long, standard dexamfetamine can be considered. This is taken every few hours. Only if they cannot tolerate lisdexamfetamine or methylphenidate or their symptoms have not responded to either of these drugs, atomoxetine should be offered.

New Zealand racing boats in black & white - photo by Claudio Bianchi
New Zealand racing boats – photo by Claudio Bianchi

ADHD Stimulant Prescribing Regulations & Authorities in Australia & New Zealand

Here’s what the AADPA (the Australian ADHD Professionals Association) has to say about the amphetamines for ADHD situation. “All states and territories within Australia and New Zealand have their own laws about schedule 8 (i.e., dangerous drugs/poisons) which includes stimulants. Currently, all states and territories have different laws about stimulant prescribing which poses a problem for patients moving between jurisdictions and for doctors engaging in tele-psychiatry across jurisdictions. In addition, some states/territories do not honor prescriptions from other jurisdictions. All states and territories have regulations on their Health Department websites ranging from well laid out, specific instructions, ready access to application forms and Expert Reference Stimulant Panels to increasingly vague information to contact the local S8/Drugs of Dependence Units with all enquiries. Stimulant prescribers seeking permission to prescribe are advised to phone their state health department and speak to the department dealing with S8/controlled medicines or the pharmacy section.”

The Royal Australian and New Zealand College of Psychiatrists

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has a website on the Professional Practice Guideline 6: Guidance for the use of stimulant medications in adults, October 2015. In the document it is stated that, ” Methylphenidate and dexamphetamine and other stimulant medications enhance the presynaptic release of catecholamines, in particular dopamine. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) supports the appropriate use of these drugs in the treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy in adults, for which there is a sound evidence base. Although stimulant medications have occasionally been used in other clinical disorders (see below), those indications are supported by a limited evidence base, and generally fall outside prescription regulations. This document provides clinical guidance for the use of stimulant medications, as one part of a holistic treatment plan.”

Dunedin Railway Station built in 1906 - photo by Arvid Olson
Dunedin Railway Station built in 1906 – photo by Arvid Olson

Our Reader’s Question Still Stands

We are awaiting a reply to the question that we sent The Royal Australian and New Zealand College of Psychiatrists on December 21, 2021, and do hope to hear back from them. The question was this: If a psychiatrist in New Zealand decides that it would be in the patient’s best interest to initiate a trial of dexamphetamine, is there a pathway forward to allow its use? It seems that the professional organizations in Australia and New Zealand agree with opinions in the UK, the US, and Canada, that there are people of all ages with ADHD for whom the best medication is one of the amphetamine-based medicines. So, if such an individual resides in New Zealand, is there a mechanism by which the person can be treated for the ADHD with an amphetamine?

British Columbia’s Mental Health Care – Free Page

British Columbia’s Mental Health Care

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We Would Like Your Comments on This Information

If you live in British Columbia and have any added information or updates on the situation for the family members of individuals involuntarily admitted to a psychiatric unit, please write to us at: Comment@NeuroSciRandD.com  We would appreciate getting more first-hand updated information.

Mental Health Law in British Columbia

Through the past three years we’ve been posting updates about the British Columbia Mental Health Act and how it treats family members of people with mental health conditions. British Columbia is Canadian Province. Our posts have been in response to a query from a reader. The reader asked what a family member can do when a relative has bad medication side effects, or stops taking their medication, and the Mental Health Authorities put up a brick wall keeping the family out. The authorities respond that the individual is an adult and should be able to make their own choices. If we’re talking about someone with schizophrenia off their medications this might be complete nonsense. The reader pointed out that the person in question is clearly too mentally ill to make any choices. The reader further commented that they need to change the laws to give the family a say.

Welcome to the Neuroscience Site

Welcome to the Neuroscience Research and Development Consultancy website. Have a question or a comment? Send it to us at: Comment@NeuroSciRandD.com

The Dilemma in British Columbia

The crisis seemed to arise from an overly strict interpretation of Canadian law about treating people with psychiatric diagnoses. The law is called the Mental Health Act. Under this Act people who are involuntarily detained, or out of the hospital on leave during an involuntary detention, have no right to give or to refuse consent for any psychiatric treatment. Under the law they are said to have “deemed to consent”, interpreted as consenting to all psychiatric treatment. Medications can be given against their wishes or preferences. The Law could allow electroconvulsive therapy that they don’t want. This situation holds true even when they might well be capable of making their own treatment decisions. They aren’t even allowed the right to a substitute decision maker, a legal representative or family member, to give or refuse consent on their behalf.

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Photo by Thi

“Deemed Consent” with Involuntary Detention Can Be Awful

If you’re a person with a mental health medical condition, “deemed consent” can be a miserable part of the law. That’s because “deemed consent” means that when people are involuntarily detained under British Columbia’s Mental Health Act they have no right to give consent to or refuse consent to any psychiatric treatment. And among all the Canadian Provinces and Territories only British Columbia uses “deemed consent”. This lack of any right to have a say in their own care is also true if they are released from the hospital on leave. “Deemed” here is a legal term. It means people detained for their mental health are “deemed” to have given consent to any and all psychiatric treatment even if it seems that they are mentally capable of making their own treatment decisions.

The British Columbia Schizophrenia Society Information

The crux of the matter for our reader was the issue of not having the right to choose a family member as a substitute decision maker. The British Columbia Schizophrenia Society seems to present that the situation is now a bit better. They provide information for families on their website. Some of the information seems than less helpful, like, “Families should encourage their loved one to obtain treatment voluntarily.” They say that families often play a crucial role in facilitating involuntary admission. The British Columbia Schizophrenia Society offers that If the individual is truly unwilling to voluntarily see a physician and get medical help family can (1) appeal directly to a physician to have their relative seen, (2) request police assistance, or (3) get an order from a judge or justice of the peace. It would be great if this “crucial role” part were true during an involuntary admission.

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Photo by RyanMcGuire

But What About After That Involuntary Admission?

But the three paths for family members listed above are just to get the person into an involuntary psychiatry unit admission. Can the family still play a crucial role after the involuntary admission? It’s great that when an admission to a psychiatric unit is being considered the families can provide important collateral information to the physician, police officer, or judge. But do the inpatient physicians listen to the family after the admission? Well, yes and no. The patient is involuntarily admitted under a “First Certificate” for up to 48 hours and if needed under a “Second Certificate” for up to a month. And, on admission, information is provided to both the patient and a near relative on their rights on how to access a “Review Panel”, how to get a lawyer, and how to request a second opinion on the treatment.

A Word About “Representation Agreements” In Canadian Mental Health Law

In British Columbia, a Standard Representation Agreement, sometimes called a Section 7 Representation Agreement, lets an individual choose a person to make or help with making health-care, personal-care, legal, or routine financial decisions. The person chosen is legally known as your representative. This Standard (Section 7) Representation Agreement can be made by an adult even if that adult has trouble understanding the information. This adult individual can use this Agreement to name a representative. There’s a different Representation Agreement called an Enhanced (Section 9) Representation Agreement. This agreement is for individuals who can understand what the agreement is about and what it allows their representative to do. The individual can use this Section 9 Agreement to name a representative to make health-care and personal-care decisions on their behalf.

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It Can Work Well For The Concerned Family, But Not Always

Usually families can offer the treating physician information that might be relevant and helpful after a person is admitted to a psychiatric unit. Information such as how well any previous treatments worked, any issues with side effects, and the treatment plan that the patient would prefer. With an involuntary admission the patient is likely viewed as not being capable of making decisions, so the unit’s Director who will authorize any treatments. If a family member has Standard (Section 7) Representation Agreement that includes treatment preferences, the preferences can be considered by the unit’s Director, but this does not apply to treatment under the Canadian Mental Health Act. In the case of a person involuntarily committed to a hospital, the British Columbia Mental Health Act takes precedent over a formal Representation Agreement, and decisions are solely made by the unit’s Director with advice from the treating physician.

Certified and Involuntarily in the Hospital – Family Can Only Suggest

So it would seem, talking to people and reading all of this, that once the individual has been certified and involuntarily admitted to the in-hospital psychiatric unit, the family can offer hopefully helpful suggestions but the treating physician and unit Director have the final say and the family cannot do much about it. But, there is the Review Panel. If an involuntary patient wants to be discharged from hospital or from Extended Leave against their physician’s advice, the patient (or anyone else, like a family member, acting on the patient’s behalf) can appeal to a Review Panel.  If the appeal is successful, the patient must be released.

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Photo by John Torcasio

The Review Panel Story

Setting up the situation at this point, a person is detained in a hospital’s psychiatric unit. They might or might not have a Standard (Section 7) Representation Agreement to name a representative. But either way, the British Columbia Mental Health Act takes precedence over the Standard (Section 7) Representation Agreement, so for a person who is involuntarily committed treatment decisions are solely made by the unit’s Director (with advice from the treating physician). But the patient wants to be discharged from the hospital against their physician’s advice. So, the patient or anyone else, like a family member, acting on the patient’s behalf can appeal to a “Review Panel”. A Review Panel has a lawyer, a physician, and a non-lawyer non-physician lay person, and all three people are independent of the hospital.

The Review Panel Is an Independent Tribunal

Review Panels are run by the Mental Health Review Board, an independent tribunal. It gets its authority from the Mental Health Act for Protecting the Rights of Involuntary Patients. Each Review Panel consists of three members appointed from the Mental Health Review Board: a physician member, a legal member, and a community member, with the attorney (legal member) chairing the Review Panel hearing. A Review Panel reviews the situation and decides whether the patient’s certification and involuntary detention should continue. To reach this decision the panel uses four criteria. All a Review Panel can do is decide yes or no on the continuation or not of the involuntary hospitalization. The Panel can’t offer any opinion about the patient’s treatment. If a family member is opposed to their relative being released they can be involved in the Review Panel hearing.

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Photo by Jesús Antonio Ávila Burgueño

The Four Criteria Used By A Review Panel To Reach a Decision At a Hearing

  • Does the patient suffer from a disorder of the mind that seriously impairs their ability to react appropriately to their environment or to associate with others?
  • Does the patient require psychiatric treatment in or through a designated facility?
  • Does the patient require care, supervision and control in or through a designated facility to prevent their substantial mental or physical deterioration or for their own protection or the protection of others?
  • Can the patient be suitably admitted as a voluntary patient?

More About the Actual Review Panel Hearing

If a patient appeals to a Review Panel a family member is told and given the date of the hearing. By contacting the attending physician, family members are able to offer information in support of keeping their relative in the involuntary admission. A family member or friend may participate in a hearing either as a patient representative or as a witness. Alternatively, a family member or friend may observe a hearing as a support person. In fact, the Mental Health Review Board encourages the patient to bring someone to represent them at the hearing. This representative may be a lawyer, an advocate, a family member, a friend, a near relative, or another person who will advocate for and represent the interests of the patient. The family has the Mental Health Act on their side in the Review Panel hearing in that the Act states:

“A hearing by a Review Panel must include:

(a)  consideration of all reasonably available evidence concerning the patient’s history of mental disorder including (i) hospitalization for treatment, and (ii) compliance with treatment plans following hospitalization, and

(b) an assessment of whether there is a substantial risk that the discharged patient will as a result of the mental disorder fail to follow the treatment plan the director or a physician authorized by the director considers necessary to minimize the possibility that the patient will again be detained under section 22. [the admission criteria]”

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Other Rights The Patient Has In Addition to the Review Panel

The Mental Health Act requires that the psychiatric unit sends a written notice to a near relative upon an application for a review panel hearing. The patient needs to choose a near relative but if the patient doesn’t or can’t choose one, the hospital will choose one or send the notice to a Public Guardian or Trustee. A “near relative” can be a grandparent, parent, sibling or half-sibling, spouse, a friend, a caregiver, or a companion. A “near relative” can also be a legal guardian. A common law spouse or same sex partner is considered a near relative. The “near relative” receives notice of admission, review panel application, discharge, and rights. They may exercise rights on person’s behalf for the following:

  • Renewal certificate examinations
  • Second opinion on appropriateness of treatment plan (patient, or family request)
  • Review Panels or Courts for discharge

Well, Yes, Sort of Okay, But…

After all this, let’s return to our readers concern. What can a family member can do when a relative on involuntary admission to a psychiatric unit has bad medication side effects want to stop taking their medication? And the answer after all this explanation is, nothing. During an involuntary hospital stay, or a leave during an involuntary hospital stay, the family cannot have any real impact. At best, the family can offer suggestions. But the psychiatric unit Director has the final say and if the Director ignores the family members they cannot do much about it.

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How to Live to Age 100 – Free Page

woman brushing teeth 675239882 21Dec2020
Start Young to Make It to 100

How to Live to Age 100

Most people don’t believe it, but it’s absolutely true. It’s medically and scientifically proven. And, it does make a huge difference. So, here’s how to live to age 100, or at least, one important thing you can do to help you make it to age 100. And, in addition, increase your chances to make it to age 100 with a clear mind. No Alzheimer’s. No dementia. Really? Yes, really.

One of Our Website’s Fans Pointed Out…

In a previous version of this page we had a comment about the proximity of the mouth and teeth to the brain. A regular reader pointed out that the brain and mouth being close to each other is probably not that important. The inflammation signals against food bits and bacteria in the mouth would travel to the brain though the blood stream. Poor dental hygiene can cause cancer and heart and blood vessel problems in parts of the body distant from the mouth. While we mostly agree, it’s also true that there are many connecting channels like nerves, blood vessels, and lymph vessels in the mouth, face, head, and brain area. The nearby location could make a difference.

Floss and Brush Your Teeth at Least Twice a Day

Yes, really, this is not a joke. Good dental hygiene. (Hygiene is taking care of your health before you get sick.) And, it has to be twice a day at least (more on this below). Once every 24 hours is not enough. And you can’t just brush, you also have to floss your teeth. And lightly brush the top of your tongue with your toothbrush. Stop the old “coated tongue” problem.

How Can That Be? Live to 100 by Good Dental Hygiene?

This information is actually not new, and comes from many sources over decades. People with gum disease are much more likely to get Alzheimer’s dementia. One article posted by the UK’s National Health Service says that people with chronic gum disease are have a 70% higher chance of getting Alzheimer’s that people with healthy gums and teeth.

That Doesn’t Make Sense

Well, actually, it does make sense. Here’s why. Gum disease, tooth decay, bad breath, all involve inflamed tissue. Inflammation. Bacteria eating and growing on all the food bits and sugar left on your mouth and on your teeth. And the immune system goes into high gear to fight and kill those bad breath bacteria. The immune response is involved in causing Alzheimer’s (and cancer and heart disease). The immune system signal molecules get into your blood stream and go everywhere. Once in your blood it’s a short hop to your brain. That high-gear immune response in your mouth can easily change your brain.

There Is a Catch About How to Live to Age 100

Good grief, there’s always a catch! Dental hygiene. Hygiene is what you do to preserve health. That is, hygiene is prevention. So, here’s the catch. You have to start young and practice the good dental hygiene daily for decades. So that twice a day of both brushing and flossing, and brushing your tongue, has to start as soon as you read this and continue twice a day for the rest of your life.

But It is True – How to Live to Age 100 Is About Brushing Your Teeth

Lower you chance of dementia, cancer, and heart and blood vessel disease just by practicing good dental hygiene.

But, Come On, Do We Really Need to Brush Twice a Day?

Yes. After you eat, little leftover bits of food stay in your mouth. This helps the bacteria in your mouth form a sticky gunk. Because it’s sticky it sticks to your teeth. So you have bacteria stuck to your teeth, held there by this sticky film. As the bacteria eat and digest the bits of food they release an acid. This acid in the sticky film dissolves the enamel in your teeth. Dissolving enamel is called tooth decay. If the sticky plaque is left on your teeth and gums too long (more than about 12 hours) it hardens. This hardened plaque is called tarter. Tarter is a yellow color and it’s too tough to be brushed away. It takes about a day for plaque to become tarter. By brushing twice a day you get rid of the plaque while it’s still soft, before it turns to tarter.

Okay, Fine, But Why Floss Twice a Day?

Brushing gets rid of the sticky, gunky plaque on your teeth. Or, at least, the part of each tooth that is above the gum line. There’s more of each of your teeth below the gum. Your toothbrush can’t reach below the gumline. The floss slides down the sides of your teeth to below the gum, getting the gunk off down there before it hardens into tarter. Once it solidifies into hard, yellow tarter, it’s too hard for flossing to scrape off.

Okay, Okay. But Why Brush Your Tongue? That Sounds Icky

Taking your toothbrush after you brush your teeth and brushing it a few times across the top you your tongue gets rid of a huge number of bacteria. Fewer bacteria means less sticky, gunky plaque and less chance for plaque to turn to hard, yellow tarter on your teeth. It also means fewer bacteria to cause bad breath. After you brush your tongue, rinse you mouth really well with water and, swish, away go the tons of bacteria.

Helpful links:

The National Institute on Aging on Large Study Links Gum Disease to Dementia

United Kingdom National Health Service on Gum disease linked to Alzheimer’s

University of Central Lancaster on Poor dental health leading to Alzheimer’s

The Cleveland Clinic on Oral Health and Cardiovascular Disease

Express Dentist on Improving Oral Health for Patients with Alzheimer’s Disease

Postscript

If you’re one of those people who likes to go crazy with dental care…

Here are a couple of oddball tips.

2 Toothbrushes

There is a school of dental thought that says that your toothbrush should be clean and dry before you wet it and brush your teeth. To fully dry usually takes about 24 hours, and you brush your teeth twice a day. So, we would do best to have 2 toothbrushes, a morning toothbrush and an evening toothbrush. That way each of the toothbrushes will have 24 hours to dry before it is used again.

Brushing Your Tongue

As we mentioned above, it’s good to lightly brush the top of your tongue with your toothbrush twice a day when you brush your teeth. A smaller toothbrush head is usually better for brushing your teeth so it can get down into all the little places around and between your teeth. But it’s hard to brush a tongue with a small-headed toothbrush. So maybe we should each have 4 toothbrushes, 2 with smaller heads for your teeth and 2 with larger heads just to brush your tongue quickly and lightly.