Depression: Should I go herbal or the medication route?

 
I have some patients who come to me for Depression who wonder whether St. John’s Wort is adequate in the treatment of Depression. My answer is it depends on the severity of the Depression. 
 
In mild to moderate cases where the Depression has been experienced for 3-6 months or less I would suggest the possibility of St. John’s Wort as a chemical remedy. There has been some recent promising research showing the effectiveness of St. John’s Wort in these cases. The advantage of using St. John’s Wort is not only in its effectiveness but it has fewer side effects than antidepressants. Antidepressants can have side effects such as weight gain, sexual dysfunction, fatigue and insomnia for some. Usually I see these side effects in the higher doses of antidepressants. There are some antidepressants that are worse than others as far as side effects are concerned.
 
If the Depression has been going on for greater than 3 months and especially for recurrent types of Depression I would suggest trying an antidepressant. Both St. John’s Wort and antidepressants increase Serotonin and other neurotransmitters.
 
This article is not meant to say that other forms of help should not be tried. I am a strong believer of Cognitive Behavioral Therapy (CBT) which seems to have the most promising research out as far as effectiveness. However, in the more severe types of depression the best combination appears to be a therapy like CBT combined with an antidepressant. That appears to be the quickest route to the remission of moderate to severe Depression.  
 
If you are not sure what type of treatment is best for you I would suggest you confer with a mental health specialist who prescribes, either a Psychiatric Mental Health Practitioner (Sometimes called an Advanced Practice Nurse) or a Medical Doctor. In some states Clinical Nurse Specialists (CNS) in mental health can also do the evaluations and prescribe medication.

Insomnia: Who should I see for help?

When I see patients in my office I would say that 75% have as a major complaint of insomnia or having difficulty going to sleep and/or staying asleep. Many times the problem has been going on for years. How does one know who to see about their insomnia? The general practitioner? The Sleep Specialist? The Mental Health Specialist?

Questions to ask yourself: How long have you had this problem? If it’s only been a few days or weeks then I would say it would be ok to see your general practitioner or mental health practitioner. Both have the knowledge to help you get to sleep. If you say all your life or since I put on a lot of weight, that is work for the specialist. There could be a mental health disorder or a physical structural disorder that is causing a disorder called “Sleep Apnea.” This is a condition where a person stops breathing in the middle of the night sometimes thousands of times resulting in a restless or inadequate sleep. A major symptom of this is if a person snores loudly and a sleep partner observes the person actually stopping breathing for seconds at a time. Another major symptom is extreme fatigue during the day.

In the mental health category, if a person has been experiencing anxiety or depression and he/she is having trouble sleeping then a mental health evaluation may be appropriate.

Major Depression, General Anxiety Disorder, PTSD and Bipolar Disorder are all conditions that interfere with sleep. These are treated in different ways. In my practice I teach my patients “Sleep Hygiene.” This is a program to help the body cue itself that it is time for sleep. We often lose that cue with bad habits and lack of routine over time.

What kind of medications are the best for insomnia? I always start with the mildest remedies that are not addictive. Melatonin and antihistamines top my list. Second tier would include medications in the antidepressant class such as Trazadone. One does not
have to be depressed to use Trazadone. It is very effective. Third tier would be other antidepressants and mood stabilizers according to what are the diagnoses. I totally avoid the Benzodiazepine class. Benzodiazepines are only meant for the occasional sleep problem. If one has issues with addictions of any kind, or has it in their family, then I would recommend avoiding this class altogether.  The problem is Benzos can cause addictions but also can cause Depression when used long-term. 

Accountability and Mental Health

I had a patient that I worked with a few years back from California (I am in Oregon now) call me and request my long-distance counseling services. “I’ve been seeing a counselor here for awhile and while I have learned a lot since working with her, she doesn’t hold me accountable.” 

That got me to thinking about the role of accountability and responsibility in mental health. A person could have years of counseling and medication services, yet if there is no accountability on the patient’s part then what good would they do? 

My goals are to help the patient become accountable and responsible. Without these traits, then how could a person succeed in work or school? If an employer asks for the employee to be there at 8 am will it matter if the employee shows up at 8:15? Most employers would not stand for repeated infractions. What about school? Just because the teacher requires a student to show up at 9 am for a test, does it really matter if a student is 15 minutes late? Ridiculous question, right? The American culture does not tolerate being late or not showing up. Yet, surprisingly, many people have difficulty with these concepts. 

So, when I check your homework assignment that I gave you, when I require a 48-hour notice on cancellations, when I require a 3-day notice with refill requests, or if I require payment at the time of service and I hold you accountable, think of it as a therapeutic technique. You will thank me for it in the end.

Anxiety Disorders in Children: a family affair

According to the Surgeon General, anxiety disorders affect approximately 13% of children. Some diagnoses that reflect a problem with anxiety are: Generally Anxiety Disorder, Social Phobia, Avoidant Personality Disorder, and Panic Disorder. All of these show similar symptoms of anxious feelings, sweaty palms, pounding heart, increased respiratory out put, sick or sore stomach, and other symptoms. 

What is the cause of anxiety disorders? It’s not fully understood, but we do know that anxiety disorders tend to run in families—probably a mixture of environmental upbringing and heredity. 

There is also a correlation between anxiety disorders and children that have trouble sleeping. Sometimes it is hard to know what came first, the chicken or the egg. But children that have trouble sleeping tend to have higher levels of stress during the day, which increases stress hormones like Cortisol. Cortisol tends to deplete Serotonin, a feel-good neurotransmitter, which sets them up for problems like anxiety or depression. 

When I see a child for anxiety, I test the parents as well. More than not, I find at least one parent that will also be experiencing anxiety. I will also note that the parent tends to have an “anxious parent” type of parenting style. This is shown by a tendency of over-protectiveness and a tendency towards elevated expressed emotion when stressed. Unfortunately, too often a child learns from this parent how to experience and deal with the world. If the parent has a highly reactive style towards spiders, for example, the child often will also. 

I also would like to note the correlation between anxiety and frequent illness. If you see your child getting sick a lot and missing school you might want to go get your child checked for an anxiety disorder with your Psychiatric Mental Health Nurse Practitioner or Psychiatrist. They are often missed. Thousands of dollars later you may find that your child has an anxiety disorder and not an ulcer!

Secondhand Smoke and Mental Illness — Is there a link?

Very interesting study published in the Archives of General Psychiatry. It is reported that secondhand smoke exposure may have a link to schizophrenia, depression, delirium and other psychological conditions. It turns out that tobacco also brings on negative moods in animals, and other studies on humans seem to show a correlation between depression and smoking. 

I thought this was highly interesting as I recently had a patient go to Rehab who suffered from some other mental health conditions. She told me that at Rehab there was a social group on the back patio every couple of hours for the smokers. The patient ended up coming home with a new addiction to smoking. She basically replaced one addiction for another. I can’t help wondering if these facilities have the best interest of patients in mind… I also think it is interesting to observe that the very large majority of Schizophrenics (I think it’s in the 90ish percentile) are smokers. Coincidence?

An aspirin a day keeps Schizophrenia away?

According to a recent article in the Journal of Clinical Psychiatry, aspirin therapy reduces symptoms of psychosis in Schizophrenia Spectrum Disorders. It is speculated that inflammation is causing havoc in the brain as well as the body now. This reminds me of a study published I believe in the early 2000’s that suggested Ibuprofen may prevent Alzheimer’s Disease, another prevalent brain disease. 

Does that mean that we should all start taking aspirin daily? I wouldn’t do this without consulting with your psychiatric mental health nurse practitioner or psychiatrist. For some people aspirin and other anti-inflammatories can actually irritate the digestive tract and may even cause inflammation, so if you are in the category you may not be a good candidate for aspirin. Like anything, it is important to weigh the benefits with possible consequences. No two people are alike… However, it is the middle of the day and I am feeling a little cognitively fuzzy (and I have Schizophrenia and Alzheimers in the family)…not much of a caffeine drinker—just an occasional diet coke—perhaps I should try an aspirin? Hmm….

Memory Loss: Is it Alzheimers?

I get a lot of questions about concerns patients and family members have about troublesome symptoms of memory loss when I am treating them for Depression and Anxiety. They wonder whether they have Alzheimer’s Disease and not Major Depression. 

Memory loss—and that is short-term memory loss—is very common with Depression. Depression affects the brain in a way that impairs the storage of information into long-term memory. What I mean by short-term memory is the memory of what you had for dinner the night before or what you discussed with a friend earlier in the day. People with Depression often lose some short-term memory but not memory from when they were a child (or long-term memory). 

It is normal for people to have some trouble with memory when they are stressed from time to time. But if it is happening every day and creating embarrassment in your life, i.e. forgetting 3 days in a row your preschooler needing to be picked up at a certain time or repetitively forgetting appointments, then I would suggest you go get an evaluation from your Psychiatric Mental Health Nurse Practitioner. You may be depressed or anxious and could be helped with some therapy and possibly medication. 

Years ago, I suffered from a bout of Post Partum Depression after my last child. My older daughter who was about 14 at the time felt the brunt of it. One day she called me from school and asked me to bring her term paper that she forgot. She had called me in the middle of the day to bring it at the end of the day. A half hour before she needed it, she called me again to remind me because she knew I had an issue with that. I reassured her that I would be there. Then I get a third call from her after I didn’t show up 10 minutes after I should have been there. She was very upset with me and distressed. I was so embarrassed! I felt bad knowing that I had let her down and how she must have felt thinking that her own mother didn’t put her needs on a higher priority than what I was doing at the time. I’ve always wondered if I scarred her for life during that very dark time for me. Hopefully, she has forgiven me… 

Please don’t let this happen to you! Get help if you see some concerns with memory—particularly short-term memory.

Supplement may prevent psychosis!

Attention families with psychosis among relatives! Omega-3 fatty acids may prevent onset of psychotic disorders in high-risk populations. This is according to a study published by Amminger and associates in the Arch Gen Psychiatry, 2010 Feb;67(2):146-54. The study suggests that a common supplement that we use for heart disease and stroke prevention may also prevent the progression of psychotic illness in those who have what is called prodromal symptoms (or what I call “pre-psychotic symptoms”). What are pre-psychotic symptoms? Early symptoms may include hearing voices or having some unusual sensory experiences; mood disorders; disorganization in surroundings, speech or actions; and unusual motor activities or posturing. My opinion with this study is that it is certainly worth trying as we all have heard how good Omega-3s are for the body and brain. I think too often we are inclined to jump to powerful drugs earlier than is necessary. How about trying upping our fatty fish consumption or using a supplement? For many the Omega-3s may be enough!