In my practice I often see patients self referred or sent in by their general practitioner who tell me that he or she has Major Depressive Disorder. Problem is, medications and therapy have had little success so my expert advice is needed.
When evaluating a patient it is crucial not to miss the diagnosis of bipolar depression. A recent article in a Chilean medical journal (Rev Med Chili 2010 Jun) identifies suggestions of how a proper diagnosis can be achieved. This information resonates with my practical experience seeing patients through the years.
First it is important to use standardized diagnostic criteria such as the DSM-IV or ICD 10 manuals. Second it is important to check whether certain clinical features are present. These features tend to be less known to the general practitioner and population. These criteria include whether there are previous episodes of mood elevation. Mood elevation can include times when mood is either positively elevated as in euphoria or high energy that is distinct from other times, or it can be negatively elevated. An example of the latter would be “road rage”. One is driving and the person in front of him lingers a little too long at the stop sign and the drivers gets unusually angry and wants to punch the guy out. We all have heard of that happening.
Another lesser known criteria is current or past episodes of psychotic depression which are episodes of depression that are so severe and debilitating that a person has great difficulty getting out of bed in the morning and functioning.
Recurrent depressive disorder before the age of 25 and a strong family history of mood disorder and suicide are other red flags for Bipolar Disorder.
Finally there are the signs related to past antidepressant usage that can be valuable information in proper diagnosis. If a patient has had a lack of response or “wearing off” to well conducted antidepressant treatment, or an unusually fast response to antidepressants with features of elation these are all red flags of Bipolar Disorder.
Finally, it is important that the proper professionals are utilized in making the diagnosis. While it can be a starting place, it can not be adequately done by self-diagnoses through the internet!
There is a growing body of evidence that many mental health conditions are related to dietary deficiencies. A currently recognized deficiency these days is Vitamin D.
It is commonly reported these days that 75% of people have a deficiency of Vitamin D. This is all over the world. Interestingly, the country that is reported to have the highest Vitamin D levels isThailand. I’m not sure it is known why that is. Vitamin D deficiency it turns out is related to many illnesses from Depression to Cancer. What is the recommended amount of Vitamin D these days? In my practice I recommend a level no lower than 32 ng/ml. Although there is research that suggest levels of 50-70 are necessary to prevent Cancer.
People susceptible to Vitamin D deficiency are infants, pregnant and lactating women, the elderly, individuals living in Northern latitudes, those who avoid sun, and dark pigmented individuals. There are also conditions that predispose a person to Vitamin D deficiency including people who have chronic renal failure, people with malabsorptions syndromes that come as a result of bariatric surgery, biliary tract disease, Cystic fibrosis, Celiac disease, inflammatory bowel diseases and certain medications.
If you are taking a Vitamin D supplement please be aware that it is recommended that you take Vitamin D3 as opposed to D2. Most research uses Vit D3. Also be aware that Vit A antagonizes the action of Vit D. (Attention Cod Liver Oil and Retinol users!)
Lastly, if you are being evaluated for Depression please have your medical practitioner check your Vit D levels before undergoing any other treatment. You may be able to save yourself a lot of time and money!
I am a big fan of Dr. Amen. I find his neuroimaging work to be highly fascinating. Not everyone agrees and some question his science. You may have seen some of his programs on the brain on PBS over the last few years. I have been using Dr. Amen’s mental health questionnaires on my patients for years. I especially love his ADHD assessments. He identifies at least 6 different types of ADHD that have to be treated differently from each other to get the best results. I have been using them with my patients for the last number of years and have seen some highly effective results from the treatments advocated. Some types of ADHD may necessitate an antidepressant. Other types may be helped best by stimulants. Others may need a mood stabilizer. Some types need a combination of a few types of medications. There are also some supplements that can be effective in its treatment. Of course, as shown last month, there are other psychosocial types of treatment that can help including Cognitive Behavioral Therapy.
It is exciting to see all the advancements that are being made with understanding ADHD and its treatment. One day there may even be gene therapy to prevent the problem in the first place. Until then, we can use all the best of what science has to offer us.
Cognitive Behavioral Therapy improves ADHD Scores
This month a very interesting research study was recorded in the journal of JAMA. It addresses Cognitive Behavioral Therapy as an ADHD treatment
Cognitive Behavioral Therapy, also known as CBT, is most successfully used in conjuction with medication in my opinion, but often the medication does not offer complete relief of all bothersome symptoms. This study compared CBT with relaxation and educational support. Please note that all the subjects were already on medication but all had symptoms that remained.
Results of this study showed CBT to be superior to relaxation and educational support in the lessening of ADHD symptoms.
I love and highly recommend CBT and find it very effective for many types of mental health conditions from depression, anxiety, bipolar, and psychotic types of illnesses. I am glad to hear that it shows promise with ADHD as wel
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.
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.
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.
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!
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?
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….