Seasonal Affective Disorder

Hello, people… welcome back to the blog! Last week, we finished our two part series on phobias, and it seems everyone enjoyed it. I got a lot of great feedback on it, and people have been sharing their weird phobias with me even more than ever… I’ve really added to my list of doozies! This week, I wanted to talk about a topic I ran into recently, seasonal affective disorder, or SAD. 

What is SAD? In the shrink bible, the DSM-5, it’s identified as a type of mood disorder. It’s not a standalone, but is specified as a major depressive disorder with a seasonal pattern, meaning that it happens every year at the same time, typically starting in fall or early winter and ending in spring or early summer. Because of this, some people call SAD the “winter blues,” but this is misleading, as there is a rarer form of seasonal depression known as “summer depression” that begins in late spring or early summer and ends in fall. And while the two types obviously share many symptoms, interestingly, their profiles are slightly different. More on that in a moment. 

First, let’s talk statistics. In the United States, the percentage of the population affected by SAD is about 5%, but varies widely based on geographical location, from 1.4% of the population in Florida, to 9.9% in Alaska. This should give you a clue about one of the main factors associated with SAD, the amount of available sunlight. SAD may begin at any age, but it typically starts between the ages of 18 and 30, and as with other types of depression, SAD is much more common in women; they are three times more likely to be affected than men.

Calling SAD the “winter blues” makes it sound like no big deal, but people with SAD experience serious depression- the mood changes and symptoms are very similar to chronic depression- and these symptoms can have a major impact on their lives for 40% of the year, as symptoms usually occur during the fall and winter months and typically improve with the arrival of spring, with January and February being the most difficult months in the US. While temporary, SAD symptoms can be overwhelming, and in some cases, it can seriously interfere with daily functioning. Thankfully, it can be treated, and that’s why I decided to cover this topic. Recognizing the disorder is very important because it can cause such serious psychosocial impairment, but it’s not just important to recognize it… getting help is key, because acute treatment can be very effective, and maintenance treatment can actually prevent future episodes. 

SAD Symptoms 

People with SAD experience mood changes and symptoms similar to depression, and these can vary from mild to severe. Everybody gets bummed out from time to time, those everyday feelings of sadness or fatigue brought on by life’s ups and downs- even during the holidays- but depression is a different animal. 

Seasonal depression is marked by some specific symptoms, and these may include:

-Sleeping more than usual and still feeling drowsy and fatigued during the day

-Low energy

-Loss of interest in activities that once brought you joy

-Increase in purposeless physical activity, like pacing and hand wringing; an inability to sit still

-Slowed movements or speech, severe enough to be observable by others

-Feeling irritable and anxious

-Feeling guilty, worthless, hopeless, sad, tearful

-Decreased libido

-Desire to isolate, not wanting to see people

-Difficulty thinking, concentrating, or making decisions

-Increased appetite, overeating, and weight gain

-Cravings for carbohydrates

-Physical symptoms, such as headaches

-Thoughts of suicide or death

Clearly you don’t have to have every one of these to have SAD, and as with anything else, symptoms occur on a spectrum. Some people with SAD have mild symptoms and basically feel out of sorts or cranky, while others have symptoms that totally interfere with relationships and work. As I mentioned earlier, spring and summer SAD is much less common, but still occurs. The symptom profile is a little different; instead of people eating their way through it as a result of increased appetite, it’s difficult to get summer SAD people to eat at all, as they tend to have zero appetite. In my experience, it also seems to feature more agitation, almost manic type behavior. 

What causes SAD? Like so many disorders, the cause isn’t completely understood, but we know that the body uses sunlight to regulate sleep, appetite, and mood. It’s believed that the decreased sunlight in the fall and winter months disrupt the body’s circadian rhythm. Lower light levels in winter disrupt the body clock, leading to depression and tiredness. As seasons change, people already naturally experience a shift in their biological internal clock that can cause them to be out of step with their daily schedule, so people may be more vulnerable during this time. The change in season, with shorter daylight hours, can lead to a biochemical imbalance in the brain, specifically in levels of serotonin and melatonin, two hormones that affect sleep and mood. SAD has been linked to this imbalance. There are risk factors involved as well. You’re more likely to develop SAD if you have an existing form of depression, or a relative with SAD or another form of depression. And Captain Obvious says that SAD is much more common in people living far from the equator where there are fewer daylight hours, so living somewhere where you expect months of darkness during the year isn’t the best plan if you have any of the risk factors. 

Diagnosis

The main feature of SAD is that your mood and behavior shift along with the calendar. So how do you know if you have it? If for the past 2 years, you:

-Had depression or mania that starts as well as ends during a specific season

-You didn’t feel these symptoms during your “normal” seasons

-Over your lifetime, you’ve had more seasons with depression or mania than without

I should note that sometimes it takes a while to diagnose SAD, because it can easily mimic so many other other conditions, like chronic fatigue syndrome, underactive thyroid, low blood sugar, viral illness, and/ or other mood disorders. If you suspect that you or a loved one may have it, the best course of action is to see a physician. There are online resources available as well, from the Center for Environmental Therapeutics, at cet.org. More on that at the end of this blog.

SAD Treatment

Clearly, you can’t stop the changing of the seasons, but there are some things you can do to combat SAD, including light therapy aka phototherapy, antidepressant medications, talk therapy aka cognitive behavioral therapy, or a combination of all three. Meds are usually brought in as adjuvants if light therapy is insufficient in reducing symptoms. Wellbutrin XL was the first drug approved specifically for SAD in the United States, and I’ve seen some success with it. Symptoms will generally improve on their own with the change of season, but it happens far more quickly with treatment. Treatment course differs depending on how severe your symptoms are, and of course, depending on whether you have another type of depression or bipolar disorder. For some people, simply increasing exposure to sunlight can help improve symptoms of SAD, and it’s recommended that people get outside early in the morning to get more natural light. If this is impossible because of the dark winter months, then phototherapy is key.

Light Therapy

As I mentioned, light affects the biological clock in our brains that regulates our circadian rhythm, a physiological function that may induce mood changes when there’s less sunlight in winter. We know that natural or “full-spectrum” light can have an antidepressant effect. In phototherapy, you mimic that by sitting about 2 feet away from a light box, usually a 10,000-lux light box specifically, so that full spectrum bright light- about 20 times brighter than normal room lighting- shines directly upon you, but indirectly into your eyes. You do this for 15 minutes per day to start, and the times are increased as necessary with a max of 30 to 45 minutes a day, depending on your response. If using a weker lightbox, such as those that emit 2,500 lux, it will require much longer, about two hours of exposure per day. 

Light therapy should be done in the early morning, upon waking, to maximize treatment response. Morning therapy also helps to specifically correct any sleep-wake cycle issues contributing to the symptoms. Please people, don’t look directly at the light source of any light box, to avoid possible damage to your eyes. I’ve heard of some practices that provide light boxes for patients with SAD. Again, the Center for Environmental Therapeutics has info on this. I’m sure you can also rent light boxes, and I know you can purchase them, but they’re expensive, and health insurance companies don’t usually cover them. But if you have SAD and live in a “dark” winter area, they can be worth their weight in gold.

Optimum dosing of light is crucial, since if done wrong it can produce no improvement, or partial improvement, and that can potentially lead to worsening of symptoms. I read some research that found that even a single, one hour light session can improve symptoms of depression in people with SAD. It varies; some people recover within days of using light therapy, most see some improvement within one or two weeks of beginning, but a few take longer. To maintain the benefits and prevent relapse, light treatment is usually continued through the winter, until you can be out in the sunshine again in the springtime. Because of the anticipated return of symptoms in late fall, I highly recommend that SAD patients begin phototherapy when fall first starts, even before feeling the effects of SAD. If the SAD symptoms don’t go away, your physician may increase light therapy sessions to twice daily. While side effects are minimal, be cautious if you have sensitive skin or a history of bipolar disorder. Common side effects of light therapy include headache, eyestrain, nausea, and agitation, but these effects are generally mild and transient, or disappear with reducing the dose of light.

Cognitive behavioral therapy or CBT can also be an effective treatment for SAD, particularly if it’s used in conjunction with light therapy and/ or medication. CBT involves identifying negative thought patterns that contribute to symptoms, and then replacing these thoughts with more positive ones. For many of my patients, I utilize all three modalities for treating SAD, as this has shown the most benefit.

SAD Prevention

… is worth a ton of cure in this case. So what can you do to avoid SAD?

Get out! Get as much natural sunlight as you can. Spend some time outside every day, even when it’s cloudy, as the effects of daylight still help. If it’s too cold out, let the sunshine in… open your blinds, and sit by a sunny window, even at work. If trees block the sunlight, trim them. I have a SAD patient that has her trees pruned way down in early fall so she can get as much light in the house as possible.

Eat a healthy, well-balanced diet. Our diets do more than provide us with energy, they also impact our mental health. A healthy diet rich in fruits and veggies and low in processed garbage can help curb feelings of depression by reducing inflammation in the body, which is a big risk factor for depression. Pass up all those sweet starchy “foods” in favor of lean proteins and veggies. This will help you have more energy, even if you’re craving carbs bigtime. If you recall the blog on Vitamin D, research has found that people with SAD often have low levels, so people with SAD are also often encouraged to increase their intake of Vitamin D through supplementation, in addition to diet and sunlight exposure. 

Stay Active! Exercise is a great way to naturally combat the imbalance of brain neurotransmitters like serotonin, norepinephrine, and dopamine that can contribute to depression. When you exercise, your body produces endorphins, the mood boosting hormones that counteract serotonin and dopamine deficiencies that can bring you down. Exercise for 30 minutes a day, five times a week. That doesn’t have to mean you’re tied to the gym pumping iron all the time… Do something structured, but also pick an activity you enjoy and do it. Gardening, walking, dancing, and even playing with your kids can all be good forms of exercise.

Stay Connected! Social connections can be a great defense against depression. Whether you talk on the phone, video chat, or better yet, meet in person, keep in regular contact with friends and family for a healthy and happy mind. Experiencing depression of any kind isn’t a sign of weakness and shouldn’t be dealt with alone. Social support is very important, so stay involved with your social circle and regular activities. If you’re experiencing symptoms of depression that keep you in, seek help. Ask your physician what treatment options are available.

When should you call your physician? If you feel depressed, fatigued, and cranky at the same time each year, if it seems to be seasonal in nature, you may have a form of SAD. Talk openly with your physician, and follow their recommendations for lifestyle changes and treatment.

The Center for Environmental Therapeutics, CET, is a non-profit organization that provides information and educational materials about SAD, along with free, downloadable self-assessment questionnaires and interpretation guides, to help you determine if you should seek professional advice. All of that can be found on their website, cet.org. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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N-ACETYL CYSTEINE

N-Acetyl Cysteine

Hello, people! Last week, we finished up our discussion on the darker side of OCD and talked about the most difficult subtype to deal with, the pure hell of pure obsession OCD, aka Pure O. As promised, we’re back this week with a new topic, N-acetyl Cysteine, or NAC. NAC is an amino acid used by the body to build antioxidants. Antioxidants are vitamins, minerals, and other nutrients that protect and repair the body’s cells from damage, usually referred to as oxidative stress. Historically, NAC has been used mainly in emergency rooms to treat people who overdose on acetaminophen… I’ve ordered it innumerable times for this very purpose. These days, it can be purchased as a supplement OTC, and new studies have begun investigating its effectiveness as both a stand-alone and adjunctive treatment for depressed mood associated with depression, bipolar disorder, schizophrenia, OCD, and trichotillomania, as well as abuse and dependence on nicotine, Cannabis, and cocaine. And it has shown some promising results. 

Before we get to that, let’s talk about some things NAC does in the body. 

1. NAC is essential for making the body’s most powerful antioxidant, glutathione. Along with two other amino acids- glutamine and glycine- NAC is needed to make and replenish glutathione, which helps neutralize free radicals that can cause oxidative stress- damage to cells and tissues in your body. It’s essential for immune health and for fighting cellular damage, and some researchers believe it may even contribute to longevity. Its antioxidant properties are also important for combatting numerous other ailments caused by oxidative stress, such as heart disease, infertility, and some psychiatric conditions. More on those later.

2. NAC helps detoxify the body to prevent or diminish kidney and liver damage, helping to prevent deleterious side effects of drugs and environmental toxins. This is why doctors regularly give intravenous NAC to people with acetaminophen overdose. It’s usually organ failure that gets you in acetaminophen overdose, and NAC helps to prevent or reduce damage to the kidneys and liver, increasing the chances of survival. NAC also has applications for other liver diseases due to its antioxidant and anti-inflammatory benefits.

3. NAC helps regulate levels of glutamate, the most important neurotransmitter in your brain, and this may improve some psych disorders and addictive behavior. While glutamate is required for normal brain function, excess glutamate paired with glutathione depletion can cause brain damage. This state- excess glutamate with glutathione depletion- is commonly seen in certain psych disorders; specifically, it’s thought to contribute to bipolar disorder, schizophrenia, obsessive-compulsive disorder, and addictive behavior.

For people with bipolar disease and depression, NAC may help decrease symptoms and improve overall ability to function, and research suggests that it may also play a role in treating moderate to severe OCD. In addition, an animal study implied that NAC may minimize the so-called negative effects of schizophrenia, such as social withdrawal, apathy, and reduced attention span. NAC supplements can also help decrease withdrawal symptoms and prevent relapse in cocaine addicts, and preliminary studies show that NAC may decrease marijuana and nicotine use and cravings. Many of these disorders currently have limited or ineffective treatment options, so NAC may be an effective option for individuals with these conditions. More on this in a moment.

4. NAC can help relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in the air passageways. As an antioxidant, NAC helps replenish glutathione levels in your lungs, and reduces inflammation in the bronchial tubes and lung tissue. People with chronic obstructive pulmonary disease (COPD) experience long-term oxidative damage and inflammation of lung tissue, which causes airways to constrict, leading to shortness of breath and coughing. NAC supplements have been used to improve these COPD symptoms, leading to fewer exacerbations and less overall lung decline. In a one-year study, 600 mg of NAC twice a day significantly improved lung function and symptoms in people with stable COPD. But those with chronic bronchitis can also benefit from NAC. Bronchitis is the term for when the mucous membranes in your lungs’ bronchial passageways become inflamed, restricting airflow to the lungs. Not much fun. By thinning the mucus in the bronchial tubes, while also boosting glutathione levels, NAC may help decrease the severity and frequency of wheezing and coughing in respiratory attacks. In addition to relieving COPD and bronchitis, NAC may improve other lung and respiratory tract conditions like cystic fibrosis, asthma, and pulmonary fibrosis, as well as symptoms of garden variety nasal and sinus congestion due to allergies or infections. Ultimately, NAC’s antioxidant and expectorant capacity can improve lung function in everyone by decreasing inflammation and breaking up and clearing out mucus.

5. NAC boosts brain health by regulating glutamate and replenishing glutathione. The neurotransmitter glutamate is involved in a broad range of learning, behavior, and memory actions, while the antioxidant glutathione helps reduce oxidative damage to brain cells associated with aging. Glutamate levels are subject to the three bears law: you need some, but too much isn’t good, as it’s an excitatory neurotransmitter. Because NAC helps regulate glutamate levels and replenish glutathione, it may benefit those with brain and memory ailments. The neurological disorder Alzheimer’s disease slows down a person’s learning and memory capacity, and animal studies suggest that NAC may slow the loss of cognitive ability in people with it. Another brain condition, Parkinson’s disease, is characterized by the deterioration of cells that generate the neurotransmitter dopamine. Oxidative damage to cells, and a decrease in antioxidant ability, contribute to this disease, and NAC supplements appear to improve dopamine function as well as disease symptoms, such as tremor.

6. NAC may improve fertility in both men and women. Approximately 15% of all couples trying to conceive are affected by infertility, and in nearly half of these cases, male infertility is the main contributing factor. Many male infertility issues increase when antioxidant levels are insufficient to combat free radical formation in the male reproductive system, leading to oxidative stress and cell death, culminating in reduced fertility. In some cases, NAC has been shown to combat this, improving male fertility. One condition that contributes to male infertility is varicocele. This is when veins inside the scrotum become enlarged due to free radical damage; surgery is currently the primary treatment. In one study, 35 men with varicocele were given 600 mg of NAC per day for three months post-surgery. The combination of surgery and NAC supplement improved semen integrity and partner pregnancy rate by 22% as compared to the control group with surgery alone. Another study in 468 men with infertility found that supplementing with 600 mg of NAC and 200 mcg of selenium for 26 weeks improved semen quality. Researchers suggested that this combined NAC/ selenium supplement should be considered as a treatment option for male infertility. In addition, NAC may improve fertility in women with polycystic ovary syndrome (PCOS) by inducing or augmenting the ovulation cycle which is altered by the condition. 

7. NAC may stabilize blood sugar by decreasing inflammation in fat cells. High blood sugar and obesity contribute to inflammation in fat tissue. This can lead to damage or destruction of insulin receptors, which puts you at a much higher risk of type 2 diabetes. When insulin receptors are intact and healthy, they properly remove sugar from your blood, keeping levels within normal limits. When the insulin receptors are damaged, blood sugar levels are more difficult to control. Animal studies show that NAC may stabilize blood sugar by decreasing inflammation in fat cells, keeping receptors happy, and thereby improving insulin resistance. That said, human research on NAC is needed to confirm these effects on blood sugar control.

8. NAC may reduce heart disease risk by preventing oxidative damage. Oxidative damage is caused by free radicals, and this type of damage to heart tissue often leads to heart disease, causing strokes, heart attacks, and other serious cardiovascular conditions.

NAC may reduce heart disease risk by reducing oxidative damage to tissues in the heart. It has also been shown to increase nitric oxide production, which helps veins dilate, improving blood flow. This expedites circulation and blood transit back to your heart, and this can lower the risk of heart attack. Interestingly, a test-tube study showed that when combined with green tea, another well recognized antioxidant, NAC appears to reduce damage from oxidized “bad” LDL cholesterol, another bigtime contributor to heart disease.

9. NAC and its ability to boost glutathione levels appears to increase immune function, boosting immune health. Research on certain diseases associated with NAC and glutathione deficiency suggests that immune function might be improved, and potentially even restored, by supplementing with NAC. 

This has been studied mostly in people with human immunodeficiency virus (HIV). In two studies, supplementing with NAC resulted in a significant increase in immune function, with an almost complete restoration of natural killer cells, the main patrol cells. High levels of NAC in the body may also suppress HIV-1 reproduction. A test-tube study indicated that in other immune-compromised situations, such as the flu, NAC may hamper the virus’s ability to replicate; this could potentially reduce the symptoms and lifespan of the associated viral illness. Other test-tube studies have similarly linked NAC to cancer cell death and blocked cancer cell replication. Great news, but more human studies are needed. 

This is a short blog, but that’s a good place to stop for this week. Next week, we’ll talk about how NAC may alleviate the symptoms of multiple psychiatric disorders, as well as reduce addictive behavior; and we’ll talk about some preliminary study findings as well. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Treating Thyroid Disease

Hello, welcome back to the blog, people! We’re continuing our look at thyroid disease. Last week, we took a pretty deep dive into diagnosis, especially lab tests. I mentioned that the TSH (thyroid stimulating hormone) test is considered by most practitioners as the gold standard test, as it regulates the release, and therefore balance, of the thyroid hormones T4 and T3. A T4 (thyroxine) test is commonly ordered with the TSH, as together, they offer a good snapshot of overall function, as well as suggest a cause for an abnormality. A T3 (triiodothyronine) test is usually only ordered to support a diagnosis of hyperthyroidism, as it’s not very helpful in hypothyroidism, since it’s the last hormone to be affected. Thyroid antibody tests can also be run to help identify different types of autoimmune thyroid conditions, such as Hashimoto’s hypothyroidism and Graves’ Disease hyperthyroidism. 

There are different recommendations on how to screen for abnormal thyroid hormone levels, and your health insurance may “help” determine what tests are done and when. In most US states, and probably elsewhere as well, you can order your own thyroid tests on the interwebs, and this may be a more affordable way to have them done. You can find plenty of analyzers there too, so you can enter your results if you’re confused about what they mean. 

A TSH alone can be a sufficient screening test for abnormalities, and it can be followed by a T4 and/or T3 should any be found. 

Generally speaking, an elevated TSH, with or without low T4 or T3, is associated with hypothyroidism, and a low TSH with high T4 and/or high T3 is associated with hyperthyroidism. I should note that in order to receive a diagnosis of hyperthyroidism, lab tests must demonstrate that one or both thyroid hormones are elevated, so there must be a high T3 and/ or T4. 

In addition to lab tests, diagnosis of thyroid disease generally involves a review of signs and symptoms, physical examination of the neck to feel for masses or nodules, while noting the condition of hair, nails, and eyes, with imaging and ultrasound tests to further evaluate findings if needed. A primary care physician can make the diagnosis and formulate an effective treatment plan, but a physician who specializes in the thyroid, an endocrinologist, is very helpful, and may be required in some cases. 

Once diagnosed, treatment is aimed at correcting the imbalance and returning thyroid hormone levels to normal, in order to alleviate the symptoms the person is experiencing. This can be done in a variety of ways, depending on the cause, and whether the imbalance has resulted in a hyper- or hypothyroid condition. 

Hyperthyroidism Treatment

Several treatments for hyperthyroidism exist. The best approach depends on your age, personal preference, physical condition, and the underlying cause and severity of your disorder. 

Radioactive Iodine 

Taken by mouth, radioactive iodine is given to a large percentage of adults with hyperthyroidism, as it effectively destroys the cells of your thyroid, preventing it from making high levels of thyroid hormones. It also causes the gland to shrink, which may make it a good choice in cases of goiter. Symptoms usually subside within several months, and excess radioactive iodine disappears from the body in weeks to months after treatment is discontinued. This treatment may cause thyroid activity to slow enough to actually be considered underactive, meaning that it may result in secondary hypothyroidism; so you may eventually need to take medication every day to replace thyroxine. Common side effects include dry mouth, dry eyes, sore throat, and changes in taste. Precautions may need to be taken for a short time after treatment to limit or prevent radiation exposure to others.

Antithyroid Medications 

Medications like methimazole (aka Tapazole) and propylthiouracil gradually reduce symptoms of hyperthyroidism by preventing your thyroid gland from producing excess amounts of hormones. Symptoms usually begin to improve within several weeks to months, but treatment typically continues for at least one year, and often longer. For some people, this clears up the problem permanently, but other people may experience a relapse. These drugs can be pretty gnarly. If you’re allergic, you can develop skin rashes, hives, fever, or joint pain. They can make you more susceptible to infection, and can cause serious liver damage, sometimes even leading to death. Because propylthiouracil has caused far more cases of liver damage, it should really only be used when you can’t tolerate methimazole.

Beta Blockers

Beta blockers such as propranolol and Inderal are usually used to treat high blood pressure. They don’t affect thyroid levels, but they can ease some symptoms, such as tremor, sweating, rapid heart rate, and palpitations. For this reason, your physician may prescribe them to alleviate symptoms until your thyroid levels are closer to normal. For patients with temporary forms of hyperthyroidism, ie thyroiditis, inflammation of the thyroid gland, beta blockers may be the only treatment required. Once the thyroiditis resolves, they can be discontinued. These medications are generally well tolerated, but aren’t recommended for people who have asthma, and side effects may include fatigue and sexual dysfunction.

Surgical Thyroidectomy

In a thyroidectomy, most of your thyroid gland is permanently removed. If you’re pregnant, can’t tolerate antithyroid drugs, and don’t want or can’t have radioactive iodine therapy, you may be a candidate for thyroid surgery- although this is usually an option of last resort, as it is permanent. Risks of this surgery include damage to your vocal cords and parathyroid glands, those four tiny glands situated on the back of your thyroid gland that help control the level of calcium in your blood. Postoperatively, you’ll need lifelong treatment with synthetic hormone to supply your body with normal amounts of thyroid hormone. If your parathyroid glands are also removed, you’ll need medication to keep your calcium levels normal as well.

Hypothyroidism Treatment

If you have hypothyroidism, low levels of thyroid hormones, the main treatment option is to replace the hormone. Daily use of the synthetic form of thyroid hormone thyroxine, called levothyroxine, ie Levo-T and Synthroid, restores adequate hormone levels, and reverses the signs and symptoms of hypothyroidism. Determining proper dosage may take time, but you should start to feel better soon after you start treatment. To determine the proper initial dosage, your physician may check your TSH level after six to eight weeks. With a proper diet, the medication will gradually lower cholesterol levels elevated by the disease, and may also reverse any weight gain. Treatment with levothyroxine will be lifelong, but because the dosage you need may change, your physician should check your TSH levels periodically as needed. If you have coronary artery disease or severe hypothyroidism, your physician may start treatment with a smaller dose and increase it gradually. This progressive replacement allows your heart to adjust to the increase in metabolism.

Levothyroxine

Having excessive amounts of this hormone can cause side effects, such as increased appetite, insomnia, heart palpitations, and tremor or shakiness. It causes virtually no side effects when used in the appropriate dose and is relatively inexpensive, but try to stick to the same brand, as there can be some variances in dosing. Don’t skip doses or stop taking it because you’re feeling better; if you do, your symptoms will return. Food hinders absorption of levothyroxine, so it should be taken on an empty stomach at the same time every day. Ideally, you take it in the morning and wait one hour before eating or taking other medications. If you take it at bedtime, wait four hours after your last meal or snack. Certain medications, supplements, and even some foods may seriously affect your ability to absorb it. Tell your physician if you eat large amounts of soy products or a high fiber diet, or you take other medications, such as iron supplements or multivitamins that contain iron, aluminum hydroxide, which is commonly found in antacids, and calcium supplements. 

Thyroid Disease: Prognosis 

Generally speaking, even if you have a thyroid disease, you can usually live a normal life without many restrictions, as long as you have appropriate treatment. The overall prognosis varies depending on your diagnosis. With hypothyroidism, your levels and overall symptoms may improve with medication, but it’s a condition you’ll be treating for the rest of your life. You’ll take medication daily, and your physician will likely monitor you to make adjustments over time if needed. But this is not necessarily the case with hyperthyroidism. If antithyroid medications work, then your thyroid hormone levels will most likely return to normal without any further issues. That said, once you have any form of thyroid disease, your physician may need to monitor your condition with occasional blood tests to make sure your thyroid hormones are at optimal levels.

Thyroid Disease: Complications

As with any disease, early diagnosis and treatment of symptoms improves the long term outlook. The complications of undiagnosed, uncontrolled, and/or inadequately controlled thyroid disease can lead to a number of health problems that can affect your long term quality of life, and in some cases, can even be life threatening. 

Even if you are under treatment or have received treatment for thyroid disease, if you start to notice signs of any of the following issues, see your physician to check your thyroid levels, or seek emergency treatment when appropriate.

Hyperthyroidism: Complications

Heart problems

Some of the most serious complications of hyperthyroidism involve the heart. These include a rapid heart rate, a heart rhythm disorder called atrial fibrillation, which increases your risk of stroke, and congestive heart failure, a condition in which your heart can’t circulate enough blood to meet your body’s needs.

Brittle bones

Excess thyroid hormone interferes with your body’s ability to incorporate calcium into your bones, so untreated hyperthyroidism can lead to weak, brittle bones and osteoporosis. 

Eye problems

People with Graves’ Disease can develop eye problems, including bulging, red or swollen eyes, sensitivity to light, and blurry or double vision. When left untreated, severe eye problems can lead to vision loss.

Red, swollen skin

People with Graves’ disease can develop Graves’ dermopathy. This affects the skin, causing redness and swelling, often on the shins and feet.

Thyroid Storm

Thyroid storm, aka thyrotoxic crisis, is a life threatening hypermetabolic state induced by excessive release of thyroid hormones, resulting in a sudden worsening of symptoms. An individual’s heart rate, blood pressure, and body temperature can reach dangerously high levels, causing delirium. This requires urgent medical attention, as without prompt, aggressive treatment, thyroid storm is often fatal.

Hypothyroidism Complications

Goiter

Constant stimulation of your thyroid to release more hormones may cause the gland to become larger, a condition called goiter. Although it’s generally not painful, a large goiter can affect your appearance and may interfere with swallowing or breathing.

Heart problems

Hypothyroidism puts you at greater risk for heart disease and heart failure, and can raise your levels of LDL, low-density lipoprotein or “bad” cholesterol.

Mental health issues

Hypothyroidism can cause depression that becomes more severe over time. You may notice decreased interest in activities you used to enjoy. It can also cause slowed mental functioning, and memory or concentration lapses.

Peripheral neuropathy

Long term uncontrolled hypothyroidism can cause damage to your peripheral nerves that carry information from your brain and spinal cord to the rest of your body. Peripheral neuropathy causes pain, numbness, and tingling in affected areas, most often the legs and feet.

Joint pain

Uncontrolled hypothyroidism can cause you to have aches and pains in your joints and muscles, as well as tendonitis.

Infertility 

Low levels of thyroid hormone can interfere with ovulation, which greatly impairs fertility. In addition, some autoimmune causes of hypothyroidism can also impair fertility.

Myxedema

Myxedema is a life threatening condition that can result from undiagnosed hypothyroidism. The term “myxedema” can be used to mean severely advanced hypothyroidism. But it’s also used to describe skin changes in someone with severely advanced hypothyroidism. The classic skin changes include swelling of your face, including lips, eyelids, and tongue, and/ or the swelling and thickening of skin anywhere on your body, but especially on your lower legs. Signs and symptoms include intense cold intolerance and drowsiness, followed by profound lethargy and unconsciousness. In people with severe hypothyroidism, trauma, infection, exposure to the cold, and certain medications can trigger a life threatening condition called myxedema coma, which causes a loss of consciousness and hypothermia, extremely low body temperature. If you have signs or symptoms of myxedema, you need immediate emergency medical treatment.

That’s all for this week, folks. Next week will be devoted to thyroid disease and mental health issues. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Thyroid 2

Welcome back, people! Last week I introduced a new topic- the thyroid- and hopefully you remember that it’s a butterfly shaped endocrine gland that wraps around the windpipe in the forward aspect of the middle throat. It plays a major role in regulating the body’s metabolism, growth, and development by production and release of thyroid hormones, called T3 and T4, into the bloodstream. When it doesn’t work properly, it can have a huge impact on multiple systems throughout the entire body. We also talked about how all of the functions of the endocrine glands are interlinked, and that the thyroid works especially closely with the pituitary gland located in the brain. In order to make the right amount of T3 and T4, the thyroid gland needs the help of the pituitary, to “tell” it- through its own hormone called thyroid stimulating hormone, TSH- when to produce and release more or less hormones into the bloodstream. And we left off with an introduction on the two basic states that result from thyroid disease or dysfunction: hyperthyroidism, when you make too much thyroid hormone, and hypothyroidism, when you make too little. 

This week, we’ll get deeper into thyroid disease and talk about the various symptoms of thyroid imbalance. But I should remind that the endocrine system and the thyroid are very dynamic and can change temporarily in response to normal natural processes other than disease. If and when the body needs more energy in certain situations- if it’s during a growth spurt, time in a very cold environment, or during pregnancy for example- the thyroid gland may temporarily produce more hormones. That increase in T3 and T4 increases the basal metabolic rate, so all of the cells in the body work harder. That causes a faster pulse and stronger heartbeat, a rise in body temperature, and activation of the nervous system and then other systems needed to accomplish whatever the situation may call for. Because the cells are working harder, they need more energy, so energy stored in the liver and body is broken down and utilized faster, and food is used up more quickly as well. When the situation has ended- say the growth phase is over, or mom has the baby- the demand is lessened, the thyroid will produce less T3 and T4, the basal metabolic rate will slow, and energy requirements will reduce to previous levels.  Ultimately, the thyroid and entire endocrine system will return to their previous functional levels, ready to respond next time. 

Thyroid Disease by the Numbers

Thyroid disorders are very common, and very commonly run in families, and affect more than 12 percent of Americans, or an estimated 20 million people. They can occur in anyone- men, women, teens, children, or infants- at any time, meaning they can be present at birth or may develop later. Hypothyroidism is much more common than hyperthyroidism, though the latter is easier to diagnose. About one in 20 people has some kind of thyroid disorder, which may be temporary or permanent, and up to 60 percent of people with thyroid disease are unaware of their condition. While they can occur in anyone, thyroid disease affects 5 to 8 times more women than men, so one woman in 8 will develop some type of thyroid disease at some point in her life. 

When the thyroid is properly balanced, it produces and replaces just the right amount of hormones to keep your metabolism working at the proper rate. When the thyroid makes too much hormone, as in hyperthyroidism, that’s sometimes also called overactive thyroid. And the flip-side of this, when your thyroid makes too little hormone, in hypothyroidism, that’s sometimes called underactive thyroid. These conditions can be standalone or caused by other diseases and conditions that impact the way the thyroid gland works, including genetic and inherited disease.

Hyperthyroidism Causes and Conditions

There are several conditions that can cause overactive thyroid, or hyperthyroidism. The most common cause is an inherited autoimmune disorder that affects 1% of the general population, called Graves’ disease. This causes immune cells attack the thyroid gland, which responds by enlarging and secreting excess thyroid hormone. Immune cells may also go on to attack the muscles and connective tissue of the eyes, causing them to bulge, a state known as exophthalmos, and this eye condition is usually then referred to as thyroid eye disease or Graves’ eye disease. 

Thyroid nodules, which are small, round, usually benign masses present within the thyroid gland tissue, can also cause thyroid overactivity. There may be a single autonomously functioning nodule or a condition called toxic multinodular goiter, where there are multiple nodules within the thyroid which produce too much hormone. As the nodules increase in size and/ or number, it can cause a large, externally obvious swelling called a goiter in the neck. 

Having excess iodine in your body can also stimulate the thyroid to make more hormone than it needs, since iodine is the mineral used to make T3 and T4. Excessive iodine can be found in some cough syrups and other medications like amiodarone, a heart medication. 

An inflammatory process of the thyroid called thyroiditis may also cause hyperthyroidism. The person may or may not be aware of it, as it can be painful or not felt at all. In early stages of some types of thyroiditis, the thyroid may release or leak hormones that were stored there, and this hyperthyroid state can last for a few weeks or months. If it continues, the inflammation will eventually impair the production of thyroid hormone, and this will result in hypothyroidism.

Hypothyroidism Causes and Conditions

Some of the conditions associated with underactive thyroid, or hypothyroidism, include other types of thyroiditis, where the swelling of the thyroid gland impairs hormone production. Hashimoto’s thyroiditis is the most common cause of hypothyroidism. This is an inherited autoimmune disorder whereby the body’s own immune cells attack the thyroid, causing inflammation and damage to the tissue that inhibits or halts production of hormone. 

Postpartum thyroiditis is a usually temporary condition that occurs in 5% to 9% of women after childbirth, whereby the thyroid is temporarily inflamed and underactive as a result. 

An iodine deficiency is a common cause of underactive thyroid, or hypothyroidism, outside of the US. When the body is deficient in iodine, it simply doesn’t have enough to produce a sufficient amount of T3 and T4 hormone. Even today, iodine deficiency affects several million people around the world. 

Sometimes, the thyroid gland simply doesn’t work correctly from birth, and for obvious reasons, this can have severe implications. This condition affects about 1 in 4,000 newborns. If left untreated, the child can have both physical and mental issues in the future. Because of the potential consequences, all newborns are given a screening blood test in the hospital to check their thyroid function.

Thyroid Disease Risk Factors

The causes of thyroid dysfunction are largely unknown, but there are several factors that can place you at a higher risk of developing a thyroid disease. The first and most obvious is if you have a family history of thyroid disease, as it is commonly familial. Also, if you have had treatment for a past thyroid condition, such as a partial thyroidectomy, or cancer treatment such as radiation, you are more likely to have thyroid issues later. If you are Caucasian or Asian your risk is slightly higher. If you have prematurely graying hair, your risk for developing thyroid disease is higher. In addition, if you have certain other medical conditions like Down Syndrome, Turner syndrome, and bipolar disorder, it increases your risk. If you have autoimmune or related disorders, you are at especially increased risk: lupus, rheumatoid arthritis, pernicious anemia, celiac disease, type 1 diabetes, primary adrenal insufficiency, Sjögren’s syndrome, Addison’s disease, or vitiligo. If you take a medication that’s high in iodine, such as amiodarone, this excess iodine increases the risk for developing hyperthyroidism. And if you are over 60 years old, your risk increases. This is especially true in women, as their risk is already so much greater than men. 

Thyroid Disease Symptoms 

Because there are such a variety of symptoms associated with thyroid disease, many can be very similar to the signs and symptoms of other medical conditions, as well as general stages of life changes. This can make it difficult to know if your symptoms are related to a thyroid issue or something else entirely. 

Symptoms of Hyperthyroidism

Because the thyroid is overactive, it speeds cellular activity and generally causes the body processes to move faster. This causes the body to use energy too quickly, so people with hyperthyroidism usually have increased appetite, and may feel weak unless they consume more food to keep up with energy demands; and even if they do, they may still lose weight unintentionally. In addition, it may cause them to have trouble sleeping and sleep disturbances, confounding the fatigue they feel. Hyperthyroidism also tends to cause increased heart rate, stronger heart beat, tremors, heat sensitivity, itching, and increased sweating. It often results in feelings of anxiety, irritability, and nervousness, and causes racing thoughts, and difficulty focusing on one task. It may cause an enlarged thyroid gland to the point of goiter, where it is visible externally, as well as problems with vision or eye irritation, including protruding or bulging eyes called exophthalmos. Women with hyperthyroidism will typically have light and irregular menstrual periods. And rarely, men with hyperthyroidism can see some breast development. Be aware that if someone experiences symptoms like irregular heart rate, dizziness, shortness of breath, and/ or loss of consciousness, that requires immediate medical attention. Hyperthyroidism can cause atrial fibrillation, which is a dangerous arrhythmia that can lead to strokes as well as congestive heart failure. This is an extreme medical emergency. 

Symptoms of Hypothyroidism

When the thyroid is underactive, body processes move more slowly, and this causes people to feel extremely tired and fatigued. Because cellular processes move more slowly, less energy is required, so less stored energy is utilized. Because the metabolism is sluggish, less food is required and more is stored, so having hypothyroidism makes someone much more likely to gain weight. Mentally, people commonly experience depression, mental slowness, and forgetfulness. Physically, they commonly experience constipation, puffy face, muscle cramps, dry skin, brittle nails, dry and coarse hair, hair loss, hoarse voice, and intolerance to cold temperatures. They may experience fatigue and shortness of breath with exercise. They are likely to have joint pain, stiffness, and swelling, and even carpal tunnel syndrome. Women with hypothyroidism are likely to have frequent and heavy menstrual periods.

Kids and teens with hypothyroidism can have all of the signs above, but may also have delays in sexual maturity or puberty, growth delays and shorter stature, slow mental development, and slower development of permanent teeth. 

Infants and babies with hypothyroidism may have no symptoms at all. But if symptoms do present, they can include cold hands and feet, constipation, extreme sleepiness, weak or hoarse cry, little or no growth, poor feeding habits, puffy face, stomach bloating, swollen tongue, and umbilical hernia. In addition, you may notice low muscle tone, sometimes called floppy baby, as well as persistent jaundice, which is yellowing of the skin and whites of the eyes. These symptoms require immediate medical attention. 

I think we’ll pick up there next week, with complications and prognosis.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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When Home Becomes Work:Challenges of Working Remotely

When Home Becomes Work: Challenges of Working Remotely

Captain Obvious says that while coronavirus is responsible for thrusting us (with IT people kicking and screaming) into working remotely as a necessity, it was already a fairly common practice BR (before ‘rona). In fact, a statistic I read indicated an overall global trend toward remote work long BR, with a global increase of 159% between 2005 and 2017. As far as US stats on remote work go, 17% of US employees report that they worked from home five days or more per week BR, but that jumped to 44% DR (during ‘rona). As for the future, polls indicate that totally AR (after ‘rona) a minimum of 16% of American people who had previously worked outside the home BR will switch to working remotely from home at least two days per week AR. In addition, more than one-third of US firms that had employees switch to remote work DR believe that it will remain more common at their company AR. Globally, polls now predict that 25% to 30% of the earth’s workforce will work remotely multiple days per week by the end of 2021. In short, the genie is out of the bottle, and it’s not likely to go back in.

Many employers and business leaders think that going remote is as simple as sending an employee away from the office with a laptop and a to-do list, but unfortunately, it’s not that simple. In truth, there are real life consequences associated with working remotely. It may sound like a dream come true, but from where I’m sitting, it’s become more like a nightmare. A lot of people have gone back to their outside offices now, but many are still working from home. This is either because they- or their employers- are still too reluctant to make the switch and return, or have found it beneficial enough that it behooves them to continue remote operations. Regardless of why you may find yourself doing so, working remotely does present its own set of challenges, not the least of which is that companies were essentially forced into it overnight, without benefit of true preparedness and system checks. 

But in any event, if you are still working remotely at this point, you may find yourself continuing to do so indefinitely. I find that most of my patients enjoy lounging in their pajamas all day as they work from home, never leaving their house because it’s such an effort to get dressed; though they fail to understand why they’re so anxious, irritable, and depressed. The good news is that there is a way to do this work from home deal effectivelyand happily, and even excel at it, while still having a personal life and functioning appropriately. The bad news is there are some not-so-nice ramifications and consequences associated with the routine, and a lot of people are starting to recognize this after far too long being “trapped” at home. Spoiler alert: most people actually are not. The bottom line is that your whole world doesn’t have to change just because you’ve eliminated a commute. Out of necessity DR, it did change for a time, but at this point, it’s time to get out and reclaim some normalcy. Some of the issues that come up with working remotely are more rooted in the personal realm, and deal with basic self care and psychological health, while others center more on professional matters. But don’t kid yourself, there’s a lot of overlap and cross reactivity betwixt and between them. So this blog marks the beginning of a series dedicated to identifying the issues surrounding working remotely, and discussion on how to address them appropriately, with some tips and tricks and coping methods thrown in for good measure.  

Today’s blog will deal with some problems that I’ve noted in video calls and appointments with my patients. I sometimes call them “duh!!” issues, because a lot of you are going to be like, “Duh, Dr. Agresti, we all know that!” Well, what some people know and what they do are two very different things. If you’re depressed, and you haven’t brushed your hair or gotten dressed for a week straight, then you might hear me say, “Duh, go brush your hair and get dressed, you’ll feel better.” I suppose you could also call them “helll-ooo!!” issues, as in, “Helll-ooo… you really need to take a shower!!” That’s a real thing, people. Not all of the things I’ll discuss are quite that extreme, but my list of remote work must-do’s includes some personal care requirements that must become- and remain- second nature to you; they must be part of a regular routine, regardless of the fact that you may be all alone, with nobody even there to see (or smell) you. So that’s where we’re starting; with just some very basic, very simple recommendations for a better life and more success in a remote work situation. Most of these you probably already know, but you may not be doing them. Allow this to be your kick in the can if that’s the case.

-Sleep in your bed, but then get out of said bed when you get up in the morning. Don’t just wake up and roll over to reach for your laptop to start your day. I cannot tell you how many patients I talk to while they’re working in bed; they’re literally in bed 24/7. Get out of bed!

-Create a dedicated office, preferably with a door you can close to keep things quiet and help you avoid distractions. If you don’t have a spare room, then at least create a dedicated work space. Even a corner of a room will do if that’s all you can spare. You really just need room for a table or desk large enough to hold a computer and whatever supplies you need, and a chair. Try to make it as comfortable- and functional- as possible.

-Make a schedule and stick to it. And be sure to keep an accurate account of the hours you work. I’ll be discussing supervisory micromanaging in the next blog, but if you keep a regular schedule and good records of your hours, you’ll have all the info you need if you are questioned by a micromanaging supervisor.

-Now that you aren’t commuting to and from the office, you’re going to be physically moving a lot less. So you must make time each day for exercise. So many of my patients that have switched to working remotely have gained a fair bit of weight and almost all of them have lost serious muscle tone. When you’re working from home, it’s easy to get comfortable and complacent, and turn into a flabby flaccid couch potato. Do something to move your muscles every day. 

-Eat three square meals each day, and no more 24/7 snack attacks. Just because your refrigerator is mere steps away doesn’t mean you should make the trip every 30 minutes. A small midmorning, midafternoon, or late night snack is okay, but that’s it. Note my word choice: or not and. Three decent meals and one small snack each day is acceptable- just try not to go too crazy- and try to make it reasonably healthy, maybe a yogurt, cottage cheese, or piece of fruit. Like, a box of girl scout cookies is not a snack, people. 

-Because you aren’t commuting to and from the office, you’re also rarely going to be required to go outside. So you must make a special point to go outside every day, even if it’s just for 15 minutes after lunch. Human bodies require vitamin D, and nothing’s a better source than sunlight. Try taking a walk around your neighborhood after you have lunch, just something where you’re exposed to the sun. 

-A lot of my patients are complaining of decreased intimacy and a lack of sexual energy since they started working remotely. So my next suggestion is to do whatever you can to be close to your partner. Emotional and physical intimacy are important, so have sex, but maybe don’t combine this suggestion with the one above it, unless you have an excellent privacy fence. 

-When work is over, stop working. It can be tempting to work more hours when you’re at home. This may sound counterintuitive, but it’s true. To avoid this trap, work the same schedule and number of hours each day at home as you would if you were commuting to an office. Don’t try to cram jam in four16 hour days days a week in order to take a 3 day weekend, unless it’s an unavoidable situation, and/ or you receive permission or clearance from a supervisor if applicable.

-Make sure to get adequate sleep. Go to bed at a reasonable time, get up at a reasonable time, and try to stick to a sleep schedule. And remember to avoid blue light exposure for at least two to three hours before you go to bed, otherwise you’ll have a hard time falling asleep. 

-Keep your regular grooming routine- you’ll feel better about yourself. If you didn’t get the hint, shower every day. Brush your hair, and your teeth. Shave and put on makeup if you’re about that life. Work is not a pajama party, so get dressed in appropriate clothing. You don’t have to wear a suit or heels, but make an effort to be presentable, even if there’s no one to present yourself to. 

This isn’t rocket science, people. Basically, you should follow the same routine you always have, and do everything you would do if you were going to an actual outside office or workplace: go to bed at a reasonable and regular time on work nights, get up at a reasonable and regular time each morning, and resist the urge to hit snooze 97 times. Shower, shave, get dressed in decent clothing, and eat breakfast. Then go to work in your in-house office space, just as you would if you were going to commute to an office. Avoid distractions and get your work done. Take a one hour lunch break maximum, and make sure to actually eat something reasonable, but avoid eating at your desk. Think about taking lunch outside for some fresh air, vitamin D, and a change of scenery, and you can kill multiple birds with a single stone. After lunch time is not nap time- and it hasn’t been since kindergarten- so after lunch, go back to work until it’s time to stop at the end of the day. Make sure to put in a full day’s work, while also being careful not to overwork. Behave as if you owned the company and were paying employee salaries. Supervisors will be less likely to micromanage you to death if you give them no reason to mistrust you or doubt your motivations.  

No Nearly Naked Zooming

Captain Obvious says that videoconferencing has become a big part of our lives DR, and will continue to be long AR. Here’s a fun fact for you, Zoom saw phenomenal growth in 2020, and ended the third quarter of 2020 with an astounding report of 367% year-over-year revenue growth. If you had stock in Zoom Video Communications BR, which I did not, that’s a very fun fact for you. And get this… Zoom hosted an average of 300 million meeting participants per day throughout 2020. That’s 300 million people that don’t need to see you in your underwear, people. Same goes for gnarly, used-to-be-white, ripped t-shirts with yellow pit stains. Get it? If you didn’t, here’s the simple concept: put on a shirt. One with at least two buttons at the top. 

Drinks, not Zinks

Even if you dress appropriately for video conferencing calls, there’s really no replacement for real deal interaction, because shockingly, humans are hardwired for human connection. Even Captain Obvious wouldn’t bother with that one. It’s just not possible to simply erase our evolutionary zeitgeist and replace millions of years of in-the-flesh interactions with technologically mediated virtual communications. While Zoom and its brethren have helped us in our attempts to recreate a certain degree of face-to-face experiences, that’s really as much thanks to the power of human imagination as it is to technology; and nothing stifles human creativity and imagination like isolation and loneliness. As a society, we spend a lot of time creating tech to replicate real-life experiences, but it’s a cheap substitute. In most situations, we’re better off spending a larger portion of that time experiencing real-life personal experiences. If you live alone and work from home, you could literally spend days without any human contact. You should make an effort to socialize, but remember to do so responsibly and wear your mask, people. Call a friend and suggest you meet for dinner, coffee, or lunch, or go on a date night. Drinks are hands down better than Zinks, so arrange to meet a friend IRL. 

Loneliness or isolation is one of the most commonly reported issues that remote workers and digital nomads face, along with anxiety, stress, and depression. Next week, in part deux of this remote work blog, I’ll talk more about those, as well as some professional issues that can come into play when working remotely, and I’ll make some suggestions on how to deal with them. Then in part three, I’ll talk about some specific anxiety and stress busting techniques you can incorporate into your routine during the day, as you need them, and they won’t complicate or derail your work schedule, or negatively affect your productivity. In fact, they’ll do just the opposite.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too.

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well, people!

MGA

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Postpartum Depression,Signs,Symptoms,and Treatment

Postpartum Depression: o

Signs, Symptoms, New Treatment?

Last week, we talked about sex and orgasms, so it seems only fitting that this week, I talk about the potential ‘homework’ that may come after the sex and orgasms: pregnancy… and the postpartum depression that may accompany it. 

It is one of life’s greatest joys, and for me personally, the proudest moment of my entire life: the birth of a child. But no matter how much you love that baby or how you’ve looked forward to its arrival, having a baby is stressful on both parents for many reasons. However, there are specific reasons that make it more physically and emotionally taxing on mom. Captain Obvious says that there are many physical, emotional, and chemical changes in a woman’s body that allow them to (help) create, carry, and birth these little miracles. And add to that the onset of new responsibilities, sleep deprivation, and lack of time for any personal care, it’s not a big shock that lots of new moms get overwhelmed and feel like they’re on an emotional rollercoaster from hell. In fact, the mild depression and mood swings that are so common in new mothers have earned them a name, “the baby blues.” But how do you know if what mom is feeling goes beyond the blues? What should you look for, and when should you seek help? 

The majority of women experience at least some symptoms of the baby blues immediately after childbirth. Why? It’s all down to female hormones: specifically, progesterone and estrogen, the big kahunas in the female hormone universe.

Progesterone’s role in pregnancy is so vital that it’s referred to as the “pregnancy hormone.” Actually, progesterone comes into play long before pregnancy, as it is one of the hormones secreted by the ovaries that governs ovulation and menstruation in post-pubescent women. Then upon conception, it gets the uterus ready to accept, implant, and maintain a fertilized egg, and it also prevents the uterine muscle contractions that would otherwise cause a woman’s body to reject it. During fetal gestation, it helps create an environment that nurtures the developing baby. It makes it sound like progesterone is in there painting, hanging curtains, and fluffing pillows, but its role goes way beyond that. The placenta, which is the structure inside the uterus that provides oxygen and nutrients to a developing baby, will itself begin to produce progesterone after about 8 to 10 weeks of pregnancy. At this point, the placenta increases progesterone production to a much higher rate than the ovaries ever thought about making. Those high levels of progesterone throughout the pregnancy cause the mom’s body to stop producing more eggs, as well as prepare her breasts to produce milk. 

Also produced by the ovaries when not pregnant, and then later by the placenta during pregnancy, estrogen helps the uterus grow, maintains the uterine lining where the budding baby is nestled, steps up blood circulation, and activates and regulates the production of other key hormones. In early pregnancy, it also helps mom develop her milk-making machinery. And baby benefits too, as estrogen triggers the development of those teeny tiny organs and regulates bone density in those cute little developing arms that wave and legs that kick. 

The increased levels of progesterone and estrogen during pregnancy actually make mom feel good and feel bonded to baby, even though she may be crying her eyes out for virtually no reason (sorry ladies) in the beginning. Levels of both hormones continue to increase as the pregnancy advances, and mom’s body actually gets used to these high levels. Then when the baby is born, there’s no more placenta, so mom’s progesterone and estrogen levels drop suddenly and precipitously, in a matter of hours. So mom goes essentially cold turkey from high hormone levels to comparatively no hormone levels. Sudden hormonal change + stress + isolation + sleep deprivation + fatigue = tearful + overwhelmed + emotionally fragile mom. Generally, these feelings can start within just the first day or so after delivery, peak at around one week, and taper off by the end of the second, third, or maybe up to the fourth week postpartum; that’s if it’s the baby blues. 

These baby blues are perfectly normal, but if symptoms are extreme, don’t go away after a month, or get worse, mom may be suffering from postpartum depression and likely needs help.

Postpartum Signs & Symptoms

Though they share some symptoms, postpartum depression is a much more serious problem than the baby blues, and should never be ignored. Shared symptoms of the two include mood swings, crying jags, sadness, insomnia, and irritability.      

Postpartum depression is the most common complication of childbearing, and it occurs in 10% to 20% of all moms after delivery. It is different from the baby blues in that the symptoms are more severe and longer lasting. It is an issue that can’t be blown off or underestimated, because it begins at a critical time, when mom is caring for a helpless infant and needs to be bonding with them. 

Symptoms of postpartum depression can include suicidal thoughts, an inability to care for the newborn child, and in extreme cases, even thoughts of harming the baby. Postpartum can be extremely debilitating, and certain signs can put the lives of mom and/ or baby in jeopardy.

Beyond the Blues

Common Red Flags for Postpartum:

-Mom withdraws from partner

-Mom’s unable to bond well with baby

-Mom’s anxiety gets out of control, preventing ability to sleep and/ or eat

-Mom feels guilty, worthless, useless, overwhelmed

-Mom seems preoccupied with death or wishing she were no longer alive

There’s no single reason why some new moms develop postpartum depression and others don’t, but a number of interrelated causes and risk factors are generally at play.

Postpartum Causes/ Triggers

Hormonal changes after childbirth cause fatigue and depression:

 -Progesterone/ estrogen levels drop

 -Thyroid levels can drop

 -Changes in blood pressure, immune system functioning, metabolism

Numerous physical/ emotional changes after delivery: 

 -Physical delivery pain

 -Difficulty losing baby weight

 -Insecurity, especially in physical/ sexual attractiveness

Significant stress of caring for a newborn:

 -Mom is sleep deprived

 -Mom is overwhelmed/ anxious about her abilities to properly care for baby

 -Mom has difficulty adjusting

All of the above factors are especially true in first time moms, as they must also get used to an entirely new identity at the same time. 

Postpartum Risk Factors

Several factors can predispose a mom to suffer from postpartum depression:

  -History of postpartum depression

A prior episode can increase the chances of a repeat episode by 30% to 50%.

  -History of non-pregnancy related depression and/ or family history of mood disturbances

  -Social stressors, including lack of emotional support, abusive relationship, and/ or financial uncertainty 

  -Significantly increased risk in women who discontinue medications abruptly for purposes of pregnancy.

Postpartum Psychosis

Postpartum psychosis is an even more rare, and more extremely serious disorder that can also develop after childbirth. Characterized by a loss of contact with reality, postpartum psychosis poses an extremely high risk for suicide or infanticide, and hospitalization is nearly always required to keep both mom and baby safe. Postpartum psychosis develops suddenly, usually within the first two weeks after delivery, and sometimes within a matter of 48 hours. 

Postpartum Psychosis Symptoms

Postpartum psychosis is considered a medical emergency requiring immediate medical attention.

  -Hallucinations: seeing things and/ or hearing voices that aren’t real 

  -Delusions: paranoid, irrational beliefs

  -Extreme agitation and anxiety

  -Suicidal thoughts or actions

  -Confusion and disorientation

  -Rapid mood swings

  -Bizarre behavior

  -Inability or refusal to eat or sleep

  -Thoughts of harming or killing baby

There is a screening tool that can be used to detect postpartum depression, called the Edinburgh Postnatal Depression Scale. I will put the questions and explain the scoring of this scale at the conclusion of this blog. It can be helpful if mom or partner isn’t quite sure if symptoms are the baby blues or true postpartum depression. 

Coping with Postpartum Depression

Four Tips for Moms:

1) Create a secure attachment with baby.

The emotional bonding process between mom and child, known as attachment, is the most important task of infancy. The success of this wordless relationship enables a child to feel secure enough to develop fully, and affects how he or she will interact, communicate, and form relationships throughout their entire lives.

A secure attachment is formed when moms respond warmly and consistently to baby’s physical and emotional needs. When baby cries, quickly soothe them. If baby laughs or smiles, respond in kind. In essence, the goal is for mom and baby to be in synch, and to be able to recognize and respond to each other’s emotional signals.

Postpartum depression can interrupt this bonding. Depressed moms can be loving and attentive at times, but at other times may react negatively or not respond at all. Moms with postpartum depression are generally inconsistent in their care, and tend to interact less with their babies; they are also less likely to breastfeed, play with, and read to them. Postpartum is sinister in this way, as learning to bond with baby not only benefits the child, it also benefits mom by releasing endorphins that make mom feel happier and more confident. By its very presence, postpartum makes the bonding process difficult, and therefore mom is less likely to produce those endorphins that would make her feel better. It’s a vicious cycle.

If mom didn’t experience a secure attachment as an infant, she may not know how to create a secure attachment as a mom. However, this can be learned, as human brains are definitively primed for this kind of nonverbal emotional connection that creates so much pleasure for both mom and baby.

2) Lean on others for help and support.

Human beings are social creatures. Positive social contact relieves stress faster and more efficiently than any other means of stress reduction. Historically, and from an evolutionary perspective, new moms have typically received help from those around them after childbirth. In today’s world, new moms often find themselves alone, exhausted, and lonely for supportive adult contact. 

Ideas to better connect with others:

 -Make relationships a priority. When feeling depressed and vulnerable, it’s more important than ever to stay connected to family and friends, even if you’d rather be alone. Isolating will only make the situation feel even bleaker, so make adult relationships a priority. Let loved ones know your needs and how you wish to be supported.

 -Don’t hide feelings. In addition to the practical help that friends and family can provide, they can also serve as a much-needed emotional outlet. Share experiences- good, bad, and ugly- with at least one other person, and preferably face to face. It doesn’t matter who mom talks to, so long as that person is willing to listen without judgment and offer reassurance and support.

 -Be a joiner. Even if mom has supportive friends, she may want to consider seeking out other women who are dealing with the same transition into motherhood. It’s very reassuring to hear other mothers share the same worries, insecurities, and feelings. Good places to meet other new moms include support groups for new parents or organizations such as ‘Mommy and Me.’ Pediatricians can also be excellent neighborhood resources.

3) Take care of yourself. One of the best things moms can do to relieve or avoid postpartum depression is to take care of themselves. The more moms care for their mental and physical well-being, the better they’ll feel. 

Simple lifestyle changes can go a long way toward helping moms feel more like themselves again.

 -Skip the housework. Make yourself and baby the priority, and give yourself the permission to concentrate on just that. Remember that being a 24/7 mom is far more work than holding down a traditional full-time job.

 -Ease back into exercise. Studies show that exercise may be just as effective as medication when it comes to treating depression, so the sooner moms get back up and moving, the better. No need to overdo it: a 30-minute walk each day will work wonders. Stretching exercises, like those found in yoga, have shown to be especially effective.

 -Practice mindfulness meditation. Research supports the effectiveness of mindfulness for making moms feel calmer and more energized. It can also help moms become more aware of what they feel and need.  

 -Don’t skimp on sleep. A full eight hours may seem like an unattainable luxury when dealing with a newborn, but poor sleep makes depression worse. Moms must do whatever they can to get plenty of rest- from enlisting the help of the partner or family members, to catching naps at every opportunity.

 -Set aside quality time for yourself to relax and take a break from mom duties. Find small ways to pamper yourself, like taking a bubble bath, savoring a hot cup of tea, lighting scented candles, or getting a massage at a day spa, or even calling a masseuse to come to you.

 -Make meals a priority. Nutrition often suffers during depression. What mom eats has an impact on her mood, and also the quality of breast milk the baby requires, so always make the best effort to establish and maintain healthy eating habits, for yourself and baby.

 -Get out in the sunshine. Sunlight lifts the mood, so try to get at least 10 to 15 minutes of sun each day.

4) Make time for your relationship with your partner. More than half of all divorces take place after the birth of a child. For many men and women, the relationship with their partner is their primary source of emotional expression and social connection. The demands and needs of a new baby can get in the way and fracture this relationship, unless couples put time, energy, and thought into preserving their bond.

 -Don’t scapegoat. The stress from nights of no sleep and new or expanded responsibilities can leave parents feeling overwhelmed and exhausted. It’s all too easy to play the blame game and turn frustrations onto your partner. Instead of finger pointing, remember that you’re in this together. If you tackle parenting challenges as a team, you’ll find that you’ll become an even stronger unit.

 -Keep the lines of communication open. Many things change following the birth of a baby, including roles and expectations. For many couples, a key source of strain is the post-baby division of household and childcare responsibilities. It’s important to talk about these issues, rather than letting them fester. Don’t assume your partner has a crystal ball or knows how you feel or what you need, because you’re bound to feel perpetually disappointed and frustrated if you do. 

 -Carve out couple time. It’s essential to make time for just the two of you when you can reconnect. But don’t put pressure on yourself to be romantic or adventurous, unless you’ve discussed it and found you’re both game. And you don’t need to go out on a date to enjoy each other’s company. Just spending even 15 or 20 minutes together, undistracted and focused on each other, can make a big difference in how close you feel to each other.  

Treatment for Postpartum Depression

If, despite self-help and the support of family, mom is still struggling with postpartum depression, it’s best to seek professional treatment.

 -Individual therapy/ marriage counseling A good therapist can help moms deal better with the adjustments of motherhood. If moms or partners are experiencing marital difficulties or are feeling unsupported at home, marriage counseling can also be very beneficial.

 -Antidepressants. In postpartum cases where mom’s ability to function adequately for herself or baby is compromised, antidepressants may be an option, though they are more effective when accompanied with psychotherapy. Obviously, medication must be closely monitored by a physician.

 -Hormone therapy: Estrogen replacement therapy can sometimes be helpful in combating postpartum depression, and is often used in combination with an antidepressant. There are risks that go along with hormone therapy, so moms must be sure to talk to their doctor about what may be best, and safest, for them.

Helping New Moms with Postpartum

If your loved one is a mom experiencing postpartum depression, the best thing you can do is to offer support, give her a break from her childcare duties, provide a listening ear, and always be patient and understanding. But, be sure to take care of yourself too. Dealing with the needs of a new baby is hard for the partner as well as mom. And if your significant other is depressed, that means you are dealing with two major stressors.

Tips for Partners:

 -Encourage mom to talk about her feelings. Listen without judgement and without making demands. Instead of trying to ‘just fix’ things, simply be there for mom to lean on.

 -Offer help around the house. Chip in with the housework and childcare responsibilities, and don’t wait for mom to ask… trust me on this one!

 -Make sure mom takes time for herself. Rest and relaxation are even more important after a new edition. Encourage her to take breaks, hire a babysitter, or schedule some date nights.

 -Be patient if she’s not ready for sex. Depression affects sex drive, so it may be a while before mom’s in the mood. Offer her physical affection, but don’t push it if she’s not up for anything beyond that.

 -Getting exercise can make a big dent in depression, but it’s hard for moms to get motivated when they’re feeling low. So do something simple, like going going for a walk with mom. Better yet, make walks a daily ritual for just the two of you, or for the whole family.  

There is a fairly new breakthrough drug called Zulresso (brexanolone). Approved in 2019, Zulresso is a neuropathic drug, and first in its class. So what is it? Basically, it’s an aqueous (water-based) solution of progesterone products. They have taken the component product of progesterone and put it into solution; it is then administered to a new mom with postpartum depression. And then a miracle happens… seriously! This lifts postpartum depression like a kid does candy. It is a scientific breakthrough; never before have we had a drug that treats postpartum depression faster than any drug for any type of depression, ever. That’s the good news, but guess what comes next… the bad. While we know it works, very well and very quickly, there are some major disadvantages of this drug. The first one is that it can only be administered by IV infusion. So that means that you have to place an IV map into mom’s vein and drip the drug in with IV fluid. That brings me to the next big disadvantage: it can only be administered in a hospital setting. Why is that? Well, studies show that during administration, which takes place over about 60 hours, two and a half days, some moms can become very dizzy and faint, can lose consciousness, and can even stop breathing. For all of these reasons, moms must be medically monitored with an oximeter and telemetry for two and a half days, during which time they must be checked on every two hours. And they cannot be in charge of baby during this hospital stay, because they may be in and out of consciousness and/ or have severe respiratory issues. While that’s no bueno, the last disadvantage is muy loco, people. Are you ready? The drug costs $34,000. Yep. But wait, it gets better, which in this case, actually means worse. That little $34K is just for the drug! The hospitalization and monitoring costs more… a lot more. And to add insult to injury, you have to shell out the cash to pay for a sitter to watch baby, as mom could potentially be very busy losing consciousness and going into respiratory distress.  

Needless to say, Zulresso is not used very much, even though it is an amazing breakthrough product, essentially curing the notoriously difficult-to-treat postpartum depression in a mere 60 hours. There are some other anti-depressants that work pretty well. Effexor (venlafaxine, desvenlafaxine) and Wellbutrin (bupropion) with antipsychotics like Abilify help to speed up the treatment process generally show some progress in about a week. 

So while I’m very impressed with Zulresso as a novel, first-in-class drug, you can see my practical issues with it. Although, I suppose that everything is relative: if my wife were suffering from serious postpartum depression, to the point that she was suicidal, or the baby’s life was in danger, and it was refractory, meaning all other treatment options had been tried and failed, I would find a way to get the Zulresso treatment; I’d make it happen, by contacting the manufacturer for patient support options. Or maybe by selling a kidney. Whatever it took.

Edinburgh Postnatal Depression Scale

This 10-question self-rating scale has proven to be an efficient way of identifying patients at risk for “perinatal” or postpartum depression. While this test was specifically designed to be administered by a medical professional, to a woman who is pregnant or has just had a baby, it can be used as an effective at-home guide to determine if you or someone you care about has postpartum depression. Just make sure to follow all of your score’s corresponding action(s).

For each of the 10 questions, please check mark the answer that comes closest to how you have felt in the past 7 days. Scoring is explained after the questions.1) I have been able to laugh and see the funny side of things.

____  As much as I always could

____  Not quite so much now

____  Definitely not so much now

____  Not at all2) I have looked forward with enjoyment to things.

____  As much as I ever did

____  Rather less than I used to

____  Definitely less than I used to

____  Hardly at all3) I have blamed myself unnecessarily when things went wrong.

____  Yes, most of the time

____  Yes, some of the time

____  Not very often

____  No, never4) I have been anxious or worried for no good reason.

____  No not at all

____  Hardly ever

____  Yes, sometimes

____  Yes, very often5) I have felt scared or panicky for no very good reason.

____  Yes, quite a lot

____  Yes, sometimes

____  No, not much

____  No, not at all6) Things have been getting on top of me.

____  Yes, most of the time I haven’t been able to cope at all

____  Yes, sometimes I haven’t been coping as well as usual

____  No, most of the time I have coped quite well

____  No, I have been coping as well as ever7) I have been so unhappy that I have had difficulty sleeping.

____  Yes, most of the time

____  Yes, sometimes

____  Not very often

____  No, not at all8) I have felt sad or miserable.

____  Yes, most of the time

____  Yes, sometimes

____  Not very often

____  No, not at all9) I have been so unhappy that I have been crying.

____  Yes, most of the time

____  Yes, quite often

____  Only occasionally

____  No, never10) The thought of harming myself has occurred to me.

____  Yes, quite often

____  Sometimes

____  Hardly ever

____  Never

SCORING VALUES AND GUIDE

Grade each of your checked answers with the specifically stated score, then add the scores together. Take that sum and apply to the interpretation/ action scale and follow the stated suggestion.1) I have been able to laugh and see the funny side of things

0 As much as I always could

1 Not quite so much now 

2 Definitely not so much now 

3 Not at all 2) I have looked forward with enjoyment to things

0 As much as I ever did 

1 Rather less than I used to 

2 Definitely less than I used to 

3 Hardly at all 3) I have blamed myself unnecessarily when things went wrong

3 Yes, most of the time 

2 Yes, some of the time 

1 Not very often 

0 No, never 4) I have been anxious or worried for no good reason

0 No, not at all 

1 Hardly ever 

2 Yes, sometimes 

3 Yes, very often 5) I have felt scared or panicky for no very good reason

3 Yes, quite a lot 

2 Yes, sometimes 

1 No, not much 

0 No, not at all 6) Things have been getting on top of me

3 Yes, most of the time I haven’t been able to cope 

2 Yes, sometimes I haven’t been coping as well as usual 

1 No, most of the time I have coped quite well 

0 No, I have been coping as well as ever 7) I have been so unhappy that I have had difficulty sleeping

3 Yes, most of the time 

2 Yes, sometimes 

1 Not very often 

0 No, not at all8) I have felt sad or miserable

3 Yes, most of the time 

2 Yes, quite often 

1 Not very often 

0 No, not at all 9) I have been so unhappy that I have been crying

3 Yes, most of the time 

2 Yes, quite often 

1 Only occasionally 

0 No, never 10) The thought of harming myself has occurred to me 

3 Yes, quite often 

2 Sometimes 

1 Hardly ever 

0 Never 

EPDS Score Interpretation/ Action

Score of 8 or less: depression not likely, but continue to seek support.

Score of 9 to 11: depression is possible, continue seeking support and re-screen in 2 to 4 weeks. Seriously consider appointment with primary care provider or established mental health professional.

Score of 12 to 13: fairly high possibility 

of depression. Continue to monitor and seek support. Make appointment to see primary care provider or established mental health professional.

Score of 14 and higher: this is a positive screen for probable postpartum depression. Diagnostic assessment is required to determine appropriate treatment. See mental health specialist or primary care provider for referral to same. 

Note: if there is any positive score (a rating of 1, 2, or 3) on question 10 (suicidality risk) definite immediate discussion and possible emergency management is required. Refer to primary care provider, mental health specialist, or emergency resource for further assessment and intervention as appropriate. The urgency of the referral will depend on several factors, including: whether suicidal ideation is accompanied by a plan, whether there has been a history of suicide attempt(s), whether symptoms of a psychotic disorder are present, and/ or if there is concern about harm to the baby.

So that’s all the news on postpartum depression. If you liked this, please share with friends and family. Look for new blogs here every Monday, and check out my book, Tales from the Couch, for more education and patient stories, available on Amazon.com. See my YouTube channel for new lectures- I post them all the time. And I’d appreciate it if you hit that subscribe button, people! Thanks everybody, be well. 

MGA

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Caplyta(lumateperone):NEW Treatment Schizoprenia and Bipolar Disorder

Caplyta (lumateperone): New for Schizophrenia…and More? 

Before we talk about Caplyta (lumateperone), I want to announce that I take no remuneration of any kind from any pharmaceutical or healthcare company. I am providing the following information solely for educational purposes. 

Caplyta (lumateperone) has recently been approved by the FDA for the treatment of schizophrenia in adults, and it is expected to be available by prescription by late April 2020. This new drug seems to have a lot of promise, especially for patients who don’t do well on other drugs, or cannot tolerate the side effects of other drugs. This may sound strange, but scientists don’t actually know what the drug’s mechanism of action is, meaning that they don’t know exactly how it works. They have some educated guesses, and I’ll talk about those later. But believe it or not, it’s not that unusual for a drug’s mechanism of action to be partially or poorly understood…it happens frequently. 

They’ll figure it all out in time, but what matters right now is that they do know the drug’s efficacy, which is it’s effectiveness, in treating schizophrenia in adults. I think that this will be a vitally important drug, especially for patients who don’t respond to other drugs and/ or cannot tolerate the side effects of other drugs. And I’ll go into that later as well. But first, I want to go over some general information about schizophrenia. 

Schizophrenia is a very serious, disabling, and complex mental illness impacting approximately 2.4 million adults in the United States. It is most disabling because there is no for schizophrenia, but there are treatments, and it must be treated and monitored for a lifetime. Like many mental illnesses, it not only severely impacts patients, it also majorly impacts patients’ families. The clinical presentation of schizophrenia is very diverse. Acute episodes can be characterized by psychotic symptoms, such as hallucinations and delusions, and these can be so debilitating that these patients require hospitalization.  The disease is chronic and lifelong, and is often accompanied by depression. There can also be a deterioration of social functioning and cognitive abilities. Patients with schizophrenia often discontinue treatment, stop taking their meds, because of major side effects, which can include weight gain, lactation, gynecomastia, and movement disorders. More on these side effects later. For now, suffice it to say that an effective and well tolerated treatment can be game-changing for people living with schizophrenia. 

I thought it might be fun to have a little quiz, just to see what you do or don’t know about schizophrenia, all in an effort to educate and de-stigmatize. If you don’t know them now, you will when you finish. I’ll give you the answers and explanations later. No cheating, people!

1) Schizophrenia is the most disabling of all mental illnesses.
A)   True
B)   False

2) There are 50 million people with schizophrenia in America.
A)   True
B)   False

3) Schizophrenia is often called “split personality disorder.”
A)   True
B)   False

4) Psychosis means that a person…
A)   Has suffered memory loss
B)   Suffers from chronic insomnia
C)   Can’t distinguish imagination from reality
D)   Has a virus that affects the brain

5) The most common hallucination in schizophrenia is…
A)   Visualizing shadows
B)   Smelling smoke
C)   Feeling cold
D)   Hearing voices

6) The first symptoms of schizophrenia can include:
A)   Irrational statements
B)   Excessive crying
C)   Outbursts of anger
D)   All of the above

7) Who has more symptoms at the onset of schizophrenia?
A)   Men
B)   Women
C)   Children
D)   Elderly

8) Many schizophrenics believe that ____ actually eases their symptoms.
A)   Silence
B)   Eating
C)   Screaming
D)   Smoking

Let’s see how many you got right and I’ll explain the correct answers:

1) True/ False: Schizophrenia is the most disabling mental illness.

Correct answer: True
Explanation: Schizophrenia is an incurable, severe, and lifelong disease that is the most disabling of all mental illnesses. Treatments for schizophrenia focus on controlling the symptoms.

2) True/ False: There are 50 million people with schizophrenia in the US. Correct answer: False
Explanation: About 1% of people in the U.S. have schizophrenia, which is just over 2 million people.

3) True/ False: Schizophrenia is often called “split personality disorder”

Correct answer: True
Explanation: Schizophrenia is sometimes confused with other mental illnesses and may be mistakenly referred to as “split personality disorder.” While “schizo” does mean “split,” patients with schizophrenia do not have split personalities. What they do have is psychosis, which is a distorted perception of reality.

4) Psychosis means that a person…
Correct answer: C) Cannot distinguish imagination from reality
Explanation: Experts don’t know what causes schizophrenia. In some people, brain chemistry and brain structure are not normal. Family history may be a factor in some cases. Schizophrenia is never caused by anything a person did, or by any personal weakness, bad choices, or a person’s upbringing.

5) The most common hallucination in schizophrenia is…
Correct answer: D) Hearing voices Explanation: Auditory hallucinations, or “hearing voices” is the most common hallucination in schizophrenia. Voices can seem to be coming from within one’s own mind or externally, as if a person is talking to them. These voices may tell the person with schizophrenia to do things, or they may comment on their behavior. The voices may even talk with one another. It is common for people with schizophrenia to hear voices for a long time before anyone else notices the problem. Other kinds of hallucinations experienced by people with schizophrenia include seeing people or objects that are not there, feeling as if they are being touched by invisible fingers, or smelling odors that no one else can smell.

6) The first symptoms of schizophrenia can include…

Correct answer: All of the above
Explanation: There are numerous early symptoms of schizophrenia. In some cases, family and friends may notice a shift in behavior or sense something is “off” about the person who is schizophrenic. Early signs and symptoms of schizophrenia may include irrational statements, excessive crying or inability to cry, outbursts of anger, social withdrawal, and extreme reactions.

7) Who has more symptoms at the onset of schizophrenia?
Correct answer: Men
Explanation: Schizophrenia affects men and women at equal rates, and symptoms may start suddenly or occur gradually. Men tend to develop schizophrenia slightly earlier, between 16 and 25 years old, while women develop symptoms several years later, in the late 20s to 30s. Schizophrenia symptoms tend to be more severe in men, while women with schizophrenia may have more depressive symptoms and paranoia.

8) Many schizophrenics believe that _______ eases their symptoms.

Correct answer: Smoking

Explanation: Many schizophrenics believe smoking cigarettes eases their symptoms, and up to three times more schizophrenics smoke than in the general population. It is thought that smoking may be a kind of self-medication. The nicotine seems to help with some of the cognitive and sensory symptoms experienced by schizophrenics, and it can ease some of the side effects of medications commonly prescribed. However, it’s important to note that smoking still causes cancer, lung disease, and heart disease.

Now that you probably know a little more about schizophrenia than you did 15 minutes ago, let’s talk about this new drug treatment, Caplyta, generic name lumateperone. Obviously, since it hasn’t been released yet, I haven’t had the opportunity to prescribe it to my patients, but I have been following its development and have read about it extensively. Based on that, I think this drug will be well tolerated, and a valuable drug in the armamentarium for the treatment of schizophrenia. In addition, I think it will be valuable in treating bipolar disorder and could also benefit patients with Alzheimer’s and/ or dementia with agitation. 

Let’s talk turkey. Why is it good to have a new option for treating schizophrenia? Here’s where those side effects I mentioned before come in. The current drugs used to treat schizophrenia are chock full of side effects, some of which are stigmatizing and intolerable to patients. So a new drug, a better tolerated one, is a big deal. Older drugs like Olanzapine cause weight gain, metabolic syndromes, insulin resistant diabetes, increased cholesterol, and increased triglycerides. Other drugs like Risperdal are known to cause elevations in prolactin, which causes lactation, milk production in women, and breast enlargement in men, all of which are very unsetteling to patients, to say the least. Another major factor in older antipsychotic drugs like Aripiprazole, Brexpiprazole, and Haloperidol involve what are termed extrapyramidal symptoms, dystonia and tardive dyskinesia. All those fancy words just mean involuntary muscle contractions that can cause repetitive movements like tics, ie grimacing and eye blinking, muscle spasms, and all sorts of uncontrollable muscular movements that people obviously find very uncomfortable and cosmetically disfiguring. These extrapyramidal symptoms are problematic in terms of compliance, meaning that patients don’t take the drugs, they are not not compliant, because while they are already stigmatized by their illness, they are further stigmatized by these side effects of breast enlargement and lactation, and the disfiguring extrapyramidal muscular movements and motor tics the drugs cause.  

Caplyta, lumateperone is apparently different. And this is where I’ll explain a little about the mechanism of action, how I believe it works. We know from previous accepted research that the undesirable extrapyramidal motor symptoms like tics and spasms associated with antipsychotic medications are the result of a high affinity for a receptor called the D2 receptor. Having a high affinity for a receptor basically means that a drug likes to bind there, and in doing so, it blocks that receptor. That would be a mechanism: the binding of a drug to a receptor and its subsequent blocking of that receptor. So, the older antipsychotic drugs have a high affinity to, they like to bind to, D2 receptors, blocking them. But this new drug, lumateperone, has low affinity for these receptors, the D2 receptors, so they are left unbound and unblocked. As a result, those stigmatizing involuntary muscle movements and tics are absent. Before I go further, here’s a quick and simplified synopsis on the basics of clinical trials: when drugs are tested in clinical trials, they begin with randomly giving the drug being tested to a certain number of subjects, while giving a placebo (an inactive substance, sometimes called a “sugar” pill) to the other people in the trial. The study is randomized, meaning the people in the study don’t know if they’re being given the drug being tested or the placebo. In most studies, even the people running it and those dispensing the study “medications” don’t know which is which or who’s getting what. That way there is no bias, people just honestly report their symptoms. At the end of the study, when the results are tabulated, the drug company hopes to be able to clearly see the difference between the study drug and the placebo in symptoms and efficacy and whatever other traits they want to look at. Then they use those numbers to report the findings of the testing drug versus the placebo. So for this new schizophrenia drug Caplyta (lumateperone), the reported trial numbers shake out to subjects taking the study drug lumateperone reported having extrapyramidal symptoms/ side effects only 0.4% more than reported by subjects taking the placebo, and that is evidently due to its very low affinity for the D2 receptor, so those D2 receptors are mostly open. D2 receptors blocked= extrapyramidal symptoms, involuntary motor tics. D2 receptors open= no extrapyramidal symptoms. Make sense? This is all very simplified, and there are more receptors and pathways in the body than you would ever want to know…and they all do different things depending on if they are open or blocked, presynaptic or postsynaptic, agonistic or antagonistic, upstream or downstream, activated or inactivated, partially or completely and everything in between. It’s complex stuff…I just want you to have an idea of why drugs cause or don’t cause different side effects, because that’s the name of the game when it comes to efficacy and tolerance of drugs, and that’s what determines patient compliance in taking drugs, and that’s what determines how much their mental illness affects them, and that’s what determines their place in this world. Phew! Get it? It’s a big deal. 

So that’s an example of how lumateperone avoids those extrapyramidal side effects. Now you may ask how it works in controlling the hallmark syptoms of schizophrenia: delusions,  hallucinations, disorganized speech, and disorganized behavior. That mainly has to do with its effect on another receptor, the Serotonin 5-HT2A receptor. Lumataperone has a high affinity for this receptor; it binds and blocks it. We know that a drug called Pimavanserin does the same thing, and Pimavanserin is used to treat Parkinson’s disease psychosis, so we can correctly infer that blocking and binding the Serotonin 5-HT2A receptor in lumataperone makes it effective as an antipsychotic drug, controlling delusions, hallucinations, disorganized speech, and disorganized behavior associated with schizophrenia. Along those same lines, lumataperone also affects dopamine receptors in a specific pathway called the mesolimbic pathway. That happens to be the pathway that blocks hallucinations, delusions, disorganized speech, and disorganized behavior. This is all good stuff. 

What else? Lumataperone has decreased muscarinic receptor activity. When activated, muscarinic receptors cause dry mouth, pupil dilation, blurred vision, constipation, and flushing. Because that activity is decreased, those effects are reduced or absent, so no dry mouth, dilated pupils, blurry vision, constipation, or flushing. It also does not cause or lead to any metabolic syndromes, elevation in cholesterol, significant weight gain, and insulin resistance, another big plus.

Lumataperone has decreased effects on the alpha adrenergic receptor, which causes orthostatic hypotension, meaning a drop in blood pressure upon standing that often leads to a fainting episode. Because of lumataperone’s decreased effects on this receptor, this removes this risk.  

Lumataperone also has minimal effects on the endocrine system, and therefore it does not affect prolactin like the older drug Risperdal does, so female patients do not experience lactation and milk production, and men do not get breast enlargement. This is majorly important in drug compliance. Patients are more likely to take the medication if they don’t have to leak milk from existing breasts or grow breasts where they don’t belong.

Lumataperone metabolics and dosing is convenient becuase it does not require titration, meaning patients don’t have to build up to the full dose by taking smaller doses first. Patients start at 42 milligrams, peak plasma level is in 3-4 hours, and it has a half-life of about 13 hours. This is nice, because that means it can be taken just once a day, because the half-life is long enough.  

While lumateperone seems to be far superior to the older schizophrenia drugs in nearly every way, there is no such thing as a perfect drug…yet. It does have some possible side effects, including nausea, dizziness, fatigue, and vomiting. But these appear to be fairly insignificant, not affecting quality of life. It has also been shown to cause drowsiness; I think it must have something called a histaminic effect. This is really its most major side effect, with anywhere between 10% and 24% of people to experience drowsiness. But we can turn that frown upside down…we can use this drowsiness to our advantage by dosing it when it’s time to go nite-nite. And since it’s dosed once a day, it works out great. 

The last important footprint of Lumateperone has to do with it’s metabolism by the Cytochrome P450 3A4 system (I told you this stuff can get a little complicated). Abbreviated CYP3A4, this is a very important enzyme in the body, mainly found in the liver and the intestine. It oxidizes small foreign organic molecules, such as toxins or drugs, so that they can be removed from the body. Patients taking lumateperone should not take any drug which blocks CYP3A4 enzyme concomitantly. This is really the only contraindication at this time.  

So, when we put all of this stuff together, what do we have?

– Caplyta (lumateperone) for schizophrenia

– Dosing: 42 milligrams, once per day, with food, at night if causing drowsiness.

– Works mainly by affecting dopamine, serotonin, and glutamine.

– Binds and blocks Serotonin 5-HT2A receptors, eliminating negative symptoms of schizophrenia: delusions, hallucinations, disorganized thoughts, and disorganized behaviors.

– Low affinity for D2 receptors leaves them unbound and unblocked, eliminating the stigmatizing extrapyramidal symptoms of involuntary muscle movements and tics, dystonia and tardive dyskinesia.

– Minimal endocrine effects, preventing female patients from experiencing lactation, and male patients from breast enlargement, and relieving patients of these stigmatizing side effects.

– Decreased muscarinic receptor activity, eliminating dry mouth, dilated pupils, blurry vision, constipation, and flushing.  

– Elimination of metabolic syndromes: no elevated cholesterol, no significant weight gain, no insulin resistance, no diabetes.

– Decreased effects on the alpha adrenergic receptor, eliminating fainting episodes due to orthostatic hypotension. 

– Possible side effects: nausea, dizziness, fatigue, and vomiting. But these appear to be fairly insignificant, not affecting quality of life. 

– The only significant side effect is drowsiness, 10% to 24%. This can be turned around and used to help insomnia when dosed at night. 

– Utilizes CYP3A4: lumateperone is contraindicated in patients taking 

drug(s) which block CYP3A4 enzyme.

Essentially, that adds up to getting all the good stuff for treating schizophrenia without getting any of the bad stuff, and all it’s going to cost you is maybe some minor nausea, vomiting, and/ or fatigue, all of which will likely go away after two weeks. You might have some drowsiness, but I see that as a plus, as lots of patients complain of insomnia, and it can be taken only at night due to its once a day dosing. 

Schizophrenia for now…what about later? Lumateperone is a weak serotonin transporter pump inhibitor just like SSRI (Selective Serotonin Reuptake Inhibitor) antidepressants are. To simplify the mechanism: serotonin is a happy neurotransmitter regulated by a pump. It’s pumped out, but can be removed by being “uptaken,” if you will, which leads to low serotonin levels commonly found in people with depression. So an SSRI drug, an antidepressant, is given. The SSRI is employed, and the RI, which stands for reuptake inhibitor, stops (inhibits) the reuptake of the serotonin, leaving higher levels of free happy serotonin circulating and thereby increasing mood. It has other antidepressant effects which I think will make it very effective for treating depression and bipolar disorder. And because it has a low affinity for D2 receptors, leaving them open, I think it could control agitation in people with Alzheimer’s and/ or dementia without causing any of those horrible side effects of current antipsychotic medications. When physicians prescribe Caplyta for anything other than schizophrenia, or prescribe any drug for any diagnosis it was not labelled for (ie originally developed for), it is called off-label prescribing, and it is a common practice in psychiatry, as the regulation of receptors and pathways overlap in many different mental illnesses. 

In summary, Caplyta (lumateperone) shows a great deal of promise, and I’m looking forward to being able to offer it to my schizophrenia patients that are having compliance issues due to the stigmatizing side effects of current antipsychotic therapeutics. This could be a game changer and a life changer for them. And then once I really see how it’s tolerated, I’ll give great consideration to using it off-label for bipolar depression and to combat agitation in my Alzheimer’s and dementia patients. It could be a much needed breakthrough for them as well. 

If you liked this blog, please comment and pass it along. Even posting simple comments and sharing information help reduce the stigma of mental illness…and it’s certainly high time for that. If you’re interested in reading more about the subjects discussed here, and a lot more, check out my book, Tales from the Couch, available in my office or on Amazon.com. 

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How To Determine If Someone Is Suicidal

A Coronavirus PSA

Before we get to this next blog on suicide, I must say something related to Coronavirus transmission, because I’m tired of yelling it at my television when I see people doing it or talking about it, how “safe” it is. What is it? It’s “elbow love,” bumping elbows with someone to say hello, goodbye, good job, whassup, whatever. Think about this, people: during this viral outbreak, what have we been asking people to do when they sneeze or cough? Ideally, to do so in a tissue, but that’s not realistic, it rarely happens, so we ask them to sneeze or cough into their bent arm, at the elbow. Get the picture? The droplets they expell during that sneeze or cough are deposited everywhere surrounding that area, including the part you bump, so if your “bumpee” has Coronavirus, even if they have no symptoms, you, the “bumper” get those bijillions of virions on your elbow, and you can take them home with you. Then maybe your spouse or partner welcomes you home by putting their hands on your arms to give you a kiss… and now half a bijillion virions may be on one of their hands, just waiting to be deposited everywhere. Bottom line: for as long as this virus is around, use your words, not your body, to say whassup. So pass this knowledge on…not the virus. 

Suicide Assessment

Suicide is always a very difficult topic for every family, and in thirty years as a psychiatrist, it’s never gotten much easier to broach this subject. What motivated me to write this blog is a recent conversation I had with the father of one of my young patients, a fourteen-year-old named Collin, who in fact had just made what I believed was a half-hearted suicide attempt; the proverbial ‘cry for help.’ Understand that half-hearted does not mean it’s totally safe to blow it off, but we’ll get to an explanation about that later. His father, Lawrence, who prefers to be called Law, was a single parent, a widower after metastatic melanoma devastated the family of three about eighteen months before. Shortly after the mother, Sharon, passed away, Law brought Collin to my office. It was clear from the first appointment that Collin was depressed, and had been for some time. Psychotherapy was difficult with him, and it took about five appointments to establish more than a tenuous relationship and for him to begin to open up to me. I had tried him on a couple of medications, but they never seemed to do the job. I strongly suspected that it was due to a compliance issue. Actually, I’m certain that it was. He just didn’t take them regularly or as directed. That always mystifies me, patients who are miserable, anxious and depressed, but they take their meds haphazardly, at best; meds that could turn their worlds around…not because they’re inconvenient, and not because of side effects, just because. So, the tenuous connection made for less than optimal psychotherapy sessions, and that, combined with the absence of appropriate meds, put Collin on a path that led here, my office, 22 hours after his attempt. I was a little shocked by his attempt, but very shocked at how effectively, how deeply, he was able to hide the monumental amount of pain that he had obviously been feeling. His father Law looked exhausted, shellshocked, and was having such difficulty talking about it for a number of reasons, but he told me that one of the main reasons was shame. He was ashamed that Collin was so ill, and even ashamed that he was ashamed of it. He was ashamed that he could do nothing to help him, and ashamed that he had possibly caused or contributed to his son’s illness. I told him repeatedly and in several different ways that I understood, that his feelings weren’t unusual among parents of children like Collin, that he absolutely was helping him, and that while mental illness does have a familial component, he was not responsible in any way for his sons illness or attempt. Unfortunately, I don’t think he really heard a word I said. In my experience, suicidal ideation, thoughts of suicide, suicide attempts, and the actual act of suicide affects everyone it touches in a way that no other psychiatric illness does. But in this situation, I think Law was thinking about what his life would be like if Collin tried again and succeeded. It would be very sad, alone, and lonely.

Facts and Figures

Suicide is the 10^th leading cause of death in the United States, claiming 47,173 lives in 2019. Montana and Alaska have the highest suicide rates, which is interesting because both of those states have very high gun ownership rates. Believe it or not, New Jersey is the lowest. I have no clue why that would be the case. There were 1.4 million suicide attempts last year in the US. Men are 3.54 times more likely than women to commit suicide.  Of all the suicides in the United States last year, 69.67% were white men; they don’t seem to be doing so well. The most common way to commit suicide is by firearm, at about 50%; suffocation is 27.7%, poisoning is 13.9%, and other would be the rest, things like jumping from a tall building or bridge, laying on train tracks or jumping in front of a subway car or a bus. Among US citizens, depression affects 20 to 25% of the population, so at any given point, 20% of the population is a bit more prone to suicide, as obvi people must first be depressed (chronically or acutely) before attempting suicide. There are 24 suicide attempts for every 1 completed suicide. The most disturbing statistic is that suicide rates are up 30% in the past 16 years, with a marked increase in adolescent suicides, and suicide is now the second leading cause of death in people ages 10 to 24.

You would think the US would have the highest suicide rates in the world, but in fact, Russia, China, and Japan are all higher. 

Suicide Risk Factors

What are some factors that may put someone at higher risk of suicide?

–  Family history of completed suicide in first-degree relatives

–  Adverse childhood experiences, ie parental loss, emotional/ physical/ sexual abuse

–  Negative life situations, ie loss of a business, financial issues, job loss

–  Psychosocial stressors, ie death of loved one, separation, divorce, or breakup of relationship, isolation

–  Acute and chronic health issues, illness and/ or incapacity, ie stroke, paralysis, mental illness, diagnoses of conditions like HIV or cancer, chronic pain syndromes

But, understand there’s no rule that someone must have one or more of these factors in order to be suicidal.

Mental Illness and Suicidality

In order to make a thorough suicide risk assessment, mental illness must be considered. There seem to be 6 mental health diagnoses that people who successfully complete suicide have in common: 

–  Depression

–  Bipolar disorder

–  Mania

–  Schizoaffective disorder 

–  Schizophrenia

–  Post-traumatic stress disorder

–  Substance abuse 

Suicidal Ideation

Suicidal ideation refers to the thoughts that a person may have about suicide, or committing suicide. Suicidal ideation must be assessed when it is expressed, as it plays an important role in developing a complete suicide risk assessment. Assessing suicidal ideation includes:

– Determining the extent of the person’s preoccupation with thoughts of suicide, ie continuous? Intermittent? If so, how often?

– Specific plans; if they exist or not; if yes, how detailed or thought out?

– Person’s reason(s) or motivation(s) to attempt suicide

Assessment of Suicide Risk
Assessing suicide risk includes the full examination/ assessment of:

–  The degree of planning 

–  The potential or perceived lethality of the specific suicide method being considered, ie gun versus overdose versus hanging

–  Whether the person has access to the means to carry out the suicide plan, ie a gun, the pills, rope

–  Access to the place to commit

–  Note: presence, timing, content

–  Person’s reason(s) to commit suicide; motivated only by wish to die; highly varied; ie overwhelming emotions, deep philosophical belief

–  Person’s motivation(s) to commit suicide; not motivated only by wish to die; motivated to end suffering, ie from physical pain, terminal illness

–  Person’s motivation(s) to live, not commit suicide

What is a Suicide Plan?

A suicide plan may be written or kept in someone’s head; it generally includes the following elements: 

–  Timing of the suicide event

–  Access to the method and setting of suicide event

–  Actions taken toward carrying out the plan, ie obtaining gun, poison, rope; seeking/ choosing/ inspecting a setting; rehearsing the plan 

The more detailed and specific the suicide plan, the greater the level of risk. The presence of a suicide note suggests more premeditation and typically greater suicidal intent, so an assessment would definitely include an exploration of the timing and content of any suicide note, as well as a thorough discussion of its meaning with its author.

I spent years teaching suicide assessment to other physicians, medical students, nurses, therapists, you name it. It all seems super complicated when you look at all the above factors written out, but as I always taught, it becomes clearer when you put it into practice. What are we doing when we embark on a suicide assessment? We’re determining suicidality, the likelihood that someone will committ suicide. You’re deciding how dangerous someone is to themselves using the factors discussed above. You’re either looking at how lethal they could be, how lethal they are at this time, or how lethal they wereduring a previous episode of suicidal ideation or previous suicide attempt. 

When we put this all into practice, we look at statements and actions to determine how dangerous a person is. Did someone say, ‘if so and so does this, I’ll kill myself’ or, did someone act but just scratched their wrist? Those would be low level lethality, and they would not be very dangerous. Did someone buy a gun, load the ammunition, learn how to shoot it, go to the place where they planned to kill themselves at the time they planned, and then practice putting the gun to their head…essesntially a dry run? That would be the most lethal; that person would be the most dangerous. Those are the two poles of lethality and danger, but there are variant degrees and many shades of gray, so you really have to discuss it very thoroughly with each individual. 

Let’s say a 15-year-old is in the office after taking a big handful of pills in a suicide attempt. I ask him if he realized that taking those pills could have actually killed him, and he says no. He’s not that lethal, not that dangerous, because even though his means (pill overdose) was lethal, he didn’t know it was, so lacking that knowledge mitigates the risk, making him less dangerous. Example: acetominophen is actually extremely lethal. People who truly overdose on it don’t die immediately, but it shuts down the liver, killing them two days later. A person that takes a bunch of it thinking it’s a harmless over the counter drug is not that dangerous, because even though their method was lethal, they didn’t know it. In a similar manner, I’ve had people mix benzos with alcohol, which is another very lethal method. It’s a very successful way to kill yourself, but a lot of people don’t realize it, so it’s not that lethal to them. In the reverse case, people who know about combining alcohol and benzodiazepines, who know how dangerous it is, are dangerous, highly lethal to themselves. 

People who play with guns, like Russian Roulette-type stuff; or people who intentionally try asphyxiating or suffocating themselves, as for sexual pleasure; or people who tie a rope to a rafter and then test their weight…these people are very dangerous, very lethal, very scary to psychiatrists.   

Where someone attempts suicide is also very telling, very instructive in determining their lethality, how suicidal, how dangerous they are. If they do it in a place where there is no chance of being found, of being interrupted, they are very suicidal, very dangerous. Contrast that to doing it in a place where there are people walking by, or in a house where someone is, or could be coming home, then they are not as suicidal, not as dangerous. As an exaple, let’s say someone leaves their car running in a garage when they know that no one will be around for 2 days. That is very dangerous, they are very suicidal. If someone takes an opiate overdose at night when everyone’s in bed so they won’t find them for many hours, they are dangerous. If someone takes the overdose during the day, when people are awake at home, they are less dangerous. 

A change in somone’s behaviors and/ or outlook can also help determine lethality. When people start giving away their possessions, that is a sign that they are very lethal, very dangerous. Another factor that can be informative is if an unnatural calm comes over them, and they say that they have no more problems, and everything is great. That is an indicator of serious lethality, major danger. These people have a sense of ease because they know that they’ll be dead very soon, and they don’t have to worry about things anymore. These are ominous signs.

Giving information about an attempt also informs a person’s level of lethality. If someone makes a statement of intent to commit suicide, they are not very dangerous. For example, a spouse saying ‘if you leave me, I’ll kill myself’ or ‘you broke my heart, I can’t live without you, I’m going to kill myself’ those statements alone do not indicate a very dangerous person. Not telling anyone and hiding when they plan to attempt is much more dangerous. There are many cases when people don’t come out and tell, but they aren’t being very secretive, intentionally or not, possibly even subconsciously. They leave clues, almost giving people a road map. This is very common, and these people are typically discovered. The discovery can either totally abort the act before it’s attempted, or can abort after the attempt, but in enough time to get the person help. This is why for every 1 “successfully” completed suicide, there are 24 failed suicide attempts. Similarly, someone who says ‘if this thing (interview, event) goes my way, I’ll be good, but if it doesn’t, I swear I’ll kill myself’ is not that dangerous, not very suicidal, because they’re bargaining, which means they’re still living in the real world. But, someone who does not want to negotiate, doesn’t care to affect things one way or another, may not be living in the real world, and they’re dangerous, they may be high risk to enter the world of the dead.  

There are a couple other things to be considered in assessing risk of suicide, determining how dangerous someone might be. If someone is impaired, using drugs and/ or alcohol when they attempt or consider suicide, and if they are not suicidal when they’re clean and sober, they are generally not that suicidal, not that dangerous, they just have a drug or alcohol problem. When they get clean and sober for good, the risk is essentially zero, barring anything else. In a similar way, if someone is suffering from a mental illness when they attempt or consider suicide, but when you correct that mental illness they are not suicidal, they are not a huge danger. 

So during suicide risk assessment, you can be looking at someone having a nebulous thought and/ or making a statement that a lot of people may have or make, and you know that they’re not very dangerous; or looking all the way to the opposite side, someone who thinks about it, formulates a thorough plan, picks the place and time, aquires all the things needed to commit the act, writes a suicide letter, and practices the complete act soup to nuts, and you know that they are very, very dangerous. And all the shades in between. 

So that’s my primer on suicidal thinking and assessing suicide risk. There are lots of factors to keep in mind, and sometimes it’s a little like reading minds, but you get more proficient as the years go by…it’s easier to tell when someone is misleading or being honest and open. If you enjoy a humorous approach to character studies in all sorts of diagnoses, you would enjoy my book, Tales from the Couch, available on Amazon. I mean, most of you are isolating, sheltering in place anyway, right? Might as well entertain yourself! Check it out. – Dr. Mark Agresti

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Mental Health Benefits of Dogs

Mental Health Benefits of Pets

The bond between humans and animals is a powerful one, so much so that there have been numerous books written and movies made centering on the relationships between them. Dogs were the first animals domesticated and kept as pets, as much as 45,000 years ago.Regardless of when pet ownership got started, our long attachment to these animals is still going strong. Americans own some 78 million dogs, 85 million cats, 14 million birds, 12 million small mammals, and 9 million reptiles, according to pet industry statistics. 

Studies have scientifically explored the benefits of the human-animal bond, and a positive correlation between pets and mental health is undeniable. According to a recent poll, 95% of pet owners consider their pet a member of the family. Children, adolescents, adults, and seniors all find joy in their pets, so it follows that pets and mental health go hand in hand.

Pets provide companionship, ease loneliness, bring us joy, and give us unconditional love. They also help decrease depression, anxiety, and stress. While the word “pet” usually conjers up thoughts of dogs and cats, a pet doesn’t necessarily have to be a dog or a cat. Even watching fish in an aquarium has been shown to reduce muscle tension and lower pulse rate. A pet can be a horse, parrot, turtle, rabbit, skunk, lizard, chicken, snake…whatever you love and take care of.

Pets have evolved to become acutely attuned to humans. Dogs, for example, are about as intelligent as a two-year-old human child. Some more doggie fun facts: They are able to understand about 150 human words and most are even capable of following a count of five. They understand spatial relationships and are able to use them to navigate obstacles quickly. Although they can’t see the same color spectrum we can, they can see black, white, blue, and yellow; they can’t see red and green- those just look gray to them. A dog’s smell is like 10 million times better than yours. Dogs can sense if you’re going to have a seizure, they know if your blood sugar is low, and some say they can even sniff out cancer. While they understand many of our words, dogs are even better at interpreting our tone of voice, body language, and gestures. And like any good human friend, a loyal dog will look into your eyes to gauge your emotional state and try to understand what you’re thinking and feeling (and to use their special psychic powers to get you to give them treats and throw their ball, of course). I think dogs have psychic powers. My dog Beluga used to use her psychic powers to get me to do stuff all the time.  

Pets, especially dogs and cats, can reduce stress, anxiety, and depression, ease loneliness, encourage exercise and playfulness, and even improve cardiovascular health. Caring for an animal can help children grow up feeling more secure and being more active. Pets also provide good companionship for older adults. Perhaps most importantly, a pet can add real joy and unconditional love to your life.

Early researchers had discovered physical evidence of the mental health benefits of having pets. They found that pets could fulfill the human need for touch, so when hugging or stroking a pet, the human subject’s blood pressure went down, their heart rate slowed, their breathing became more regular, and their muscle tension relaxed. All of these physical changes are signs of reduced stress, which is indicative of a positive psychological impact. 

Since then, scientists have learned much more about the connection between pets and mental health. As a result, animal-assisted therapy programs have become an important part of mental health treatment. But, by owning a pet, you can experience pet therapy benefits every day in your own home. Below are several ways in which pets support good mental health and how pets are beneficial to people with mental health issues.

Interacting with Pets Lowers Stress and Decreases Anxiety:

Just the sensory act of stroking a pet lowers blood pressure, which reduces stress. Petting and playing with animals also reduces levels of the stress hormone cortisol while stimulating endorphin production and release of the happy hormones serotonin and dopamine, which calm and relax the nervous system. It also increases the production of oxytocin, another chemical that naturally reduces stress. Having the companionship of an animal can offer comfort, help ease anxiety, and build self-confidence for people anxious about going out into the world.

Pets Make Us Feel Needed:

The act of caretaking has mental health benefits. Caring for another living thing gives us a sense of purpose and meaning, so people feel more needed and wanted when they have a pet to care for. This is true even when the pets don’t interact very much with their caregivers. In a very interesting 2016 study about pets and mental health, elderly people were given five crickets in a cage to care for. Researchers monitored their mood over eight weeks and compared them to a control group that was not caring for crickets or other pets. They found that participants that were given the crickets became less depressed after eight weeks than those in the control group, so researchers concluded that caring for living creatures produced the mental health benefits they saw. Simply put, doing things for the good of others reduces depression and loneliness.

Pets Increase Well-Being:

Pet owners lives are enriched and generally better in several areas. They have better self-esteem, they are more physically fit, they are less lonely, they are more conscientious and less preoccupied, they are more extroverted, and they are less fearful. Put simply, pet owners are happier, healthier, and better adjusted than non-owners.

Pets Provide Companionship:

Companionship can help prevent illness and even add years to your life, while isolation and loneliness can trigger symptoms of depression. Caring for a live animal can help you shift your focus away from your problems, especially if you live alone. Most dog and cat owners talk to their pets, and some even use them as a sounding board to work through their troubles. And nothing beats loneliness like coming home to a wagging tail or a purring cat.

Cats and Dogs Are Great Examples:  Because pets live in the moment- not worrying about what happened yesterday or what might happen tomorrow- they can help you appreciate life’s simple joys and help you to be more mindful. Mindfulness is a psychological technique, the process of bringing one’s attention to the present moment. This can help distract you from what might be bothering you and help remind you to try to be more carefree and playful. In people diagnosed with mental illnesses like depression, schizophrenia, bipolar disorder, or post-traumatic stress disorder, pets can be among the most supportive connections they have. They provide a unique form of validation through unconditional support, which they may not have in other relationships.   Patients report that pets help them manage their illness, navigate everyday life, and give them a strong sense of identity, self-worth, and meaning. Caring for a pet gave owners a feeling of being in control as well as a sense of security and routine. Most said that their pets helped them manage their emotions and distract them from their symptoms like hearing voices, habitual rumination, and even suicidal thoughts, because they felt needed by their pet.

Pets Help Us Build Healthy Habits:
Pets need to be taken care of every day, and as a result, they help us build healthy habits and routines and add structure to the day. Many pets, especially dogs, require a regular feeding and exercise schedule. Having a consistent routine keeps an animal balanced and calm, and it’s good for people too. No matter your mood, one plaintive look from your pet and you’ll have to get out of bed to care for them. Caring for a pet can help you adopt healthy lifestyle changes, which play an important role in easing symptoms of depression, anxiety, stress, bipolar disorder, and PTSD. Some examples of these healthy lifestyle changes include:
Physical activity: Dog owners need to take their pets for walks, runs, and/ or hikes regularly, and owners receive the benefits of that exercise. Studies show that dog owners are more likely to meet recommended daily exercise requirements.
Time in nature: Walking a dog or riding a horse gets us outside, so we experience the many mental health benefits of being outdoors.
Getting up in the morning: Dogs and cats need to be fed on a regular schedule. As a result, pet owners need to get up and take care of them, no matter what mood they are in. So in this way, pets give people a reason to get up and start the day.
Pet care leads to self-care: Caring for a dog, horse, or cat reminds us that we must take care of ourselves as well.

Pets Support Social Connection: Pets can be a great social lubricant for their owners, helping to start and maintain new friendships. Pets are able to counteract social isolation and promote social connection by relieving social anxiety, because they provide a common topic to talk about. For example, walking a dog or playing in a dog park often leads to conversations with other dog owners. As a result, dog owners tend to be more socially connected and less isolated. This improves the owners’ mental health, because people who have more social relationships and friendships tend to be mentally healthier. The benefits of having social connections include better self-esteem, lower rates of anxiety and depression, a happier, more optimistic outlook, stronger emotional regulation skills, improved cognitive functioning, and having more empathy and feelings of trust toward others.

Pets Give Us Unconditional Love:
This one is best of all! Dogs and cats and pets of all kinds love their owners no matter what. That’s unconditional love. Pets don’t care how your presentation went, how you did on a test, or if you sold a house. Pets don’t judge you based on what you look like, if you are popular, or if you’re super athletic. They’re simply happy to see you, and they want to spend time with you, no matter what! This kind of unconditional love is good for mental health. It stimulates the brain to release dopamine, the chemical involved in sensing pleasure.

To summarize, the link between pets and mental health is clear. So if you don’t have a pet, think about getting one. For a dog or cat, go to a shelter or humane society and adopt somebody, take them home and make them a member of the family. Or maybe talk to a doctor about finding an emotional support animal. Either way, it’ll do you good and you’ll feel good for it. 

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Electronics Are awesome! Right

Electronics are awesome! Right?

Home computers became available in the early to mid-80’s, but didn’t gain major popularity until about 1990. Home computers were mainly for word processing and games until the advent of the world wide web. Originally unleashed in 1989, the www was developed chiefly to facilitate the exchange of information among professionals on medical and scientific studies, technical blah blah blah and protocols for building nerdy thingamabobbers. All super tres importante stuff. It wasn’t long before the www came into its own, evolving to revolutionize life as 

we knew it in the dawn of the 90’s. And it hasn’t stopped evolving, it literally grows exponentially every minute of every day, 24/7-365. The obvious potential of the www sparked a sort of resurgence of the electronic age. Suddenly everyone wanted, no, needed a computer at home….desktop at first, then laptop once they got them to weigh less than 20 pounds and cost less than $9k. For a little while, the laptop was the most portable window to the www, but then around the mid-2000’s the first smart phones hit the market, followed by the first iPad in 2010, and now we even have watches to wear the www around our wrists. 

So roughly 30 years ago, our world changed, solidifying our entry into a realm where electronics rule. That means that people who are currently age 30 and under were raised in this electronic world. They had nearly limitless access to computers, video games, smart phones, iPads, on and on. When he was 13 years old, my son had an innate knowledge for all things electronic. If I didn’t know how to unlock this code or clear those cookies, I could hand the device to my kid and he would fix it with zero hesitation. I know I’m not the only one that’s experienced this slightly annoying/disturbing phenomena. The other day, my patient EmLea told me she hired her 15-year-old neighbor to hook up her new TV/DVR/Blu-Ray setup she had given herself for Christmas. He didn’t even look at a single word in any of the manuals. And to top that off, he knew what every button on the various remote controls meant and how to switch to the different components, etc. It took him way longer to teach EmLea that stuff than it took for him to unpack and set the TV and all the components up. Our children of the “www era” entertained themselves with computers, games, text messaging, emails, computer card games, social media like Instagram and Facebook, then YouTube and WhatsApp, on and on. They grew up on electronics and have zero fear that they might break something or permanently damage it if they pressed the wrong button the way that many of us “old folks” do. I can’t talk about the advent of the www and social media without mentioning dating apps. Talk about limitless! There are dating sites for every sexual proclivity, hookup sites like Tinder and Grindr, and social sites of all sorts. People spend unbelievable amounts of time on dating apps. They tell me about it and it blows me away. And kids have access to these sites, because parents don’t bother to block them. Then again, maybe they don’t know how to or even know it’s possible to do so. The kids have the upper hand here- they’re far more savvy than their parents, so they get quite the education from those dating and social sites, believe me.  

Speaking of education, the www really allowed people to start educating themselves independently. For someone of my, ahem, maturity level, it was incredible! I mean, when I was in college and I needed to research a topic for a paper, I went to something called a library, where there were infinite rows of shelves with books of all sorts. Technology of the day was microfiche! I can practically hear the millennials asking google or Alexa what that is at this moment. A little help: it’s pronounced micro-feesh. And once I gathered all the information I needed, I had to type my papers. Not type on a computer and print, but type on a typewriter or maybe a word processor, which back then didn’t refer to software- a word processor then was basically a high tech typewriter. Again the millennials are like, “huh?” I have to compare that to my son’s situation again- during his high school years, he was required to use a laptop in all of his classes. Every kid was, and everything had to be done on the school’s network- every project and assignment. A far cry from my day.  

But I have to say, the information available and the ease and speed of access on the www was and is almost incomprehensible. Unless it’s novel, something that a PhD candidate has studied for two years can be learned in very short order, minutes even. The www also allowed us to start finding old friends and then making new ones. It allows us to live in an alternate reality of our own creation, a place where we tune in and get likes and collect friends and build reputations and online brands. And if we come across something we don’t like, we just go someplace else, another screen, another site. Just consider this: a boy, born in 1990, growing up, all he knew was to come home from school, play videogames, hit up social media, surf the internet, kill some brain cells on YouTube, watch Netflix, shop Amazon Prime, install different apps, upload videos… why go out? Why interact with actual people when you can watch them? Same diff, right? 

Today, the socialization, the entertainment, and the information all come to you. Everything is immediate gratification. Everything is online. There is no frustration. The minute you don’t like something, you move, you uninstall, you block, you end notifications, you unfollow, you flip an electronic switch and whatever you don’t like goes away. So naturally, what happens is that you only follow what you like. That’s human nature. The world is your oyster. You create a world where online, everything is just what you like. You never have to deal with people, people who have different opinions, people who you don’t like, people who have negative things to say. You create your own world…the world according to you. That’s all you see. Everything else fades to black, ceases to exist.

It sounds great, right? You have this world where all the information you could ever need is at your fingertips. You can talk to anyone you want in the whole wide world. You can buy anything that’s for sale…and even some things that aren’t. You can collect friends that are of like mind.You can get dates when you want to. When you think about it, it’s awesome, in the strictest definition of the word, deserving of awe. The www is arguably mankind’s greatest feat to date, maybe even greater than the dawn of civilization. It’s changed us in many ways, and for the better. Huge advances in medicine, technology, science, you name it are owed to the www and what it facilitates. It has brought people together and allowed the exchange of ideas and information to and from everywhere on the planet, and it has advanced our society. 

What could ever be wrong with this? It sounds great, right? Well, as with many things, if you scratch the surface, if you look harder, go deeper, there are problems created by the www, human problems. First, it’s not real. The electronic world on the www is not reality. I’m sure some of you are like ‘duh Dr. Agresti’ but I see people in my office every day who forget that. Sane people for whom the line between real reality and the electronic world they created has blurred. When you talk to someone online, you’re not talking to someone who is sitting in front of you. It is not a human interaction- it is an electronic one, a string of 1’s and 0’s. You can’t trust it. For all you know, it could be a bot or some form of artificial intelligence. This will be the issue of the not-distant future. As it is, we humans have to prove our human condition to a computer so it will allow us to log on to secure sites these days, typing in those crazy sideways upside down wierd scrawled letter/number codes. So who’s controlling who? 

Depending on the communication medium, there is some element of reality in that it could be another person, but you don’t know who that person really is. Catfishing runs rampant online, a 22-year-old woman is often an 80-year-old man. Without meeting in person, you can’t know who you’re “talking” to, so you can’t trust. And if you can’t trust, you have to have walls up, and you can’t have a true connection through those walls. On social media you can have a thousand friends, but when life goes sideways, when you need someone, you’ll likely find there’s no one you can really talk to. And meeting real people in real life during a lifetime mostly spent in an electronic world and zoning out to your own alternate reality can be problematic. You lack the social skills, you lack the speech skills, you lack the emotional skills, and you lack the ability to tolerate frustration because these aren’t necessary in the electronic world. When you do manage to meet new people, you lack the social creativity to know how to interact, how to hold your body, how to use voice inflection, and how to read body language- these skills are missing. And in the real world, as you come across random people, you are bound to find opinions that differ from yours. This will cause anxiety, frustration, and even anger, because all of a sudden, you can’t log off, uninstall, block or unfriend…it’s in your face and you have to deal with it. I call this the “frustration phenomenon,” and this occurs frequently and consistently when people who choose to live in an electronic world of their own creation are forced to dip their toes in the deep end of the real world.

Because I mostly treat people under age 30, when I’m out and about, I find that I pay attention to what people of this age group are up to. When I notice something interesting, sometimes I’ll even approach them, introduce myself, and ask them about it. I was recently at lunch with some of my office staff and we were chatting about this and that. Next to us was a table of four mid-twenty-somethings. Even though they were less than five feet away for the best part of an hour, I couldn’t have picked a single one of them out of a lineup. Why? Because their faces were all buried in their phones. The table was silent, save for the light clickity click sound of typing. Aside from placing their orders, they didn’t speak at all. I had to know more. With my staff rolling their eyes, I cleared my throat, introduced myself as a psychiatrist and asked them why they didn’t speak to each other. They all kind of looked at each other and back at me and gingerly set their phones down, as if asked to do so by a parent. Obligatory. Some mumblings of ‘I don’t know’s’ and shrugged shoulders followed. One brave one said they just always took lunchtime to catch up on social and check comments and see what friends were up to. I went around the table and asked each how long they spent doing anything online in a given 24 hour period. Their answers shocked me: 14, 13, 11 and 12. But even more on weekends. They laughed when I commented about it being a full time job. But I wasn’t kidding. 

Another offshoot of the frustration phenomenon occurs in these age-30-and-unders. Because they surround themselves only with music, things, and opinions they like, they have little to no tolerance for anything else. I call it the “other annoyance.” I noticed this while talking to a patient named Stu. He always wore earbuds, even in appointments. When I asked him about it, he said that he had to have them because when he had to be out in public, his music helped him drown everything out. He said he found other music, other people and their voices, and even random everyday noise to be annoying, so he avoided it all whenever possible. Stu was so immersed in a virtual world he created and filled only with things he liked that he had no tolerance for anything outside of that. Anything ‘other than’ was annoyance, and I presume that my presence and voice was included. Another issue with the generation raised on an electronics diet is that they never learned how to entertain themselves. Every time that there’s nothing to do, whenever boredom rears its head, they look to the electronic devices to entertain rather than trying a new activity or trying to meet new people. So social skills suffer further, and the disconnect from the real world becomes wider. There is detachment from the real world. Everything is the same in the electronic world, no matter where in the world you might be. The scenery remains unchanged.

Because this is a new problem, we have to learn to view and solve it in a novel way. As I see it so often, I have some suggestions for parents. When raising a child, the majority of their day must be totally electronic device free. This time should be spent interacting and talking with parents, siblings, and friends. Some time should also be spent doing something independently but device free- coloring, reading, playing with pets, etc. There must be strict limits on how much time is spent on electronics, whether that’s TV, iPad, phone, or games. We’re now realizing the true impact of electronics and how critical this issue is during a child’s developmental years. I’m convinced that the human brain will not develop appropriately if we don’t have significant ‘off time.’ And I’m concerned that we humans are beginning to evolve around electronics rather than the other way around. Even adults must have large blocks of time off electronics. Addiction is a real problem. This is illustrated by the fact that we now even have detox protocols and treatment centers for electronic addiction. 

Don’t quote me on it, but I think we’re headed towards a society where we actually have electronic implants in our brain. Think about it.  They could put an electronic device in your brain, some circuitry or device where you could access the www by utilizing the chip in your brain. I think it’s coming. And I think there will come a day in the future where we may have to wonder if we’re dealing with or “talking” to a robotic device or a real person. Ultimately, I think we’ll use the power and the resources of the electronic world to our best advantage, but we just can’t be caught off guard. Through the wonder of the www, the electronic world has evolved so quickly and has become such a dominant part of our lives, but now we’re learning that we need to exercise some restraint with it. The moral of the story? We can’t be dependent on the electronic world if we also want to control it. 

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Your Brain On The Holidays

Your Brain on the Holidays

Your brain is always busy, but it feels busier during the holidays, and rightly so. There’s a lot for it to think about during the holiday season: what to buy, for whom, and how much to spend, how to make time to visit family as well as friends, how to dodge certain co-workers at the office Christmas party, and hopefully how to squeeze in holiday naps in between eating some good home cooking. Because holiday time tends to pile on the stress, researchers are fascinated with the subject of what is happening in our brains while we’re trading time wrapping presents and plastering on a smile to spread genuine holiday cheer. 

Researchers believe that not only does the brain actually change over the holidays, but that they even know what culprit is: nostalgia. Essentially, nostalgia is that bittersweet feeling of love for what is gone, and the longing we feel to return to the past. The holidays lead to a special feeling of nostalgia that is unlike any other. Reminiscing with family, watching old holiday movies, eating favorite dishes, smelling the familiar smell of your grandparent’s house, and maybe even sleeping in your childhood bed….the holidays are a heady mix that induce nostalgia on steroids. But even more than this, therapists actually say that we should basically “expect to regress” during the holiday season. Who doesn’t want to be a kid again, to look forward to going home for the holidays? While “home” means different things to different people, I think even Ebenezer Scrooge can relate to the notion that when we celebrate the holidays with loved ones, something in us changes; it feels different. There is a child-like nostalgia, a forward-looking feeling of anticipation. Research suggests that’s because there are some serious changes in our brains during the holidays. Here are some examples of things that you might experience as a result of nostalgia:

1. You Want to Eat All of the Food

That’s pretty much what happens when you’re back in your mom’s or grandma’s kitchen, eating a meal with your siblings, is it not? You’re not just eating a meal, you’re living a memory, so you want it all! Eating a lot during the holidays is totally a real thing, and science says it’s largely because aromas trigger vivid memories, just like the smell of your grandparent’s house takes you right back to being seven years old. And socially, the same thing happens. Just because you and your siblings or cousins are grown-ups doesn’t mean you’ll act that way. Remember, if you’re regressing over the holidays, so are they. But just remember to be an adult and use your manners around the dinner table.

2. You Want to Drink All the Alcohol

There are many reasons that people drink more during the holidays. Studies have shown that the average American sees a 100% increase in their alcoholic drinking habits between Thanksgiving and New Year’s. Along with the holly jolly holidays comes an increase in social functions, holiday parties and dinners out, which inevitably leads to more alcohol consumption for most adults. Many of us look forward to celebrations during the holidays, but it’s amatuer hour when it comes to drinking… a time when some people who don’t normally drink actually drink far beyond their limits. Some of these people will suffer adverse consequences that range from fights and falls to traffic crashes and deaths. Sadly, people often put themselves and others at great risk just for an evening of celebratory drinking. So please, get a clue and get an uber. There is no reason to drive after drinking…remember: more than two means an uber for you!

3. You Want to Buy All of the Things

Holiday shopping, for most of us, feels pretty miserable. The music is loud, the mall is crowded, and you’re half way to the checkout before you realize you don’t actually know your uncle’s shirt size and you didn’t double check if your office Secret Santa recipient has any allergies. What’s worse? Apparently, shopping during the holiday season changes our brain, and even the most self-controlled shoppers can fall victim to marketing masters. That cheerful holiday music? Those festive colors? Those free samples around every corner? The bright cheery lights? Marketing. Allllll marketing. And, all pretty much intended to get you to relax, have a good time…and loosen that hold on your wallet and kiss that money goodbye. And not even any misteltoe!

4. Maybe You Don’t Want to Get Out of Bed

Not everyone enjoys the holidays. For some people, it can trigger serious battles with mental health, depression and anxiety. Between 4 and 20 percent of people experience a form of Seasonal Affective Disorder, otherwise known as SAD, which is a depression that generally sets in during early winter and fades by spring or early summer. Even people who are not diagnosed specifically with SAD may still experience depression and anxiety over the holidays. Why? Well, we postulate that people’s desire for perfection can become crippling during holiday time. People see more of each other and have more than the usual amount of time to compare themselves to others during the holiday season, in terms of what they can or cannot afford to spend on gifts or where they may travel for vacation. People often try to do too much and end up over-extending themselves. 

The holidays are meaningful to people for many different reasons. For some it is a religious holiday, for others a time to spend with family and friends, and even a time of sadness and loneliness for some. Whatever the holidays mean to you, you really need to make it a point to take good care of yourself during this busy season…it’s the best gift you can give yourself.  

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Digital Addiction Disorder

Time to Log Off?

Technology addiction, electronic addiction, digital addiction, social media addiction, internet addiction, mobile phone addiction…. No matter the name, the common thread in these addictions is that they’re all impulse control disorders that involve the obsessive use of mobile phones, internet, and/or video games, despite the negative consequences to the user of the technology. For simplicity, I’ll combine all of the above names together and refer to the phenomena as a digital addiction.

*** A new special called “Digital Addiction” will air on the A&E Network (Comcast HD ch 410 / SD ch 54) on Tuesday, September 17th at 9pm. There will be stories of people addicted to video games and social media and discussion on how people are trying to recover from digital addiction. It should be very interesting, so check it out. 

Do you play video games in excess? Are you compulsively shopping or gambling online? Do you spend hours taking the perfect picture to post or ‘Gram or tweet? Do you feel a need to constantly monitor all of your social media outlets to look for likes and loves and to track people to see what they’re up to? Is your excessive use of all of these things interfering with your daily life- family, relationships, work, school? If you answered yes to any of these questions above, you may be suffering from a digital addiction disorder. These disorders have been rapidly gaining ground as they are more recognized as truly debilitating, and as a result, they are recently receiving serious attention from many researchers, mental health counselors and doctors. The prevalence statistics vary wildly, with some reports stating that the addiction disorder affects up to 8.2% of the general population, but others state it affects up to a whopping 38%. In my opinion, it affects far more than 8.2%, but not quite 38%, so my educated guess is about 20%. That’s one-fifth of the population… a staggering number of people. And we have the explosion of the digital age to thank. Advancing technology is the ultimate double-edged sword. One of the most troubling things about this disorder is that we are endlessly surrounded by technology. Most of what we do is done through the internet. And we’re enticed to do things online. Take Papa John’s as an example- if you place your order online, you get an extra discount or a free small pizza. Lots of company sites offer similar discounts. And if you do buy online, most companies then include you in their email blasts with info on sales and discounts. Even if you’re just doing research on something online, not shopping, you’ll get little photo pop-ups from online stores you’ve ordered from before. Gamers make up a huge subset of the digitally addicted. Ask any mother of a male child aged 10 and up if she and her son argue about his spending too much time playing games, and chances are she’ll tell you that it happens all the time. Of course, to the developers of these games, that’s a total eargasm! These game developers have a strategy to keep people, especially kids, glued to their seats with eyes on the screen. Many games, especially the huge multiplayer roleplaying games like World of Warcraft and Everquest, may lead to a gaming addiction because as players play together, they spur each other on. In addition, these games have limitless levels, so in effect, they never end.

Just because you use the internet a lot, watch a lot of YouTube videos, shop online frequently, or like to check social media often does not mean you suffer from a digital addiction disorder. It only crosses over into the trouble zone when these digital activities start to interfere with, or even negate, your daily life activities. Every tweet, every phone alert DING! is an interruption in your thoughts, your psyche, and your day. I have a handful of patients that struggle with just turning their phones off during a session with me. They literally get anxious being without it, being unable to check it. They have to hold it, have it in their hands. I have one patient that couldn’t turn it off but agreed to put it in her purse. That stupid thing dinged and blipped and bleated every freaking 5 – 10 minutes, I swear. And every time, I could see her leave the appointment….it interrupted her train of thought with every stupid, annoying noise it made. I told her that next time, and for every time thereafter, the phone would be off and in my drawer. She grudgingly agreed, but she regularly panicked without it, so I had to begin every session by talking her off the edge.

Like many disorders, it can be difficult to pinpoint an exact cause of digital addiction disorder, but there have been some risk factors identified. These include physical impairments, social impairments, functional impairments, emotional impairments, impulsive internet use, and dependence on the internet. The digital world can be an escape for people with various impairments, so they are at higher risk. 

Digital addiction disorder has multiple contributing factors. Some evidence suggests that if you have it, your brain makeup may be similar to those of people that have a chemical dependency, such as drugs or alcohol. Some studies even report a potential link between digital addiction disorder and brain structure- that the disorder may physically change the amount of gray and white matter in a region of the brain associated with attention, remembering details, and planning and prioritizing tasks. As a result, the affected person is rendered unable to prioritize their life, so the digital technology takes precedence over necessary life tasks.

Digital addiction disorder, as in other dependency disorders, affects the pleasure center of the brain. The addictive behavior triggers a release of dopamine, which is the happy, feel good chemical. Note the name dopamine. Drugs of all sorts are often referred to as dope, and this is not happenstance; they are called dope because drugs elicit the release of dopamine as well, causing the pleasurable high. So chemically speaking, the high that gamers or internet surfers or Facebook hyper-checkers get from indulging their addiction is exactly the same as when a drug addict takes drugs. Win a game or get a like or love on Fakebook, get a dopamine hit. And, just like with drugs, people develop a tolerance over time, so more and more of the activity is needed to induce the same pleasurable response that they had in the beginning. Ultimately, this creates a dependency. 

There are also some biological predispositions to digital addiction disorder. If you have this disorder, your levels of dopamine and serotonin may be naturally deficient as compared to the general population. This chemical deficiency may require you to engage in more behaviors to receive the same pleasurable response that individuals without the addiction have naturally. 

Another predisposition to digital addiction disorder is anxiety and/or depression. If you already have anxiety or depression, you may turn to the internet or social media to fill a void or find relief, maybe in the form of online retail therapy for example. In the same way, people who are very shy or socially awkward may turn to the internet to make electronic friends because it doesn’t require actual personal interaction.  

The signs and symptoms of digital addiction disorder can present themselves in both physical and emotional manifestations. 

Emotional symptoms may include:

Depression
Dishonesty
Feelings of guilt
Anxiety
Feelings of euphoria when indulging 
Inability to prioritize tasks

Problems with keeping schedules
Isolation
No sense of time
Defensiveness
Avoidance of work
Agitation
Mood swings
Fear
Loneliness
Boredom with routine tasks
Procrastination

Physical symptoms may include:

Backache
Carpal tunnel syndrome
Headaches
Insomnia
Poor nutrition: not eating or junk food

Poor or zero personal hygiene 
Neck pain
Dry eyes and other vision problems
Weight gain or loss

Digital addiction disorder impacts life in many ways. It affects personal relationships, work life, finances, and school life. Individuals with it often hide themselves away from others and spend a long time in this self-imposed social isolation, and this negatively impacts all personal relationships. Trust issues may also come up due to the addicts trying to hide, or lying to deny, the amount of time they spend online. Sometimes, these individuals may create alternate personas online in an attempt to mask their online behaviors. Serious financial troubles may also result from the avoidance of work, as well as bankruptcy due to continued online shopping, online gaming, or online gambling. They may also have trouble developing new relationships, and they often withdraw socially, because they feel more at ease in an online environment than an actual physical one.

One of the overarching problems with the internet is that there is often no accountability and no limits. You are hidden behind a screen, so you may say or do some things online that you would never consider doing in person. To some, that can be a very attractive proposition. One iissue that happens in digital addiction is that people who may be shy or awkward or lonely may create a new identity for themselves. They find that on the internet, they can be the person that they can’t be in real life. They develop this perfect fantasy world where everything goes their way. The problem is that the more they get into that fantasy wotld, the more distant they become from the real world. The results can be a disaster emotionally when they’re forced into the real world; they find they can’t function there and desperately need help. There’s a flip side to a created persona, where it’s done to intentionally hurt others. By now, I’m sure most people are familiar with “catfishing” from the eponymous movie and television program. For those who are not familiar, catfishing is the purposeful act of luring someone into a relationship by means of a fictional online persona. Catfish steal pictures of an attractive person, usually from that person’s social media, and they create a fictional persona and post it online with the stolen pictures to see who bites. If they get an attractive bite, they message that target to begin a relationship for their own devious purposes, which is usually just to get their rocks off, to hurt someone because they hurt, to get nude pictures, or to weasel people out of money. Catfish often do this with multiple people, leading them on, and are usually pretty proud of themselves for it. I think they’re lowlife cowards. My point is that the internet is full of people that feel brave online but who cower in real life. Online and social media digital addicts are more likely to be targeted, simply because they spend so much time on their devices, on the internet, or monitoring their social media. 

As for diagnosis, because it was only very recently added to the Diagnostic and Statistical Manual of Mental Disorders as a disorder that needs more research, a standardized diagnosis of digital addiction disorder has not been developed. This is likely due to the variability of the different digital applications that people may become addicted to, as well as the fact that digital addicts can have anxiety and/or depression as well, and therefore would have difficulty, or may be averse to, seeking help.  

As to treatment options for digital addiction disorder, the first step in treatment is the recognition that a problem exists. If you don’t believe you have a problem, you’re not likely to seek treatment. 

Developing a compulsive need to use digital devices, to the extent that it interferes with your life and stops you from doing things you need to do, is the hallmark of an addiction. If you think you or a loved one may have a digital addiction, you should definitely see a psychiatrist, because there may be an underlying issue like anxiety and/or depression that is treatable with talk therapy and/or medication. I specialize in addiction, and I work with many patients with digital addiction with a great deal of success. There is a right way to utilize technology without it running and ruining your life, so please seek help.  

Digital addiction disorder has become such a common theme in my practice that I cover this topic in several stories in my book, so check out Tales from the Couch, available on Amazon.com if you’d like to read patient stories and get more information on the digital addiction phenomenon.

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Lithium The Good The Bad The Ugly

Element 3: Better for Batteries or Brains…or Beverages???

Think back to chemistry class, when you studied the periodic table of the elements. You may remember it as being just a confusing jumble of letters and numbers. But our daily lives would be very different without element number 3. It’s a key component in the batteries that power our smartphones, laptops, and even fancy-schmancy Teslas. But that same element also happens to be one of the most effective treatments ever discovered for bipolar disorder and mania, as well as other mental illnesses like depression, schizophrenia, and eating disorders. It is especially effective for treating suicidal ideation. Through the years it’s also been used to treat anemia, headaches, alcoholism, epilepsy, and diabetes. But it’s very scary, because it has some serious and potentially lethal short and long term side effects, and there is a very narrow window between the dose where it’s effective and the dose where it’s deadly. It’s so scary that I literally have only one patient out of my entire practice on it. The element I’m talking about is lithium. Let’s consider the good, the bad, and the ugly of lithium. 

The good: it’s effective as all get out. I would call it one of the most effective drugs in the treatment of mania. It treats the high of the manic episode, the irritability, the agitation, disorganization, hallucinations, delusions, rapid speech, insomnia, racing thoughts, grandiosity, and impulsivity of mania. It prevents the mood cycling of bipolar, and it also treats the suicidality associated with mania and depression. 

The bad: it has a nasty side effect profile. It causes a host of issues. Sedation is a big one. It makes people tired and causes obvious mental slowing. I say obvious because it becomes obvious to everyone. The person appears dull and medicated. It slows the mind down. Thoughts don’t process at normal speed, and speech and reactions are slow. It also affects kidney function, causing frequent urination, as well as nausea and diarrhea. It also can be very disabling because lithium commonly causes fine tremor. When all of the side effects are looked at together, they can easily be mistaken for alcoholism or drug abuse, so it can affect people’s opinions at work and have other huge social and personal consequences. It can cause a great deal of weight gain, as well as disfiguring acne on the face and back, as well as psoriasis, red scaly patches of skin on the body. On top of all of that, it can also affect the heart, potentially causing sick sinus syndrome, which is an arrhythmia where the heart’s natrual pacemeker, the sinus node, doesn’t work properly.  

As for the ugly; let’s just say that lithium wouldn’t be winning any molecular beauty pageants… it is uuuu-uuu-gly! Lithium can cause nephrogenic diabetes insipidus and interstitial nephritis. Those are big words that simply mean it shuts the kidneys down. Like dunzo down. Patients on long term lithium therapy regularly have chronic renal failure. One of my patients that used to be on lithium is currently on a kidney transplant list. Another ugly component of lithium is that it shuts down the thyroid. You kind of need your thyroid to maintain metabolic processes in your body. It’s pretty important…without it, you become ill with all sorts of terrible issues and you must take another drug to kick it back into gear.  

There are other issues with taking lithium. There are some commonly used medications that don’t play well with it. You cannot take diuretics, and you can’t take NSAIDs ibuprofen or naproxen for pain, because these can cause dangerously high levels. Lithium is unusual in that it has that small window of operation I mentioned. You have to have levels checked to make sure they’re between 0.6 and 1.2 mEq/L. If you get toxic by taking thiazide diuretics or NSAIDs or by getting dehydrated, lithium can cause permanent brain damage, nausea, vomiting, diarrhea, and death. So, it is extremely problematic in that it has that narrow window between efficacy and death. In addition, certain drugs lower lithium levels. A big one is caffeine; people have to be very careful with caffeine intake. Even drinking too much water can lower lithium levels, because you can literally dilute it in your system. 

All things considered, I say lithium is a last line drug. Yes, it works, but it’s like using a sledgehammer to nail a one penny nail into the wall…there’s going to be collateral damage to the structure of the wall. As good as the good is, the bad is too bad and the ugly too ugly. There are so many other drugs now to try first. Lamotrigine, oxcarbazepine, valproic acid, lurasidone, aripiprazole, and quetiapine to name some. Some psychiatrists would argue with me because these other choices may not be as effective, but they won’t cause the mental slowing, acne, tremor, frquent urination, kidney failure, and hypothyroidism. I treat a patient as a whole, I don’t treat just the mental illness. If my treatment of the mental illness damages or destroys other parts of a patient’s life, is that proper treatment? I say no, but some physicians say yes. It’s a philosophical issue, a quality of life issue, that won’t be solved until somebody develops a drug that works as well but without the terrible side effects. As I mentioned above, I have only one patient in my entire practice on lithium, and I’m currently trying to get him off of it. Why? Well, he’s experiencing sedation, cognitive slowing, frequent urination, tremor, nausea, acne, and weight gain; surprise, surprise…it is making his life miserable. So we’ll continue to try other drugs and hopefully find some success elsewhere.

We’ve talked about the use of lithium in batteries and in brains, but in beverages? Believe it or not, it’s true. 

Lithium was once a key ingredient in 7 Up soda. This is a 7 Up ad in a 1948 issue of Ladies’ Home Journal magazine. Look how happy everybody is, and notice all the open bottles of liquid lithium everywhere. The father is like “These crazy kids, drinking all this 7 Up. They’re going to drive me to the poor house!” And the son is like “It’s okay, dad! Have another sip of your 7 Up!” And the daughter is like “Wheeee! I LOVE 7 Up!” And the mom is like “I hope I have enough 7 Up to keep me from murdering my entire family.” And the tagline just kills me… “You like it- it likes you!” 

7 Up debuted in 1929, and before 7 Up became it’s name, it was called “Bib-Label Lithiated Lemon-Lime Soda,” (really catchy name) and its original ingredients included a “healthy dose” of lithium citrate. Apparently there were more than 500 lemon-lime soft drinks on the market at the time, which is yet another fact that blows my mind. Anyway, to make their product stand out, Cadbury Beverages North America touted in their ads the “positive health effects” of the lithium in the soda, which interestingly was released just a few months before the 1929 stock market crash and the onset of the Great Depression….things that make you go hmmm….Apparently the recipe had some appeal, because in the 1940s, 7 Up was the third best-selling soft drink in the world. But alas, somebody got wise, and lithium was removed from the recipe in 1950. Just a little fun fact: there is a precedent for the addition of “pharmacologically active” ingredients in soft drinks. Coca Cola added a lot of coca leaves (from which cocaine is derived) to it’s original 1886 formulation, giving it it’s name. Another fun fact: the guy that formulated it was an alcoholic and opium addict who was looking for a cure for his affliction. Evidently it contained a great deal of the cocaine molecule, a fact that undoubtedly led to it’s popularity in those olden days. I’m sure lots of folks were bummed out when it was removed from the formulation in 1903. Didn’t matter to the formulator/owner, because he’d been found dead long before on his office floor with an opium stick in his hand. 

For more interesting stories on psychiatric conditions and the medications that treat them, check out my book, Tales from the Couch, available in my office or on Amazon.

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Mood Disorder

Mood disorder is the term designating a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR) classification system where a disturbance in the person’s mood is hypothesized to be the main underlying feature. The classification is known as mood (affective) disorders in ICD 10.

English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.

Two groups of mood disorders are broadly recognized; the division is based on whether the person has ever had a manic or hypomanicepisode. Thus, there are depressive disorders, of which the best known and most researched is major depressive disorder (MDD) commonly called clinical depression or major depression, and bipolar disorder (BD), formerly known as manic depression and characterized by intermittent episodes of mania or hypomania, usually interlaced with depressive episodes.

Disorders in this Category

• Bipolar Disorder
• Cyclothymic Disorder
• Dysthymic Disorder
• Major Depressive Disorder

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