What If It Works?

worksFor a number of years after I first got started in psychiatry I wrestled with the dilemma of what to do when someone with severe, disabling depression came in for an evaluation, seemed to be an excellent candidate for treatment with an anti-depressant, but was completely preoccupied with potential adverse effects and focused almost entirely on all of the negative information about the medication (and with the internet it is easy to find reports of negative effects of medications).  

I would find myself in the odd position of arguing and arguing in favor of at least considering a medication, especially since many people with this kind of story had tried many different psychotherapies and herbal and alternative treatments without success and were clearly suffering a great deal from their depression.  

About four years into practice, the little imp that sometimes sits on my right shoulder during therapy sessions suggested to me that I ask the question “what if it works?” instead of continuing an endless discussion about what if the medication doesn’t work or has bad side effects. 

It turned out that for many of these people, a frank discussion about “what if it works?” was important to allow them to really think thoughtfully about the decision to take, or not to take, a medication.

Embedded in the question “what if it works?” is a whole series of thoughts and ideas about what it “means” to have depression and what it might mean to have a kind of depression that responds to medication.

Some people worry that, if taking a medication makes their suffering go away, they will have to wrestle with the idea that their lifetime of pain and struggle was unnecessary. And since this struggle, for some people, represents the central axis of their lives, they would suddenly have to reconsider their understanding of themselves.

Another set of questions that may be evoked by the question “what if it works?” has to do with whether a self that is not depressed because of an anti-depressant is “really” the same self.  In other words, is there something that this medication does that might change some essential attribute of personality?

And then of course there are a whole series of connected issues – including the shame and stigma that can easily get evoked by medication treatments for depression.

If you are thinking about medication, I suggest looking at the decision from both perspectives, what if the medication works, and what if it doesn’t.

Rousseau and Nature’s Way: Realistically Thinking about Treatment and Medication

MedicationWe’ve been thinking about people who come to our clinic, say that they are not sure that they have a mood disorder, and they want to try get off of their medications and use dietary supplements to cope with their ups and downs.

We have a lot of interest in the idea of using various non-medication options for managing moods. That’s one of the reasons for this website.

On the other hand, over the years, there have been some worrisome failures (as well as successes) in working with people who are considering alternatives to medications.

What does this have to do with the philosopher, Jean Jacques Rousseau?

Rousseau wrote about the idea of a “noble savage”. His belief was that man living in a purely natural environment was the highest form of human life.

You can wander through almost any art gallery and see pictures that were inspired by this romantic ideal of nature. If you do, you will probably also notice that the pictures don’t have very much in common with the experience of really living in nature. Often, the images are clearly fanciful. Women in delightful pastels frolicking in an idyllic landscape. 

Rousseau came up with his view about the desirability of avoiding of “civilization” (the idea of living as a “noble savage”) without any knowledge of the reality of “primitive” cultures. He lived his whole life in upper class society in Geneva, one of the most highly civilized cities in the world. And he never left that environment, despite his many books about the joy of uncivilized life….

The problem with some of the people we see who are intent on using purely “natural” means to deal with their moods is the same lack of realism.

Embedded in the approach some people take is the wish to get away from the realities of depression, and moods that can become unstable and out of control.

Just as Rousseau and his view of nature was really about a rejection of the civilized life that he lived in, without really considering the primitive life he embraced.

We usually can tell if a person is thinking realistically about reducing medications by observing the way they approach the problem. If the person who is tapering down off of medications becomes increasingly less attentive to mood as their medications go down we get very worried. If you think about it, is the opposite of what would be desirable since, as medications go down, the possibility of mood instability increases.

And then if that person then wants to come in to see their psychiatrist less often, and they want to stop keeping track of their moods we know that we are facing an unrealistic notion of how to reduce medications. We know, in other words, that this person is intent on embracing a new romantic ideal of “life without bipolar.”

The results can be catastrophic. Two of the handful of folks we know who committed suicide took this approach.

By contrast, people who are really interested in seeing what the smallest effective dose of medications is, will pay particular attention to moods as they taper, will want to consult with their psychiatrist, and are generally well aware that nature’s way can be harsh, as well as beautiful.

Marijuana: Reefer Madness

Psychosis Risks with Marijuana Use

marijuana

This article is taken from Bipolar Network News.

“At a recent conference Robin Murray, a researcher based in London, gave a talk about the potential adverse effects of tetrahydrocanabinol (THC). Considerable data indicate that chronic long-term smoking of marijuana is associated with the doubling of the risk of psychosis. Moreover, if a marijuana user has a common genetic variant in the catechol-o-methyltransferase enzyme (COMT), they are at substantially increased risk for the development of psychosis. New data also indicate that frequent use of marijuana can also be associated with an earlier onset of schizophrenic psychosis than would ordinarily occur without the substance use. Data also suggest that the psychosis associated with THC use is more difficult to treat than that without such use.

Murray also reported on a new risk that is associated with more potent new products. Older, natural forms of marijuana contained a compound called cannabidiol, which is associated with calming effects and possible antipsychotic effects. In a new synthetic preparation of THC called skank or spice, there is a higher amount of THC, but none of the positive diol compound. Thus there are some important caveats to the prevailing view that marijuana is relatively harmless.”

This is a much more sophisticated analysis than previous information about marijuana and its risks.

Our own experience is that marijuana can not only increase the risk of psychosis but also may over time lead to more rapid cycling in folks with bipolar. Also marijuana has clear effects on memory and attention span when used long term.

On the other hand, we know plenty of people without bipolar who find marijuana helpful for reducing anxiety and for managing pain. Our caveat is this – marijuana, like many psychoactive agents, has immediate or short term effects (reduction in anxiety for example) that may be quite different from its long term effects.

Parenting and Oxytocin

oxytocinThose of us who have been parents probably remember moments of incredible attachment to our children. Times when we were happy to just hold them while they were sleeping, and nothing else in the world seemed important. It is a state that is somewhat like the experience of new love.

Recent research suggests that part of what creates that state is a hormone named oxytocin.

Oxytocin has long been used to induce labor in women. But even way back there were intriguing reports that oxytocin increased memory (It turns out that it is a particular kind of memory, social memory, the memory of people you have met).

Now oxytocin is getting a lot of press as the hormone of love…

That is not quite right. Because oxytocin also seems to increase aggression against “outsiders”.

But if you have held your child in your arms you can understand that, you would have in that moment done anything to protect your child. And if not you can imagine what it is like to intrude upon a mother bear and her cubs…

So what is it that oxytocin does?

It creates a sense of close connection, it is increased in the early stages of romantic love. In women there is a huge increase after birth. It increases, to a lesser extent, in men after their partner gives birth.

It seems to boost ability to remember people. Rats who don’t have the receptor for oxytocin (who don’t respond to it) seem to be unable to remember other rats they have previously met.

And most recently researchers report in the July issue of Biological Psychiatry that if you give oxytocin to new dad’s it increases their attachment to their kids, and their kids respond in kind.

NAC (n-acetyl-cysteine)

NACWe were impressed by a recent study of n-acetyl cysteine as a treatment for marijuana dependence. It was a well designed study from a very reputable research group and the results were significant: the number of clean urines in the group getting NAC was twice as high as in the placebo group.

It got us more interested in the agent and other potential uses for it.

N-acetyl cysteine (NAC) is a modified form of the dietary amino acid cysteine. It is not found in food.

NAC is thought to help the body make the important antioxidant enzyme glutathione. It also has direct antioxidant effects. And, by blocking action of the excitatory neurotransmitter glutamate, it reduces brain damage in a number of situations (such as stroke and possibly stress) associated with excessive brain activation. Finally it increases the release of the neurotransmitter dopamine. A summary of these effects is to be found in this picture.

It has shown promise for a number of conditions, especially chronic bronchitis.

Optimal levels of NAC have not been determined. The amount used in studies has varied from 250 to 1,500 mg daily.

The dose in the marijuana study was 1200 mg a day. And it is reasonable to use that does since it seems to be quite safe.

Several studies have suggested that NAC may be beneficial as an aid to treating various mental health disorders including schizophrenia,  hair pulling, cocaine-dependence, and even pathological gambling.

One study found that it may be helpful for the depressive phase of bipolar.

NAC appears to be a very safe supplement by itself, although one study of rats suggested that doses that are 60 to 100 times the normal dose can cause liver injury.

The combination of nitroglycerin and NAC can cause severe headaches. Safety in young children, women who are pregnant or nursing, and individuals with severe liver or kidney disease has not been established.

Unfortunately, Consumer Laboratories, which is the only reputable source of information about the quality of supplements, has not yet tested NAC supplements. Still these sources appear to be reputable…

REFERENCES

Berk M, Copolov DL, Dean O, et al. N-acetyl cysteine for depressive symptoms in bipolar disorder–a double-blind randomized placebo-controlled trial. Biol Psychiatry. 2008;64:468–75.

Dean O, Giorlando F, Berk M. N-acetylcysteine in psychiatry: current therapeutic evidence and potential mechanisms of action. J Psychiatry Neurosci. 2011 Mar;36(2):78-86.

Grant JE, Kim SW, Odlaug BL. N-acetyl cysteine, a glutamate-modulating agent, in the treatment of pathological gambling: a pilot study. Biol Psychiatry. 2007 Apr 17.

Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009 Jul;66(7):756-63.

Gray KM, Carpenter MJ, Baker NL, et al. A Double-Blind Randomized Controlled Trial of N-Acetylcysteine in Cannabis-Dependent Adolescents. Am J Psychiatry 2012;169:805-812.

Larowe SD, Myrick H, Hedden S, et al. Is cocaine desire reduced by N-acetylcysteine? Am J Psychiatry. 2007;164:1115-1117.

Berk M, Copolov D, Dean O, et al. N-acetyl cysteine as a glutathione precursor for schizophrenia—A double-blind, randomized, placebo-controlled trial. Biol Psychiatry. 2008 Apr 22.

Medications

medicationGetting the right medicine, medication side effects, fear of being dependent on a medication, medications that stop working mysteriously… psychiatric medications evoke in us as many reactions as do psychiatric disorders… and psychiatrists.

What we propose to do on this page is to try to collect and organize information that we have found helpful in thinking about psychiatric medications. As with other parts of this website, this will most definitely be a “work in progress” as there is an endless supply of information on this topic.

We should begin with some of our beliefs about psychiatric medications. In general, we find them to be quite a bit less mysterious and magical than most people do. This is good and bad. They don’t have the ability to change who we are… as we sometimes fear they might, and sometimes desire they would. By and large, psychiatric medications are not “magic bullets” that take away problems so that we don’t have to think about them again. Adverse effects are pretty common, but in twenty years of practice, we have not (thank goodness) had any catastrophic outcomes… no one has had a reaction that didn’t resolve after the medications was stopped… although those things do happen with psychiatric medications as they do with any other medicine (including Tylenol and aspirin).

Medication “versus” Psychotherapy

One of the questions that we find we don’t know how to answer is the common question, “Is this a biological depression?” which often means, “should I take medication for this depression or is psychotherapy the answer.” The problem is that all depressions are both biological and psychological. Psychotherapy and medications both affect biology, they appear to do it by somewhat different routes. A recent article in the Archives of General Psychiatry demonstrated this with some dramatic brain scans. The implication is that they may be synergistic, working on the common problem of depression in different ways.

The important question is what is effective treatment. And, in general, comparing the two treatments, outcomes tend to be about the same. Medications tend to work a bit faster and are a little bit less expensive in the short run (the extra cost of more sessions for psychotherapy is generally more than the cost of medications, although not always), psychotherapy tends to be a bit slower and more expensive in the short run, but results from psychotherapy may be more enduring. Two recent articles in the Archives confirmed this finding. 

We find that usually medication and therapy compliment each other (although the story is not as clear for anxiety disorders as it is for mood disorders). Medications are generally necessary for conditions that are more severe, but they are not restricted to use in severe disorders. Severe depression has a profound effect on the ability of the brain to learn and therefore may block the effects of psychotherapy, which may be why medications seem to work better in severe depression. On the other hand, medications tend not to be associated with the kind of enduring changes that can occur with psychotherapy.

Adverse Effects from Medications

Many patients ask us about the long-term effects of treatment with antidepressants and mood stabilizers. Over the years, we have grown increasingly comfortable saying that there do not appear to be major adverse effects of long-term antidepressant treatment. More recently, very good quality studies have begun to show that this is only part of the total picture in terms of brain effects.

A large number of studies now find that patients with chronic mood disorders have measurable cell loss and atrophy in certain areas of the brain associated with memory. These changes are similar to changes seeing in laboratory animals who have very high cortisol or cortisol releasing factor (CRF) levels (indicating high levels of stress). New studies find that individuals with depression have much lower levels of an important chemical called brain-derived neurotrophic factor (BDNF)7. It seems that neurons need to be exposed to this growth stimulator in order to grow in a healthy way and that depression, perhaps because of increased stress hormone levels, or perhaps for other reasons, is associated with reductions in this factor.

Many mood stabilizers and antidepressants appear to counteract both the increase in stress hormones as well as the decrease in BDNF. In other words, depression is associated with brain toxicity, and the best evidence is that antidepressants reverse this brain toxicity.

There certainly are adverse effects from psychiatric medications, just as with any kind of medication.

A couple of resources to check into. But when you surf the internet for information about medications, be aware that there is always going to be a bias towards negative information (if you feel great from a medication why post on the net?).

CrazyMeds

PatientsLikeMe

These books are a pretty good resource. And have the advantage that they are likely to be a bit more balanced in considering the pluses and minuses of medications…

Vitamin D

vitamin DVitamin D is one of the fat soluble vitamins, and along with other fat soluble vitamins, it is possible to take too little, but it is also possible to take too much. And taking too much can have negative health effects, just as taking too little can.

For many of us we get enough vitamin D naturally from exposure to the sun (roughly 15 minutes of exposure to the face, arms and hands twice a week without sunscreen is enough) and from food (good sources are many types of fish, soybeans, soymilk, milk, mushrooms, and others).

Vitamin D intake is important for bone health (making stronger bones), preventing stroke and heart attacks, maintaining good balance in old age, and possibly preventing depression. If you are concerned about where you stand, get your doctor to check a “serum 25-hydroxy vitamin D level.” For most people levels between (roughly) 15 ng/mL and 30 ng/mL are fine. For people who are particularly worried about optimal bone health a narrower range of 24 ng/mL to 30 ng/mL is ideal.

Once you have your blood level you can figure out the right amount to take. For most people take 100 IU of vitamin D per day for every 1 ng/mL increase in blood level you want. (People who are obese may need to take as much as double this dose, since it is stored in body fat). So, for example, if your blood level is 16 ng/mL and you want to get the level to 24 ng/mL you should take 8 x 100 IU per day.

(A word of warning. vitamin D assays are not all equally good. A recent study suggested that two newer assays, made by Abbott and Siemens, may not be as good as other tests). 

To be sure that you are taking the right dose, get another blood level in a month. And then just keep taking that dose. By the way, since vitamin D is stored in your body fat, you can take it less often than once a day. This is good news because it can be hard to find supplements that have the smaller amounts that most people are likely to need when taken daily. So, in the example above, where the person needed 800 IU per day, it would be fine to take 1000 IU on weekdays only (none on weekend days).

For most people it doesn’t matter which of the two forms of vitamin D you take (vitamin D2 – ergocalciferol or vitamin D3 – cholecalciferol) but if you need large amounts of the supplement, vitamin D3 is probably somewhat better.

Consumers Lab does ongoing tests of vitamin D and other supplements, and about a quarter of all supplements tested fail one of their quality standards. These are good choices, however –

Supplements – Overview

supplementsSupplements are drugs that are found in nature (note: supplements don’t have to be any more “natural” in terms of how they are made than prescription drugs). Because they are found in nature they are not, in the United States, subject to review and approval by the Food and Drug Administration. Also, because they are found in nature, they tend to be safer than prescription drugs (although that is not necessarily always true). We believe in the value of supplements a great deal, but they are certainly not the right answer for everyone.

For those who are interested in the topic and are concerned about the fact that there are no regulations to ensure that these products are safe and that they contain the ingredients they claim to contain, we strongly recommend visiting this website:

ConsumerLab.com provides independent test results and information to help consumers and healthcare professionals evaluate health, wellness, and nutrition products. It publishes results of its tests online at www.consumerlab.com,including listings of brands that have passed testing. Products that pass CL’s testing are eligible to bear the CL Seal of Approval. CL addresses a growing need of consumers and healthcare professionals for better information to guide the selection of health, wellness, and nutrition products.

A recent report in the Journal of the American Medical Association by Saper and colleagues highlights the concern about safety in Ayurvedic medicines. It found that 25% of Ayurvedic supplements purchased at random contained potentially toxic levels of heavy metals (such as lead, mercury, etcetera).

What we have tried to do is summarize the available information on the supplements that have the most importance for those with mood disorders. For an overview of supplements for moodsurfing go here.

Also, for even more in depth information, in addition to subscribing to Consumer Lab, you might want to consider buying this book which we can highly recommend.

Smoking (Marijuana)

marijuannaLots of folks with depression and bipolar use marijuana to help feel more stable. We like to keep an open mind but we have to say we are not impressed with marijuana as a mood stabilizer. In fact, the closest thing that we can think of in terms of prescribed medications to marijuana (gabapentin or Neurontin) is a medication which was shown in three (suppressed) randomized controlled studies sponsored by the manufacturer of the drug to be LESS effective than placebo. Which is another story, one which ended up costing that company more than a billion dollars in penalties…

The point is that many, many smart folks were convinced that Neurontin helped stabilize their moods.

So, what do we think about marijuana? Well we think that for folks with a primary anxiety disorder and not a bipolar disorder, it is a reasonable treatment (with obvious negative effects on memory, motivation and the lungs) but we encourage folks with bipolar to stay away because it seems in our experience and in the research literature to lead to more rapid cycling and more mixed moods. That isn’t it’s immediate effect, of course, its immediate effect is to feel better, less anxious and less depressed. But for the same reason that antidepressants may not be good for many folks with bipolar, we think that marijuana is not a good choice, it causes more unstable moods.