Danielle Johnson, MD, FAPA
Lindner Center of HOPE/Chief Medical Officer
University of Cincinnati College of Medicine Adjunct Assistant Professor of Psychiatry

Medications are undoubtedly an important tool in the treatment of mental illnesses. Expert application of psychopharmacology is a game changer in improving symptoms of mental illness and helping individuals achieve a manageable baseline. Complex co-morbidities and severe mental illness make prescribing even more complex.

Psychiatric medications can stabilize symptoms and prevent relapse. They work by affecting neurotransmitters in the brain. Serotonin is involved in mood, appetite, sensory perception, and pain pathways. Norepinephrine is part of the fight-or-flight response and regulates blood pressure and calmness. Dopamine produces feelings of pleasure when released by the brain reward system.

One in ten Americans takes an antidepressant, including almost one in four women in their 40s and 50s. Women are twice as likely to develop depression as men.

Selective Serotonin Reuptake Inhibitors (SSRIs) Side Effects

Selective serotonin reuptake inhibitors (SSRIs) increase levels of serotonin. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) treat depression, anxiety disorders, premenstrual dysphoric disorder, eating disorders, and hot flashes. Potential side effects include jitteriness, nausea, diarrhea, insomnia, sedation, headaches, weight gain, and sexual dysfunction.

Zoloft Side Effects in Women

Zoloft, also known by its generic name sertraline, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Zoloft include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido, difficulty reaching orgasm, and erectile dysfunction. In some cases, Zoloft may cause weight gain or weight loss, and it can also affect blood pressure and heart rate. Rare but serious side effects of Zoloft in women may include seizures, serotonin syndrome, and suicidal thoughts or behavior.

Prozac Side Effects in Women

Prozac, also known by its generic name fluoxetine, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Prozac include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Prozac may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Prozac in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Lexapro Side Effects in Women

Lexapro, also known by its generic name escitalopram, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Lexapro include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Lexapro may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Lexapro in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs) Side Effects

Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase levels of serotonin and norepinephrine. Venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq) are used to treat depression, anxiety disorders, diabetic neuropathy, chronic pain, and fibromyalgia. Potential side effects include nausea, dry mouth, sweating, headache, decreased appetite, insomnia, increased blood pressure, and sexual dysfunction.

Tricyclic Antidepressants Side Effects

Tricyclic antidepressants (TCAs) also increase serotonin and norepinephrine. Amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), nortriptyline (Pamelor), doxepin (Sinequan), trimipramine (Surmontil), protriptyline (Vivactil), and imipramine (Tofranil) are used to treat depression, anxiety disorders, chronic pain, irritable bowel syndrome, migraines, and insomnia. Possible side effects include sedation, forgetfulness, dry mouth, dry skin, constipation, blurred vision, difficulty urinating, dizziness, weight gain, sexual dysfunction, increased seizure risk, and cardiac complications.

Other Antidepressants Side Effects

Wellbutrin Side Effects in Women

Bupropion (Wellbutrin) increases levels of dopamine and norepinephrine. It treats depression, seasonal affective disorder, ADHD, and can be used for smoking cessation. It can also augment other antidepressants. Potential side effects include anxiety, dry mouth, insomnia, and tremor. It can lower the seizure threshold. There are minimal to no sexual side effects or weight gain.

Trazodone (Desyrel, Oleptro) affects serotonin and mirtazapine (Remeron) affects serotonin and norepinephrine. They are both used for depression and sleep. Mirtazapine has minimal sexual side effects.

Monoamine oxidase inhibitors (MAOIs) increase serotonin, norepinephrine, and dopamine. Isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), tranylcypromine (Parnate), and moclobemide are associated with more serious side effects than other antidepressants. There are dietary restrictions and numerous drug interactions. MAOIs are often used after other antidepressant classes have been tried. Other antidepressants need to be discontinued for a period of time prior to starting an MAOI.

Newer antidepressants include Viibryd (vilazodone) which affects serotonin, Fetzima (levomilnacipran) which affects serotonin and norepinephrine, and Brintellix (vortioxetine) which affects serotonin. Brintellix and Viibryd have mechanisms of action that make them unique from SSRIs. Viibryd is less likely to cause sexual side effects.

Excess serotonin can accumulate when antidepressants are used with other medications that effect serotonin (other antidepressants, triptans for migraines, certain muscle relaxers, certain pain medications, certain antinausea medications, dextromethorphan, St. John’s Wort, tryptophan, stimulants, LSD, cocaine, ecstasy, etc.) Symptoms of serotonin syndrome include anxiety, agitation, restlessness, easy startling, delirium, increased heart rate, increased blood pressure, increased temperature, profuse sweating, shivering, vomiting, diarrhea, tremor, and muscle rigidity or twitching. Life threatening symptoms include high fever, seizures, irregular heartbeat, and unconsciousness.

Estrogen Levels With Antidepressants in Females

Varying estrogen levels during the menstrual cycle, pregnancy, postpartum, perimenopause, and menopause raise issues with antidepressants and depression that are unique to women. Estrogen increases serotonin, so a decrease in estrogen at certain times in a woman’s reproductive life cycle can reduce serotonin levels and lead to symptoms of depression. Hormonal contraception and hormone replacement therapy can reduce or increase depressive symptoms; an increase in symptoms may be more likely in women who already had major depressive disorder. During pregnancy, antidepressants have a potential risk to the developing baby but there are also risks of untreated depression on the baby’s development. With breastfeeding, some antidepressants pass minimally into breast milk and may not affect the baby. The benefits of breastfeeding may outweigh the risks of taking these medications.   Antidepressant sexual side effects in women are vaginal dryness, decreased genital sensations, decreased libido, and difficulty achieving orgasm. Women should communicate with their psychiatrist and/or OB/GYN to discuss the risks and benefits of medication use vs. untreated illness during pregnancy and breastfeeding; the use of hormonal treatments to regulate symptoms associated with menses and menopause; and the treatment of sexual dysfunction caused by antidepressants.

It has been observed that some antidepressants can affect estrogen levels in women. For instance, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) have been shown to decrease estrogen levels in women. On the other hand, other antidepressants such as venlafaxine (Effexor) and duloxetine (Cymbalta) have been shown to increase estrogen levels. The exact mechanisms behind these effects are not fully understood, but it is thought to be related to the interactions between the medication and the hypothalamic-pituitary-gonadal (HPG) axis, which is responsible for regulating estrogen production. It is important for women to discuss any potential effects of antidepressants on estrogen levels with their healthcare provider, especially if they have a history of hormonal imbalances or are taking hormonal therapies.

It is important for women to discuss any potential side effects with their healthcare provider before starting any depression medication.

Lindner Center of HOPE’s Approach

Lindner Center of HOPE’s residential services employ full-time psychiatrists with expertise in psychopharmacology. These prescribing physicians are designated members of each residential client’s treatment team. Medication management within Lindner Center of HOPE’s residential programs is also supported by 24/7 psychiatry and nursing staff, onsite pharmacy and an innovative Research Institute.

In some cases, patients over the course of treatment for mental illnesses accumulate many prescriptions. In cases like this, Lindner Center of HOPE’s residential units can offer a safe environment for medication assessment and adjustment. While the client participates in appropriate evaluation and treatment, their psychiatrist can also work with them on reaching rational polypharmacy — in other words, medication optimization.

For patients with more severe, treatment-resistant mental illness, Lindner Center’s psychiatrists can implement the most complicated, and often hard to use, treatments, in a safe environment, while under their observation.

If medication adjustments result in decompensation on the residential units, a patient can be temporarily stepped up to an acute inpatient unit on the same campus.

Friday, June 3, 2022

Lindner Center of HOPE Staff Psychologist, Laurie Little, PsyD, was named a finalist for the Cincinnati Business Courier’s 2022 Health Care Heroes Awards in the Patient Experience category. Here is an excerpt from Dr. Little’s nomination:

Both in her patient care role and in her responsibilities in providing clinical supervision of staff, Dr. Little is deeply involved in patient experience. She has received firsthand feedback on the challenges and opportunities synonymous with patient experience/customer service from all constituents, including:  patients, families, referral sources and internal staff.

Inspired by Lindner Center of HOPE’s commitment to excellence and empathy in all facets of the organization’s performance, Dr. Little offered to help invent a unique approach to patient experience utilizing tenants very familiar to many in the mental health field and common in the treatment of mental illnesses.

A specially-trained provider in the implementation of Dialectical Behavior Therapy (DBT), Dr. Little has an exceptional grasp on the varied applications of this therapeutic intervention that can help improve mood, thinking and behaviors. A core treatment at Lindner Center of HOPE, Dr. Little seized the opportunity to integrate the principles of DBT into customer service training for the entire Lindner Center of HOPE staff.

DBT goes beyond traditional therapies that focus exclusively on the change process and incorporates Eastern traditions to help ease emotional suffering with acceptance for things that cannot change. Building on that knowledge, Dr. Little constructed an innovative customer service training. A first of its kind, the training applies DBT “language”, one with which many Lindner Center of HOPE staff are familiar, and applies it to the language focusing on customer service. The training was designed not only to help patients have positive experiences, but also to help empower the employee to feel better prepared and more confident in dealing with stressful customer service situations.

The training reviews the three Es of customer service:  excellence, empathy, and expectations in an interactive presentation with skills development and discussion.

Dr. Little went above and beyond her responsibilities to address a need in a creative and customized way. She had a vision for utilizing a dialectical framework in understanding excellent customer service and took the initiative to be the architect of a brand new training model. The model considers:  if the focus is only on the viewpoint of the customer, employees feel frustrated and burned out. If the focus is only on the viewpoint of the employee, then the customer is more resistant and feels unheard. The dialectical framework means that even if both viewpoints on the surface appear different, they can both be true. This theme brings staff and customers closer together.

Dr. Little is a Health Care Hero for her innovative approach to improving patient experience. A specially -trained Dialectical Behavior Therapy expert, she recognized the benefit of applying the therapy’s skills and tenants to patient experience.

This inventive take on patient experience training is anticipated to have a significant impact, not only on patient satisfaction, but on employee satisfaction.

Dr. Little is a trailblazer in patient experience and thereby a Health Care Hero.

Byline:  Anna I. Guerdjikova, PhD, LISW

Binge eating disorder (BED) is the most common eating disorder in adults. The lifetime prevalence of BED has been estimated to be 2.0% for men and 3.5% for women, higher than that of the commonly recognized eating disorders anorexia nervosa and bulimia nervosa. Of note, BED is found in all cultures and ethnicities and spans from childhood to old age.

What is a Binge Eating Disorder

Binge eating disorder is an eating disorder characterized by binge eating without subsequent purging episodes. Individuals with BED consume large amounts of food in a short period of time while feeling out of control and powerless to stop the overeating. BED patients often struggle with feelings of guilt, disgust, and depression related to their abnormal eating behavior.

Since May 2014, the updated version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) formally recognized binge eating disorder as a distinct eating disorder, separate from the general Eating Disorder, Not Otherwise Specified category where BED was categorized. In order to receive the diagnosis of BED, an individual must meet the DSM-5diagnostic criteria listed below: experiencing recurring episodes of binge eating (consuming an abnormally large amount of food in a short period of time) and experiencing a lack of control over eating during the episode. Binge eating episodes must also exhibit at least 3 of the following characteristics: consuming food faster than normal; consuming food until uncomfortably full; consuming large amounts of food when not hungry; consuming food alone due to embarrassment; and feeling disgusted, depressed, or guilty after binging. A binging episode needs to occur at least once weekly for 3 months for formal diagnosis.

Examples of Binge Eating Episodes

An example of a binge episode might be: an individual would eat a bowl of cereal with milk, 2 scoops of ice cream, ½ bag of chips and a sleeve of cookies in a two hour period, shortly after a full size dinner; or a person driving through a fast food restaurant after work, consuming a whole meal there, and then going home to eat a regular dinner with family. Of note, the binge eating episode must be accompanied by sense of lack of control and distress in order to meet DSM-5 diagnostic criteria for BED.

While etiology of binge eating disorder is not fully understood, it is believed that dysregulation in dopamine, serotonin and glutamate neurotransmitter systems might contribute to BED development. Furthermore, there may be a genetic inheritance factor involved in BED. Risk factors for BED development may also include repetitive yo-yo dieting, childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood.

Individuals with binge eating disorder commonly have other psychiatric comorbidities such as mood disorders (major depressive disorder or bipolar disorder) and anxiety disorders. Binge eating is also a core symptom of bulimia nervosa. Unlike in bulimia, however, individuals with BED do not exhibit compensatory behaviors such as purging, fasting or engaging in compensatory excessive exercise after binge eating episodes.

Individuals suffering from binge eating disorder often have a lower overall quality of life and commonly experience social difficulties. BED is often associated with increased medical morbidity. Up to 80% of individuals with BED are overweight or obese and are at risk of suffering from obesity related complications like metabolic syndrome, increased risk for cardiovascular diseases, gastrointestinal problems and cancer.

Treatment of Binge Eating Disorder

Successful treatment of binge eating disorder begins with proper and thorough diagnosis. Binge eating is a shameful behavior and most of the time patients do not disclose it readily. Focusing their attention on specific examples like excessive, repetitive snacking or sneaking food or eating way beyond the point of comfort regularly might help with self-disclosure.

If binge eating disorder is diagnosed, a plethora of psychological and pharmacological options for its treatment are available. BED care is best implemented by a professional team consisting of a psychiatrist, a psychologist and a dietician. Cognitive behavior therapy (CBT) is currently considered the gold standard in the treatment for BED. Dialectical Behavior therapy techniques as well as guided self-help might also be helpful. While no medication is currently approved in the treatment of BED, certain antidepressants, antiepileptic and Attention Deficit Hyperactivity Disorder (ADHD) drugs hold promise in controlling BED. For example, Vyvanse (lisdexamfetamine dimesylatelate; approved for ADHD in the US) was recently announced to be effective in significantly decreasing binge days per week as compared to placebo in two pivotal Phase 3, multi-center, randomized studies.

Binge eating disorder is a biological illness and an important public health problem that is under-recognized. Timely diagnosis and comprehensive treatment are important in BED management, possibly decreasing long term consequences of dysregulated eating behavior and associated weight gain.

Learn more about Lindner Center of HOPE’s treatment for binge eating disorder.

Learn more about skills building options for binge eating disorder.

BY: Anna Guerdjikova, PhD, LISW, CCRC, Lindner Center of HOPE, Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program University of Cincinnati, Department of Psychiatry, Research Assistant Professor

 

An estimated 45 million Americans diet each year and spend $33 billion annually on weight loss products. WebMD lists over 100 different diets, starting with the African Mango diet, moving on to the South Beach and Mediterranean diets and ending up with the Zone. Most diets, regardless of their particular nature, result in short-term weight loss that is not sustainable. Weight cycling or recurrent weight loss through dieting and subsequent weight gain (yo-yo effect) can be harmful for mental and physical health for both healthy weight and overweight individuals. Furthermore, weight fluctuations have been related to increased risk of development of cardiovascular disease, Type 2 diabetes, and high blood pressure.

What is Dieting

The word “diet” originates from the Greek word “diaita”, literally meaning “manner of living”. In the contemporary language, dieting is synonymous with a quick fix solution for an overwhelming obesity epidemic. Dieting implies restriction, limitation of pleasurable foods and drinks, and despite of having no benefits, the omnipresent dieting mentality remains to be the norm.

Most diets fail most of the time. Repeated diet failure is a negative predictor for successful long term weight loss. Chronic dieters consistently report guilt and self-blame, irritability, anxiety and depression, difficulty concentrating and fatigue. Their self-esteem is decreased by continuous feelings of failure related to “messing my diet up again”, leading to feelings of lack of control over one’s food choices and further … life in general. Dieting can be particularly problematic in adolescents and it remains a major precursor to disordered eating, with moderate dieters being five times more likely to develop an eating disorder than those who do not diet at all.

Diets imply restriction. Psychologically, dietary restraint can lead to greater reactivity to food cues, increased cravings and disinhibition, and overeating and binge eating. Biologically, dieting can lead to unhealthy changes in body composition, hormonal changes, reduced bone density, menstrual disturbances, and lower resting energy expenditure.

The Potential Harmful Effects of Dieting

Aggressive dieting lowers the base metabolic rate, meaning one burns less energy when resting, resulting in significantly lower daily needs in order to sustain achieved weight after the diet is over. Returning to normalized eating habits at this lower base metabolic rate results in commonly seen post dieting weight gain. Biologically, dieting is perceived as harmful and physiology readjusts trying to get back to initial weight even after years since the initial rapid weight loss. Recent data examining 14 participants in the “Biggest Loser” contest showed they lost on average 128 pounds and their baseline resting metabolic rates dropped from 2,607 +/-649 kilocalories/ day to 1,996 +/- 358 kcal/day at the end of the 30 weeks contest. Those that lost the most weight saw the biggest drops in their metabolic rate. Six years after the show, only one of the 14 contestants weighed less than they did after the competition; five contestants regained almost all of or more than the weight they lost, but despite the weight gain, their metabolic rates stayed low, with a mean of 1,903 +/- 466 kcal/day. Proportional to their individual weights the contestants were burning a mean of ~500 fewer kilocalories a day than would be expected of people their sizes leading to steady weight gain over the years. Metabolic adaptation related to rapid weight loss thus persisted over time suggesting a proportional, but incomplete, response to contemporaneous efforts to reduce body weight from its defined “set point”.

Dieting emphasizes food as “good” or “bad”, as a reward or punishment, and increases food obsessions. It does not teach healthy eating habits and rarely focuses on the nutritional value of foods and the benefit of regulated eating. Unsatisfied hunger increases mood swings and risk of overeating. Restricting food, despite drinking enough fluids, can leads to dehydration and further complications, like constipation. Dieting and chronic hunger tend to exacerbate dysfunctional behaviors like smoking cigarettes or drinking alcohol.

Complex entities like health and wellness cannot be reduced to the one isolated number of what we weigh or to what body mass index (BMI) is. Purpose and worth cannot be measured in weight. Dieting mentality tempts us into “If I am thin- I will be happy” or “If I am not thin-I am a failure” way of thinking but only provides a short term fictitious solution with long term harmful physical and mental consequences. Focusing on sustainable long term strategies for implementing regulated eating habits with a variety of food choices without unnecessary restrictions will make a comprehensive diet and maintaining healthy weight a true part of our “manner of living”.

 

Reference: Obesity (Silver Spring). 2016 May ;Persistent metabolic adaptation 6 years after “The Biggest Loser” competition.; Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD.

Lindner Center of HOPE (LCOH) is making patients aware of a recent data security incident.  LCOH’s IT provider discovered that someone accessed the email account of one of our employees without authorization. Upon learning of the incident, the account was promptly secured to prevent further access. A forensic security firm was also retained to investigate and confirm security of our email and computer systems. The compromise was limited to one LCOH email account, which operates outside of and separate from our electronic medical record systems.  The LCOH electronic medical record system was not breached.

A forensic investigation revealed that the unauthorized access lasted only a few hours on July 12, 2019, and at this point, we are not aware of any fraud or identity theft to any individual as a result of this incident. We also do not know if any personal information was ever actually viewed or acquired by the unauthorized party. Nevertheless, as part of its investigation, the IT vendor searched for any personal information in the email account that could have been viewed, and on January 13, 2020, it advised us that the account contained some personal information, including dates of service, provider names, and diagnostic, treatment, surgical and/or prescription information.  A few individuals’ Social Security number or driver’s license number were also found in the account.

To help prevent something like this from happening in the future, we worked with our IT vendor to reset employee passwords, limit external email access, block access to malicious sites and IP addresses identified through the investigation of this incident, increase monitoring of network activity, add additional authentication measures for remote email access, and we continue to educate users on email security.

We have no indication that any patient information was actually viewed by the unauthorized person, or that it has been misused.  However, out of an abundance of caution, we began mailing letters to affected patients on March 13, 2020.  We recommend that our patients review any statements they receive from their healthcare providers and health insurers. If you see any services that you did not receive, please contact the provider or insurer immediately.  For eligible patients whose Social Security number or driver’s license number was found in the email accounts, we are offering complimentary credit monitoring and identity protection services.

We deeply regret any inconvenience or concern this incident may cause.  We have established a dedicated call center for patients to call with questions. If any patients have questions about this incident, please call 1-877-728-0077, Monday through Friday, 8 a.m. to 5 p.m. Eastern Time.

Please note this has been canceled.

High Hopes Auxiliary, (an organization of caring volunteers serving Lindner Center of HOPE) will host HOPE Is Blooming” on Tuesday, April 28 at Kenwood Country Club. The fundraising event will benefit Lindner Center of HOPE. Guest speaker, Nyna Giles, will serve as the keynote speaker. Giles, author of The Bridesmaid’s Daughter will share her search for understanding her mother’s misdiagnosed mental illness and her survival living with mental illness.

In her book, Ms. Giles opens up about her life as the youngest daughter of Carolyn Scott Reybold, a Ford model best known as one of Grace Kelly’s bridesmaids, whose life was derailed by untreated mental illness.  She has since traveled the globe to share her story, revealing the challenges brought on by her mother’s untreated mental illness and her own lost childhood and education.

Proceeds from the event will benefit a replication clinical trial aimed at preventing teen suicides.  Suicide is one of the leading causes of death among children and young adults in the United States. Lindner Center of HOPE will participate in this groundbreaking clinical research trial to study adolescent suicide prevention implementing a “Youth Nominated Support Team” (YST).

The April 28th event will include a silent auction and raffle, beginning at 10:30 a.m. with lunch and program at 12:00 p.m. The Bridesmaid’s Daughter will be available for purchase at the event, where Nyna Giles will be available for signing.

TO REGISTER for the event go to: www.myhighhopes.com. Tickets are $75 per individual, or $750 for a patron table of 10. Sponsorships are also available by visiting the website.

For more information, please contact Co-chairs: Blake Gustafson at: blakegusta@gmail.com or Amy Russert at: ARussert@totalprosource.com

Amanda Porter, MSN, APRN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE Board-Certified in Internal Medicine, Psychiatry/Mental Health, and Addictions

 

Depression is a serious and costly health problem facing our country. Depression is the most common form of mental illness, and is a leading cause of disability, and affects more than a quarter of the US population (CDC, 2017). To date the most prevalent theory as to the etiology of depression is the neurotransmitter theory, however not everyone responds to medications which boost neurotransmitters. Only about half of patients respond to antidepressants, and those who do respond will likely experience relapse of depression within two years (Greenblatt and Brogan, 2016). Thus, we need to consider other influences which might be causing depression.

The field of Integrative Mental Health considers other reasons for depression, such as an altered microbiome, chronic inflammation, hormones, mitochondrial dysfunction, dietary sensitivities, genetic mutations, and the role of neurogenesis.

Integrative Mental Health focuses on the whole person in order to promote recovery as holistically as possible from a mental health diagnosis. Integrative Medicine is synonymous with functional medicine and complementary and alternative medicine. Integrative Mental Health Medicine is an area of medicine that is evolving through the work of its pioneer, Dr. Andrew Weil.

It’s important to understand that integrative therapies are not necessarily a replacement for mental health medications. Rather, integrative therapies can supplement your current mental health treatment plan, or at times reduce the quantity of medications a person takes.

At the Lindner Center of HOPE Integrative Mental Health programming includes genotyping that enables the detection of the MTHFR genetic mutation, and treat accordingly. Micronutrient, thyroid, and metabolic testing is also offered with appropriate recommendations on diet and lifestyle changes. As Hippocrates famously said, “Let food be thy medicine.” Through the UC Center of Integrative Health and Wellness, treatment modalities such as massage, yoga, and acupuncture are available.

After an initial consult with an Integrative Mental Health practitioner, an Integrative Mental Health treatment plan will be developed. The treatment plan is also based off the patient’s individual mental health needs. This treatment plan incorporates lifestyle changes such as diet and exercise, nutrient therapy consisting of beneficial dietary supplements, and also considerations for services such as acupuncture, massage therapy, mindfulness, meditation, and hypnosis. The program appeals to patients who are seeking to treat their mental health diagnosis with as few prescription medications as possible. Integrative Mental Health consultations and follow-up visits are covered under many insurance plans.

Sources

Greenblatt, J. M. & Brogan, K. (2016). Integrative therapies for depression. Boca Raton, FL: CRC Press

Mental Health Basics. (2013). Retrieved from https://www.cdc.gov/mentalhealth/basics.htm

Marcy Marklay, LPCC

Child/Adolescent/Young Adult Therapist, Lindner Center of HOPE

Adjunct Instructor, Dept of Psychiatry and Behavioral Neuroscience

University of Cincinnati- College of Medicine

 

Gender identity is a person’s inner sense of being male, female, neither or both. Gender nonconforming refers to those who have behaviors and interests that run counter to what is expected of a male or female. Gender dysphoria refers to an individual’s affective/cognitive discontent with gender assigned at birth; gender dysphoria refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.  Transgender people are often unhappy with aspects of their bodies that do not conform to the gender they feel they are on the inside. There is a conflict between gender identity and biological sex and expectations. Transgender refers to the individuals whose gender identity is in contrast to their biological sex from birth.  Gender dysphoria can occur in children, adolescents and adults. Sexual orientation is not the same as gender; it has to do with who we find attractive.

Transgender individuals face discrimination and report a staggering rate of attempted suicide. It is estimated that 41 percent of transgender individuals have attempted suicide. This is greater than 25 times the rate of attempted suicide of the general population.  It is estimated that 75 percent of transgender youth experience harassment; many experience physical assault and sexual violence.  Anxiety and depression can often be found in transgender individuals. The needs of this community range from basic—safety, shelter, food, protection against discrimination and violence, to dealing with family, school and dating relationships, to transitioning with hormones and or surgery, and coming out concerns. It is crucial to respect them and respect the preferred name and pronouns they identify as, not to assume the gender or pronouns they use. Transgender individuals may face a lack of support or even open hostility from their family and friends, churches and communities. This rejection fuels high levels of anxiety and depression and makes the coming out process very difficult for many transgender people. They often have higher rates of peer isolation and hopelessness.

Coming out is a process of telling others that one is transgender, or gay, lesbian, bisexual or questioning. Parents need to educate themselves and be open to understanding their transgender child. Parents may have strong reactions with feelings of loss, worry what others may think, concerns for harassment, physical harm, possible regret, too young, not believe the child is really transgender, etc. It is important to work with a trusted mental health professional. Parents have their own social, cultural and religious views that must be addressed. `It is important to keep the communication open so the transgender child or teen can understand it is a difficult transition for the parents as well. Transgender teens and their parents benefit from support groups, in person or in a safe online network.

Each student needs to be in a supportive school environment. School administrators, counselors and teachers can help implement zero tolerance policies on bullying so that all students, including transgender students, can feel safe in school. Schools can establish a GSA, or gay straight alliance organization for transgender and other LGBTQ youth. Schools can develop a harassment policy that is specific regarding gender and sexual orientation. There needs to be a number of “safe” adults or advocates within each school. Transgender youth face challenges in the school setting also with practical issues in use of restrooms, locker rooms, use of legal name versus preferred name and pronouns if the child has not had a legal name change, etc. Issues of safety and respect are primary. Parents may be advocating for their transgender child with the school. It is important for the transgender youth to work on self-advocacy as well.

To be an ally of transgender people, it is important to spread a positive message and combat prejudice, to respect their preferred name, pronouns, accept them without judgment, give them a safe space where they do not have to hide who they are, and work on empowering them and giving them hope for the future. There are resources for both parents and transgender teens. The Gay, Lesbian, and Straight Education Network (GLSEN) is the largest national education organization working to ensure safe schools for all students. Parents and Friends of Lesbians and Gays (PFLAG) is focused on promoting the health of LGBTQ and transgender people, their families and friends. The Trevor Project is a free and confidential 24/7 crisis and suicide prevention helpline for LGBTQ youth. Trevor Space is a free, monitored social media and peer networking site for LGBTQ youth ages 13-24.

Sources of information:

 DSM-5, Diagnostic and Statistical Manual of Mental Disorders, fifth edition, American Psychiatric Association.

The World Professional Association for Transgender Health, www.wpath.org

 The Transgender Child by Stephanie Brill and Rachel Pepper, Cleis Press, 2008.

By Chris Tuell, Ed.D., LPCC-S, LICDC-CS

Lindner Center of HOPE Clinical Director of Addiction Services

 

In April of 1975, the Viet Nam War came to an end. During this 10 years of military strife, 58,220 U.S. soldiers lost their lives.  However, the end of the war also brought another difficult issue to light.  A never before scene was about to appear on the horizon.  Estimates indicated that approximately 20% or 1 out of 5 American soldiers returning from Southeast Asia were addicted to heroin.  Experts believed that once these soldiers returned home, our country would be faced with a heroin pandemic.  How would we manage such an issue?  It never happened.

Today, our knowledge of the neurology of the addicted brain has grown by leaps and bounds. We have gained a better understanding of the disease of addiction and how this new awareness clearly indicates that it is not an issue of character, nor is it a moral failing or a lack of will power.  Addiction is the result of the brain’s reward system being hijacked by outside substances (alcohol and drugs) and various behaviors (gambling, pornography, gaming, Internet).  This hijacking tricks the brain in believing that the drug or behavior has more importance than it really does.  Because of this pairing with certain neurochemicals, the brain believes this drug and/or behavior (like food) become necessary for survival.  Each of us knows that we don’t need alcohol, drugs, or gambling to survive. That’s true.  But, the brain thinks we do.  This survival drives the urges and cravings for the patient to use substances.  We know that patients who suffer from addiction, will engage in negative behaviors.  These individuals unfortunately will lie, cheat and steal in the midst of their addiction.  But equally important is the understanding that bad acts do not necessarily mean bad actors.  If each of us would be without water for three days or without food for three weeks, every one of us would lie, cheat and steal to survive.  This is what’s happening within addiction.

So why did the heroin epidemic of the 1970s not occur? Our new knowledge of the workings of the brain has also demonstrated that when substances are introduced, it impacts the very area of the brain where we develop meaningful, connected relationships. When mental illness issues surface, such as depression, anxiety, and trauma, the drug brings about relief.  It is this relationship that allows a sense of meaningful connection, even though that connection is unhealthy and problematic.  As one patient shared, using heroin was like “getting a hug from your grandmother on Thanksgiving morning.”  This experience becomes meaningful for the drug-addicted individual.  The drug’s influence on the brain creates a sense of connection causing a disconnect with truly meaningful relationships.  For the patient, the drug relationship becomes “on par” with other important relationships (i.e., spouse, children, parents, relatives, friends).  Unfortunately, sometimes the drug becomes number one.  For the Viet Nam soldier who was addicted, connection was re-established with loved ones, family and friends, and were able to reconnect within his or her community.  The heroin addiction ceased.  When an individual suffers with mental illness, the depression, anxiety, trauma, disconnects them from others resulting in a vulnerability to substance use and a hijacking of the brain’s reward system.

This phenomenon also occurred within the laboratory. In the early 20th century, research-involving rats found that when a rat was placed within a small cage and given the choice of two forms of water (pure water or water laced with heroin or cocaine) the rat would prefer the water laced with drugs.  The rat continued to use the drug laced water, eventually developing addiction, overdosing and dying.  Experiments like these shaped our view of addiction for many years.

However, a series of new research looked at the same experiment, but this time expanding the cage. In fact, the researchers created a “rat park.”  The cage was bigger with various levels and tunnels along with the addition of other rats.  The same two samples of water were provided.  Rats in this study preferred the pure water to the water laced with drugs.  No instances of overdose were recorded.

Mental illness interferes with our ability to connect with ourselves, others, and the world in which we live.   This isolation and disconnect creates the perfect storm for addiction.  Nearly 80% of individuals with a substance use disorder also have a mental illness. How many of us who have never experienced mental illness lose site of the importance of a meaningful connected relationships in our lives?   Perhaps the opposite of addiction is not sobriety.  Perhaps the opposite of addiction is connection.

By Nicole Bosse, PsyD, Lindner Center of HOPE, Staff Psychologist

Kyle has been happily married to his wife Joanne for 5 years. One night while watching a movie together, he notices the thought in his mind, “Gee, that Matt Damon is a good looking guy!” He then is suddenly flooded with a wave of panic and fear that perhaps the presence of this thought means he is gay and his whole marriage is a sham.  Although this scenario is fictional, it is an all-too common manifestation of a form of obsessive compulsive disorder.  Referred to as sexual orientation- obsessive compulsive disorder (SO-OCD).  SO-OCD is characterized by recurrent distress-producing doubts about whether one is gay or straight, fears of becoming homosexual (or becoming straight if their sexual orientation is homosexual), or fears that others might perceive the individual having the undesired sexual orientation.  (Williams, 2008). A person may have only one of these concerns or some combination. SO-OCD is very different from ordinary doubts and anxieties that are experienced by individuals attempting to discern their sexual orientation. For example, an individual coming to understand that they are gay may feel anxious about coming out or about the potential changes this will bring to their lifestyle. As clinicians, it is important to thoroughly assess if their client’s intrusive thoughts are ego-dystonic. In SO-OCD, ego-dystonic intrusive thoughts are cognitions that are inconsistent with the individual’s fundamental desires, wants, and sexual history.

Individuals with SO-OCD typically experience confusion and shame, which may unfortunately deter them from seeking appropriate treatment. Another factor that might impact entering appropriate treatment is that many of the individuals who struggle with this type of OCD have very few observable compulsions, which can prevent it from being recognized and properly diagnosed. Many of the compulsions typically take the form of cognitive compulsions, specifically mental reviewing to check the presence or absence of feelings of attractiveness or arousal, reassurance seeking, self-observation to see if one “looks”, talks, walks, or gestures like someone who is gay or straight, and avoidance of situations that might trigger fears.

Treatment for SO-OCD is very similar to treatment for other categories of OCD, specifically exposure and response prevention (ERP) is the gold standard treatment. It is important to emphasize in treatment that it is impossible to control thoughts and that typically trying to control thoughts or push thoughts away significantly increases them. Next it is key to explain ERP and to help them understand the reason why they are leaning into the anxiety. It can be particularly helpful to have them identify what in their life would be different once their OCD is no longer in the picture. Once the client is on board with and understands the importance of exposures, the client and clinician work collaboratively to create a hierarchy of exposures. It is important to begin with low distress exposures at first, and then gradually work up the hierarchy once they habituate to the low level exposures.

As with any form of OCD, exposures for SO-OCD can take various forms, depending on the client’s core fear. For example, one client’s core fear may be that they need to be 100% certain that they are attracted to individuals of the gender of their preferred sexual orientation, while another client’s core fear may be that they do not want to hurt the person they are with if they one day discover they are attracted to a different gender. In short, it is very important to first identify what their core fear is before creating the exposure hierarchy. Some common exposures for clients with whom I have worked whose obsessions focus on fears of being gay include identifying attractive individuals of the same sex, watching movies involving homosexual characters, attending pride events, writing sentences stating “I am homosexual,” or writing imaginal scripts about coming out to loved ones or sitting with uncertainty that they will never know 100% if they are in the correct relationship. It is also important to emphasize the second component of exposure and response prevention, namely response or ritual prevention. For instance, it would be necessary for the patient to not give in to reassurance seeking or mentally assess arousal before, during or after exposures.

Treatment length can vary depending on severity of symptoms. It is important to work with someone who specializes in OCD. Typically, therapy occurs once per week with the idea that once exposure work is started the client will be completing exposures each day between sessions.