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Danielle J. Johnson, MDDanielle Johnson, MD, FAPA
Lindner Center of HOPE/UC Health Psychiatrist
Lindner Center of HOPE Women’s Mental Health Program Director
University of Cincinnati College of Medicine Adjunct Assistant Professor of Psychiatry

 

 

Psychiatric medications are prescribed to treat the symptoms of mental health disorders. They 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 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.

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

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.

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By: Annie Ward, MSN, PMHNP-BC
Psychiatric Nurse Practitioner, Lindner Center of HOPE

When we think of eating disorders, our society tends to think of individuals in emaciated bodies. Disordered eating is more common than not, and does not discriminate against body size, gender or race. The line between dieting and disordered eating is blurred in our society. There are narratives tightly woven into our culture which lead to disordered eating habits being encouraged, and unfortunately often praised. Sadly, they are only acknowledged as problematic when the physical manifestations become unignorable and when they can no longer be labeled under the guise of “healthy diets”.

One of the most common disordered eating patterns that I encounter in clients (whether they are seeking help for an eating disorder or not) is the binge-restrict cycle. This pattern can start with either binge eating or restricting. Essentially, when we restrict nutrition, our bodies increase our hunger cues as they search for sustenance, to alert you that your body needs food. This can often end up in a binge-eating episode which involves eating a large quantity of food while feeling out of control. Unfortunately, the feeling of lack of control often results in shame, which may then lead to subsequent restriction of nutrition. This may be due to feeling full after a binge or primarily due to shame, but unfortunately fuels the cycle of binge-eating and restricting.

It can be helpful to think about how this cycle was useful for our hunter and gatherer ancestors. They may have gone several days without food, and when they found it, the body wanted to obtain as much nutrition possible, because it didn’t know how long it would have to survive without food again. Their bodies pumped out hunger hormones to protect them and sustain them. Your body works the same way– it cannot identify why it is not getting food. I hope that you wouldn’t expect our ancestors to feel shameful for eating more when they found food- and hope this helps you understand why you should not feel shameful for eating more after a period of restrictive eating. Additionally, our bodies have natural weight settling points and when we restrict, to conserve the energy we have, we slow down our metabolism to conserve resources. This is one reason why diets are overwhelmingly unsuccessful.

In order to learn what your body needs and wants, one of the best things that you can do for yourself is structure regular nutrition throughout the day- regardless of what your eating looked like the day before. Our society certainly defaults to making us believe that we should eat less if we “overdid it” the day before, but this is simply not true. Your body needs and deserves consistent nutrition every day.

If you struggle with fatigue, poor concentration, mood swings, headaches or lightheadedness—these are a few of the ways that inadequate nutrition can present. They can present quickly after your body realizes it needs more fuel, and may not get better until your body can trust that you will consistently give it the nutrition it needs. I would encourage you to explore your relationship with nutrition and how it may be affecting you physically— and mentally.

What should we learn from this? 

  1. If you feel you ate too much of a meal or snack, you should forgive and forget. You deserve to eat all meals and snacks the next day. Returning to a consistent pattern of nutrition will help break the binge-restrict cycle.
  2. Our society promotes “health” but this often gets twisted into unhealthy recommendations which can lead to the binge-restrict cycle. This can then lead to guilt, shame, and eating disorders. Be wary of “healthy” diets.
  3. Consistent nutrition is self-care, and it is not helpful to use nutrition as a form or judgment of self-control

If you are struggling with this, reach out for help with an eating disorder specialist who is knowledgeable about Health at Every Size- you do not have to look a certain way to have an eating disorder or be “sick enough” to get help

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By: Jessica Kraft, APRN, PMHNP-BC
Lindner Center of HOPE, Psychiatric Nurse Practitioner

Seasonal affective disorder (SAD) is a type of depression that is more isolated to the changing of the seasons. It can happen in the spring and summer but occurs most commonly in the fall and winter months. We know that everyone is going to have a bad day from time to time, and it’s not uncommon for some to face more challenges in the winter months when the weather is colder and the days are shorter. But when does this become a problem that requires intervention?

What are some of the common symptoms of SAD? 

  • Feeling down or depressed for most of the day, almost every day
  • Less interest in hobbies, social activities, or things that have brought you joy in the past
  • Decreased concentration at home and at work
  • Fatigue, sluggishness, or low energy
  • Sleeping too much or too little
  • Changes in appetite (increased craving for carbohydrates) or changes in weight
  • A general feeling of hopelessness
  • Low self-esteem
  • Thoughts of self-harm or suicide

It is hard to estimate the number of people who have SAD, as many do not know they have it. It’s also thought that the number in recent years has been higher due to the COVID-19 pandemic. Women can be at higher risk for developing SAD as well as those who live further north. SAD most commonly develops in young adulthood, it often runs in families, and can often be co-morbid with other mental health conditions including depression, bipolar, anxiety, ADHD, and eating disorders.

It is not entirely understood what causes SAD, but research indicates that people with SAD may have reduced activity of serotonin, too much melatonin production, or even vitamin D deficiency. Changes in these areas may impact the body’s daily rhythm that is tied to the seasonal night-day cycle. Negative thoughts and feelings about the winter and its associated limitations and stresses are common among people with SAD, as well as others. It is unclear whether these are “causes” or “effects” of the mood disorder, but they can be a useful focus of treatment especially when seeking therapy.

If the above symptoms start to interfere with day-to-day life, it may be beneficial to seek out care for SAD. For some it may be ideal to start with their primary care provider in order to rule out other medical conditions that could be responsible for symptoms of SAD including alterations in thyroid hormones, low blood sugar, anemia, or viral infections like mono. If there is not an identifiable medical cause, seeking psychiatric help may be beneficial.

What are some of the common symptoms of SAD?

  • Light therapy – a common approach to SAD since the 1980s. The thought is that exposure of bright light every day can supplement the lack of natural sunlight/sun exposure in the winter months. Sitting in front of a light box of 10,000 lux daily during the winter months in the morning can be a helpful intervention.
  • Talk therapy – the most common type of talk therapy for SAD is cognitive behavioral therapy (CBT).
  • Vitamin D supplementation – there is mixed research on how helpful supplementation of Vitamin D is for SAD but some find it helpful and a good option to try prior to trying a psychiatric medication.
  • Psychiatric medication – for those who haven’t seen much improvement with light therapy or CBT, psychiatric medication can be an option including SSRIs (Prozac, Zoloft, Lexapro, etc.) or Wellbutrin. It is important to keep in mind that treatment with one of these medications may take several weeks in order to be efficacious, for some up to 6-8 weeks.
  • When doing research on this topic I came across many anecdotal stories from those struggling with SAD and what interventions they tried and found helpful. Some examples included going outside more often, taking a trip, caring for something like a plant or a pet, finding a new hobby or interest, staying social, creating new rituals, consistent exercise, quality nutrition, good sleep, and maintaining a consistent schedule.

What are some of the common symptoms of SAD?

One of the helpful things about treating SAD is the predictability of when symptoms set in compared to other sub-types of depression that are much more variable. Unfortunately there is little research answering the question of whether or not this can be prevented or if there is a significant benefit to starting treatment early. Of the limited data available the medication Wellbutrin was found to be the most helpful intervention to start early.

Sources:

https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder/index.shtml 

https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder 

https://www.yalemedicine.org/news/covid-19-seasonal-affective-disorder-sad 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302868/ 

https://www.sciencedirect.com/science/article/pii/S2215036620303072 

https://forge.medium.com/advice-for-coping-with-seasonal-depression-from-9-people-who-have-it-a5c04fdfe996

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By Tracy S. Cummings, MD, Associate Chief Medical Officer for Clinical Excellence and Chief of Child and Adolescent Psychiatry, Lindner Center of HOPE

Medical school was an intense experience filled with mass information consumption regarding physiological health, followed by residency and fellowship focused on mental health care amounting to nine years of training to be a Child & Adolescent Psychiatrist. So much knowledge was amassed over those years, and what topic do I find myself talking about most nearly each day at work? The use of electronics (phone, tablet, computer) by teens. Now, the irony is not lost on me that most readers will be viewing this article online. Ever-present digital media is a reality in our society, and the complicated relationship with it in our lives has become clearer in recent years. Particularly, concerns regarding the impact of the use of electronics on the lives of young people with developing brains have been raised in the literature, by treatment providers, in schools, by families, and even by teens themselves. According to a 2019 Pew Research Center report, “nearly all US teens (95%) say they have access to a smartphone, and 45% say they are ‘almost constantly’ on the internet”. Taking the good with the bad, the need to recharge the proverbial battery in our youth has never been so necessary.

A 2020 estimate by the American Academy of Child and Adolescent Psychiatry noted 4-6 hours/day of screen time for 8-12-year-olds in the US and around 9 hours/day for teens. With a traditional school day lasting 7 hours, it seems the electronics are winning out on capturing the attention of our adolescents. While not all use is problematic, several studies have found associations between the amount of time spent online (and the number of social media platforms utilized) with symptoms of depression, anxiety, obesity, headaches, musculoskeletal pain, decreased levels of physical activity, and problems with sleep (delayed bedtime and/or decreased total sleep time). A growing number of teens sleep with the phone next to them and feel the need to check it multiple times a night with a sense of urgency to respond to any and all notifications immediately. It is striking how many families will report their child has sleep issues leading to irritability and trouble focusing, but often no type of boundary or limitation on phone use, particularly at night, exists. Nomophobia continues to rise globally (and this pertains to adults and youth alike).

Most tweens/teens use their devices to pass the time, and it has become the preferred method for many to interact with their peers. As fewer households have landlines, caregivers like the idea of their child being able to reach them if needed, therefore the age at which a child is receiving their own smartphone has decreased, with approximately 20% of 8-year-olds now having one. Considering the plethora of items one can stumble upon online, even as an adult, the use of the internet by children and adolescents carries significant risk. Frequently, caregivers are unaware of the viewing history on the device, and there is always the potential for exposure to violence, sexual content, substance use, cyberbullying, predators, diet culture, negative stereotypes, and misinformation.

Similar to other household rules, phone/electronic use needs to have parameters. As families consider how phone/internet use will be consumed in their homes, an AACAP Fact For Families Guideline on Screen Time suggests the following:

• For ages 6 and older, encourage healthy habits and limit activities that include screens
• Turn off all screens during family meals and outings
• Learn about and use parental controls
• Turn off screens and remove them from bedrooms 30-60min before bedtime

Healthy screen habits will need to include discussions about what is appropriate to view and share. Kids need to be taught about privacy and safety. Honest discussions about family expectations regarding accounts, passwords, and data usage is helpful (though not always liked by the teen). Looking up information and gaming together are ways to ensure valid resources and monitoring while online. The ability to use the electronic device as a tool to learn new things and connect positively with others can be encouraged and should ideally be modeled by the adults in the home. Consistency with setting this good example will establish a healthy foundation in the youth while holding the adult accountable at the same time. The Business Insider quotes analyst Ben Bajarin’s data about how iPhone users unlock their phones on average 80 times/day. For comparison, adults laugh about 15 times/day. This might be a good time for families to consider which one of those activities would bring us more joy so we can recharge together.

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Nicole Jederlinic, DO
Lindner Center of HOPE Staff Psychiatrist and Medical Director for the Cincinnati Children’s Hospital Acute Unit at Lindner Center of HOPE

As an inpatient and outpatient child / adolescent psychiatrist, I see children and teens, and, consequently, their families facing a wide range of mental health conditions. In the wake of the extensive remote learning related to the COVID-19 pandemic, these challenges have become increasingly common, and can range from social impairments to academic hardship to overt refusal to attend school.

According to the National Alliance on Mental Health, one in six children ages 6-17 experience a mental health disorder each year. Nearly half of all mental health conditions begin by age 14. While schools play a critical role in helping to identify concerns in children, schools are often tremendously (and increasingly) overwhelmed and can only do so much. As such, parents and guardians can play an active role in helping to identify their children’s struggles. Unfortunately, most kids won’t directly tell you they are struggling, so here are some signs to look out for:

-Talking about school becomes off limits, particularly about subjects in which your child may be struggling.

-Your child exhibits a major attitude change toward school. Children and teens may complain of being “bored”, which could also mean they do not understand the material.

-Your child exhibits changes in sleeping or eating patterns. Especially, look out for this on school nights.

-Your child spends too much time on homework. A rough estimate is that a child may have about ten minutes per grade level of homework per night. It’s important to be familiar with the teacher’s homework policy.

-Your child’s teacher explicitly expresses concerns. They see the behavior in school, BUT even they miss things, especially if your child tends to hold things in and is not disruptive.

-Your child begins to misbehave at school.

-Your child receives low grades and these are a drastic change from grades they previously earned.

-Your child spends much of the school day at the nurse with vague physical complaints, missing critical class time and socialization. At an extreme, your child may attempt to avoid going to school altogether.

Now that you’ve identified the problem, what can you do? Have an open conversation with your child – let them know what you’ve noticed and give them a chance to respond themselves. Try and stay open and really listen to their concerns without trying to assume your own interpretations like “they are lazy” or “they are overdramatic”. Remember, they may be guarded, so it’s important to gather additional information. Connect with your child’s teachers to get their thoughts. If difficulties are in one specific class, you could try tutoring or extra help from the teacher;  if they are more pervasive you may need to be more aggressive in how you address things. Try and determine the nature of the difficulty: is it more social/emotional or cognitive/academic? The school may be able to help distinguish this, and it’s okay to ask for additional help from a pediatrician, therapist or psychiatrist.

At public schools, you may formally request that the school evaluate your child’s needs by submitting a written request. Remember to sign and date the request, have the school sign and date when they receive the request and get a copy upon their acceptance of the letter. They have 30 days to respond and either agree to start an evaluation OR provide parents with a “Prior Written Notice” explaining why they do not think evaluation is warranted. This does not mean families cannot purse additional testing /evaluation on their own, but sometimes this can be costly.

Overt refusal to attend school is not a diagnosis in the psychiatric manual, but can point to a variety of psychological conditions like anxiety, trauma or depression. Approximately 2-5% of school children may experience school refusal. It’s important to remember this is NEVER normal. The failure to attend school has significant short and long-term effects on children’s social, emotional, and educational development. That said, it is a complicated problem and requires a collaborative approach to treat. Parents SHOULD NOT feel they are in this alone! Other members of the team may include a pediatrician, psychiatrist, or therapist. At some extremes, children may even require treatment in an inpatient psychiatric hospital or partial hospitalization program. It’s important to build relationships with the school and possibly others to help develop and plan for getting and keeping a child in school.

Typically, remote learning is not the answer to any school difficulties. Even prior to the pandemic, studies indicated that students who did remote learning were at a disadvantage. In 2015, a study of 158 virtual schools compared with traditional schools indicated virtual students obtained lower results in reading and math. In 2021, an analysis of virtual learning during the pandemic indicated a loss of five to nine months of learning with multiple psycho-social consequences including anxiety, depression, concentration difficulties, social isolation and lower levels of physical activity. In summary, there is little evidence of benefit with complete remote learning. More schools are offering hybrid learning models for students floundering in mainstream programs.

School is central to a child’s development. Parents now should have some tools and resources for identifying signs of struggle in their children. Early intervention is important to foster academic and social development and promote psychological well-being.

References:

NAMI. Mental Health in Schools. https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Mental-Health-in-Schools

Linnell-Olsen, Lisa. (2020, May 20). 7 Warning Signs Your Child is Struggling in School. Very Well Family. https://www.verywellfamily.com/warning-signs-your-child-is-struggling-in-school-2601436

Cincinnati Children’s Hospital Inpatient Handouts. SPED Request for Families.

Kawsar, MD S., Yilanli, M and Marwaha, R. (2021, June 11). School Refusal. StatPearls (Internet). https://www.ncbi.nlm.nih.gov/books/NBK534195/

Bissonnette, S and Boyer, C. (2021, July 27). The Effects of Remote Learning on the Progress of Students Before and during the Pandemic. Inciativa Educacao. https://www.iniciativaeducacao.org/en/ed-on/ed-on-articles/the-effects-of-remote-learning-on-the-progress-of-students-before-and-during-the-pandemic

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By: Angela Couch, RN, MSN, PMHNP-BC,
Psychiatric Nurse Practitioner

The research is in, and it’s clear. Exercise can help with depression, anxiety and cognitive decline, not to mention the physical benefits which we are all probably familiar with already. Physical inactivity can also be a risk factor for depression and anxiety.

What are the ways exercise can benefit us?

  1. Increases our energy and motivation levels
  2. Releases “feel good” endorphins, and endogenous cannabinoids that enhance our sense of well-being
  3. Reduces the inflammatory activities of immune cells that can harm us
  4. Has positive impacts on brain derived neurotrophic factor (BDNF) which can increase the growth of new neurons (cells) in the brain
  5. Enhances the ability to fall asleep and stay asleep
  6. Improves self-esteem
  7. In the immediate time frame, exercise helps reduce feelings of anxiety, drops our blood pressure, enhances alertness, and can help break the cycle of negative thoughts
  8. With time, exercise reduces feelings of depression, increases motivation, and helps with executive functioning
  9. With time, it reduces the risk of mild cognitive impairment and dementia in older adults

But lifestyle changes are hard to begin with, right?  How do I do it when I’m feeling depressed or anxious, or otherwise unmotivated?

  1. Don’t wait to have the motivation. We can always find an excuse to do it another day, or wait for the “right” time when we feel “better”, and hours can become days, days can become weeks, you get the picture.  However, choosing to do it now is choosing to do something that might make us feel better. “I’ll go for a walk now to help me feel better” instead of “I’ll go for a walk when I feel better.” Motivation levels increase when we’re in a good routine of activity.
  2. Start small, and set reasonable goals. If the idea of “exercise” is too intimidating or unpleasant to consider, shoot for increasing physical activity to start.  Just getting off the couch and moving around is a great start.  Physical activity can include working in the yard or garden for a few minutes, doing some stretching, parking further away from the grocery or the office, vacuuming the house, or walking to the end of the street and back. Don’t think of exercise as another chore on the to-do list, but as a wellness activity and part of treatment.
  3. Make it easier. Set the time, date, and activity on the calendar.  Lay your clothing out the night before, or sleep in it when you’re shooting for activity first thing in the morning.  Set your sneakers by the door.  If you need help getting out of bed for a morning workout, set the alarm on the other side of the room so you cannot lay in bed and hit the snooze button.  If mornings aren’t your thing, choose the time of day when you feel the most energy, or tend to be in the brightest mood, for getting started.
  4. Use an app or a video if you’re not sure what to do, don’t want to pay for a gym membership, or don’t particularly want to be around people. You can get lots of ideas for things you can do at home, if the gym is not your thing, by looking on Pinterest, YouTube, or the internet.  There are often options for mild, short workouts for beginners available.  Make sure to start slow, don’t do anything that causes pain, make the duration short to start, and don’t expect to master the move right away. Consult with your primary care provider, especially if you have some physical limitations or challenges.
  5. Find activities you know you’ll enjoy, or try new things. We’re much more likely to follow through on activities we enjoy. If walking on a treadmill in the basement seems boring, go for a walk or bike ride outside, or hit the local mall and “window shop” while you walk. Take the dog to the local dog park with a tennis ball for play time.  Listen to fun music, or an interesting pod cast, to make the activity more enjoyable.
  6. Enlist help. Work with your therapist or provider to come up with a viable plan to get you moving.  Set up physical activities or exercise to do with a friend,  to make it more enjoyable and  increase the likelihood of follow through. Signing up for a fitness class, or for sessions with a personal trainer, may increase the likelihood of follow through because of sense of accountability.
  7. Be kind to yourself. Reward yourself sometimes for doing the hard thing. Track your victories, even ones you feel are small, and review them when you’re feeling low or discouraged.  Allow yourself to take a break when you need to.

Exercise and physical activity are two tools we can use to help improve our well-being, which can be cost-effective and don’t require a prescription.

Toups, M., Carmody, T., Greer, T., Rethorst, C., Grannemann, B., & Trivedi, M. H. (2017). Exercise is an effective treatment for positive valence symptoms in major depression. Journal of affective disorders, 209, 188–194. https://doi.org/10.1016/j.jad.2016.08.058

Kandola A, Vancampfort D, Herring M, et al. Moving to Beat Anxiety: Epidemiology and Therapeutic Issues with Physical Activity for Anxiety. Curr Psychiatry Rep. 2018;20(8):63. Published 2018 Jul 24. doi:10.1007/s11920-018-0923-x

Stubbs B, Vancampfort D, Rosenbaum S, Firth J, Cosco T, Veronese N, Salum GA, Schuch FB. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Res. 2017 Mar;249:102-108. doi: 10.1016/j.psychres.2016.12.020. Epub 2017 Jan 6. PMID: 28088704.

Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;(9):CD004366. Published 2013 Sep 12. doi:10.1002/14651858.CD004366.pub6

Tan ZS, Spartano NL, Beiser AS, et al. Physical Activity, Brain Volume, and Dementia Risk: The Framingham Study. J Gerontol A Biol Sci Med Sci. 2017;72(6):789-795. doi:10.1093/gerona/glw130

Nuzum H, Stickel A, Corona M, Zeller M, Melrose RJ, Wilkins SS. Potential Benefits of Physical Activity in MCI and Dementia. Behav Neurol. 2020;2020:7807856. Published 2020 Feb 12. doi:10.1155/2020/7807856

Physical Activity Guidelines for Americans, 2nd edition | 2018 U.S. Department of Health and Human Services

 

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By: Jen Milau, APRN, PMHNP-BC

When I started my career as a nurse practitioner in 2017, I couldn’t have guessed that I’d end up where I am today – a psychiatric provider treating children, adolescents, and adults with a largely misunderstood and relatively controversial diagnosis that causes severe neuropsychiatric symptoms due to a misdirected immune response.

Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS), considered by expert consortiums to be a type of Autoimmune Encephalitis (AE), is characterized by a dramatic onset of severe obsessive-compulsive symptoms or food restriction that presents along with two or more of the following which cause impairment to functioning:

  • Behavioral/developmental regression (immature play, “baby talk,” afraid of the dark, wanting to sleep in parents’ bed, etc)
  • Abnormal movements such as tics, jerking/involuntary muscle spasms, stereotyped movements
  • Severe mood swings and depression
  • Out of character rage, aggression, tantrums with or without self-injurious behavior or suicidal/homicidal ideation or gestures
  • Changes to executive functioning (poor memory, impaired concentration/focus, slowed processing speed)
  • Separation anxiety and panic attacks
  • Psychosis
  • Sensory amplification (aversion to certain textures, sensitivity to noise, lights, or repetitive sounds)
  • Insomnia or other sleep disturbance (nightmares/night terrors)
  • Changes to fine motor skills or muscle strength (for example, difficulty opening doors, using utensils or holding a pencil; changes to handwriting or drawing abilities)
  • Urinary changes (bedwetting, daytime accidents, urgency/frequency of urination)

So what causes this?

While originally believed to be an unusual response to a Group A Strep infection (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, or PANDAS), we now understand that in susceptible individuals, PANS can be triggered by anything that activates the immune response – this can include infection, allergies, certain cancers, inflammatory conditions or injuries, and exposure to toxins. Like other autoimmune diseases, PANS occurs when the immune system mistakes our own cells and healthy tissue as foreign pathogens that need to be eradicated. More commonly-identified autoimmune diseases, such as rheumatoid arthritis, lupus, hashimoto’s thyroiditis, etc., present with primary physical symptoms that are associated with the type of cell that is mistakenly targeted by the inflammatory response. In the case of PANS/Autoimmune Encephalitis, however, it’s healthy tissue in certain areas of the brain that is the target of this autoimmune attack – the result being the array of severe neuropsychiatric symptoms described above.

Interestingly, since the start of the COVID19 pandemic, PANS/AE clinicians across the country have seen a significant increase in cases. In some instances, this is clearly related to infection with the COVID19 virus, itself; however, often the trigger is not straightforward, and while many theories currently center around the impact of extreme stress (which subsequently can increase inflammation and suppress the immune response which elevates the risk of reactivation of latent infection or acquiring illness from exposure), the overall etiology is not clear.

How is it diagnosed & treated?

PANS symptoms exist on a spectrum of severity that impacts the approach to a diagnostic work-up and treatment recommendations. For individuals with mild to moderate symptoms who are otherwise functioning fairly well overall, I often recommend “traditional” psychiatric treatment with the appropriate psychotherapy interventions along with low-dose medications to target their psychiatric symptoms, with the plan to keep PANS on my differential should their presentation abruptly change in the future.

Typically, however, the patients that I see have a much more severe and impairing set of neurological and psychiatric symptoms that warrants a diagnostic assessment to look for underlying infectious, inflammatory, or immunological abnormalities that might be impacting their clinical presentation. This typically consists of blood work and urine studies though can sometimes include imaging when clinically indicated. In rare and severe cases, a lumbar puncture might be considered. Collaboration with clinicians in other specialty areas such as immunology, rheumatology, and neurology, is necessary in more complex case presentations.

In general, the treatment of PANS entails a three-pronged approach:

  • Initiate appropriate psychiatric interventions including psychotherapy and medications to target specific symptoms (SSRIs/SNRIs, Non-stimulant ADHD medication, Antipsychotics).
  • Treat any underlying infection with appropriate antimicrobial medication, keeping in mind the importance of balancing this with pre/probiotics to ensure that gut flora is adequately maintained during therapy.
  • Treat immune system dysregulation with anti-inflammatory medication and/or immunomodulatory therapy if indicated.

Once someone has gotten through the most severe part of their flare-up, we often transition to a “maintenance” phase of treatment which includes lifestyle and dietary changes along with selective use of supplements to support immune health and manage systemic inflammation. Psychiatric treatment is also maintained for as long as clinically indicated. These efforts, along with quick identification and treatment of signs/symptoms of future flare-ups, help to minimize the frequency/intensity of subsequent flares and can ultimately improve long-term prognosis.

What makes this such a controversial diagnosis?

Our understanding of PANS and other neuroinflammatory conditions is still somewhat in its infancy. This means that much of the existing literature is based on empirical evidence gathered by expert consensus groups and clinicians with experience in assessing, diagnosing, and treating this special patient population. As with any emerging field of science or medicine, new research and expanded awareness of the disease have led to modifications to the original diagnostic criteria and theories associated with PANS/PANDAS – however, these updates (namely, that PANS/AE may not present as “acute” onset, but rather, as sub-acute or insidious; not limited to pediatrics – can also occur in adolescence and adulthood) are largely underrecognized, and as a result, the condition is prematurely “ruled out” in individuals who otherwise meet criteria based on their clinical presentation.

The complex and variable presentation of symptoms and potential triggers associated with PANS leads many clinicians to refute the connection between infection/immune dysfunction and psychiatric symptoms. Unfortunately, when seeking care, families often face judgment and experience repeated invalidation when they attempt to bring up their concerns for possible PANS/AE, as individual providers and occasionally even entire organizations maintain a firm stance against the assessment/diagnosis and treatment of PANS/PANDAS as a whole.

Final thoughts and resources:

PANS/AE can be a significant source of suffering not only for the individual impacted by the illness, but the entire family who is involved with their care. It’s important to strengthen your own support systems and build in time for self-care when faced with a loved one’s intense cognitive and behavioral manifestations of the disease.

Regardless of the underlying etiology, psychiatric treatment with psychotherapy and appropriate medication management is imperative for individuals with this diagnosis.

Below are a few of my favorite resources for patients, families, and clinicians who want to learn more about PANS/PANDAS/AE:

https://pandasnetwork.org/

https://www.pandasppn.org/

https://aspire.care/

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OCD is a common disorder and affects 1 in 40 people, it is also the 3rd most common psychiatric condition. This disorder can be very tricky and tries to tell lies to keep people trapped in anxiety. Below are the 10 common tricks it tries to use to keep the anxiety lingering as well as how to combat them.

The most common trick is OCD trying to convince you that “this time it is not OCD.” It is important to educate patients how to spot the difference and it’s helpful to emphasize that OCD tends to feel like an emergency and needs to be attended to immediately. One way to treat this lie is to do the “public service announcement” test which is basically challenging the patient to call the radio and request to make a public service announcement to warn people about their fear (i.e., please inform everyone they should not wipe less than 20 times when going to the bathroom, it is not safe to do less than this). This strategy helps them test out their belief and helps them realize they need to accept uncertainty but increase willingness to bet that is OCD and not give in to the compulsion.

The second most common trick is that OCD convinces you that “only crazy, bad, dangerous people have these thoughts.” It is important to teach patients that the content of one’s thoughts is the maker of “crazy, bad, dangerous.” Also educating patients that everyone has intrusive thoughts and how we cannot control our thoughts helps normalize this.

The third most common trick is “if only I knew why I had these thoughts I could stop my OCD.” Many patients have found the why, but actually only have recovered once applying evidence-based CBT skills. Teaching patients that finding the why will not solve their OCD is important.

The fourth most common trick is thinking “you’ll never beat me (OCD), so don’t even bother trying.” Teaching patients that short-term comfort will only lead to worse OCD and more discomfort overall, but short-term discomfort will actually lead to a more free and comfortable life is important for this trick.

The fifth most common trick is to convince you that you must control your thoughts. Teaching patients it is impossible to control their thoughts will be helpful for beating this trick. The more you try to control them the worse they get. Having patients use meditation like leaves on a stream to allow them to practice observing their thoughts is helpful for this.

The sixth most common trick is trying to convince you that compulsions must be done perfectly. To combat this helping the patient complete the compulsions imperfectly is helpful, such as changing the language of compulsions, or changing the preferred hand to complete the compulsion.

The seventh most common trick is convincing you that rituals will help give you the comfort of certainty. This is a common trick and one that patients spend a lot of time trying to obtain. Teaching patients that there is never certainty in anything is key here. Helping the patient see all the ways they are able to tolerate uncertainty in other areas of their life is helpful: while driving, while eating, when going to bed, going to the grocery store, etc.

The eight most common trick is that you will feel better with reassurance. Helping them reduce reassurances is helpful here, which can be done by tracking reassurances and reducing them by 20% each day to week.

The ninth most common trick is thinking you have a great responsibility to keep everyone safe. One cool technique for this trick is to have patients actually try to make something happen to you by thinking “I hope you break leg tomorrow” or “I hope you get a flat tire on your way home.” This helps the patient see that they don’t actually have control over things.

Finally, the tenth most common trick is thinking” if you don’t do this ritual, something bad will happen to you or your family.” To combat this last trick it can be helpful to change the way you do the ritual as mentioned previously, and to also purposefully wish for bad things to happen, which directly targets the fear.

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The sympathetic nervous system (SNS) is responsible for our “fight, flight or freeze” response and has been essential to our survival since beginning of our existence. In the case of traumatic, threatening emotional, mental and physical experiences, this fear response can become altered.  Connection between the amygdala and hypothalamus causes change to the hypothalamic-pituitary-adrenal axis (HPA), increasing cortisol levels and increased HR, increase respiratory rate, hypervigilance, and sleep disturbance. There are several neural connections and neurotransmitters acting on the amygdala contributing to fear response, and medication management has its risks. In hopes to improve overall outcomes of patients, many people and practitioners have utilized complementary and alternative medicines (CAM).

Yoga is probably the most known and utilized form of CAM in the united states. Yoga has been practiced for thousands of years to heal both physical and mental ailments. Philosophically, Yoga is defined as “Union”, and often interpreted as “union to the divine within”. Union is achieved through pranayama- breathing and asanas- postures.  This ancient Eastern tradition has gained popularity due to the awareness of the mind-body-spirit, holistic approaches in America and Europe. There is now a fair scientific understanding and body of research validating its potential benefit as an integrative intervention.

There are several benefits to incorporating yoga that could benefit people with trauma. It is important to assess one’s state of stability prior to introducing yoga therapy. In yoga philosophy, the concept of krama means “in the correct order” and can reduce risk of additional pain and suffering caused by the treatment. Just as establishing a sense of safety prior to other trauma therapies is essential, it is also to do so with yoga.

Controlling the length of inhale and exhale and manipulating the diaphragm stimulates the Vagus nerve or CN X and parasympathetic response to “rest and digest”. This effectively promotes cardiac relaxation, decreases contractility in the atria and ventricles (less-so). Primarily, it reduces conduction speed through the atrioventricular node. CN X can lower cortisol levels via modulating the hypothalamic-pituitary-adrenal-axis. Which is thought to be hyperactive in people with trauma and stress disorders.

Vagal tone is the body’s ability to successfully respond to stress. One study, by a team in Boston University School of Medicine (Streeter et al, 2012), hypothesized that Yoga effected the autonomic nervous system to improve stress response in PTSD. Using ujjayi pranayama (form of resistance breathing popular in Hatha yoga)  they found “increased relaxation response and increased heart rate variability” thus resilience to effects of stressors It is well understood that yoga has a calming action on the nervous system and is valuable as an adjunct treatment for those with trauma and stress related disorders.

In yoga there are two major concepts that can have psychological benefit. Chitta is the inner processes and capacity of attention and focus inward; and samskaras- the storehouse of past actions, self-beliefs/messages. In yoga the use of asanas, pranayamaand meditative practice- one works towards awareness and letting go of these unhelpful attachments that are stuck in the mind and body. As we know in people who have survived trauma, emotional scars can be felt throughout the body and leave scars of psychological destruction. Yoga offers a loving message of positive, self-compassion and promotes a gentle, non-judgmental environment.  Letting go of negative self-beliefs has many benefits psychologically.

After a trauma, in my experience and in DSM V criteria, one’s self-perception of negativity as well as negative beliefs about the world can damage spirituality or connection to a power greater than oneself.  In yoga the common ending to a practice is to bow in honor and say “Namaste”. Which translates into “the Divine light within me sees, honors and respects the Divine light within you”. For those with trauma, believing there is light within them that can shine again, can be the key to transformational healing. Yoga is not a religion, and it does not promote worship of any deity, instead “God” is expressed as truth, light, love and energy that is flowing through the universe.  Religious and non-religious can benefit from the spiritual practice of Yoga.

Yoga has proven its place in the holistic approach to mental health treatment, and because the only requirement is to be able to breathe, it is accessible to anyone who can breathe.  It has been said about yoga, by a great teacher… the breath is a wonder drug! I hope you consider utilizing a yoga practice for yourself or recommending it to someone who could benefit.

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Christine Collins, MD, Lindner Center of Hope

By: Christine Collins, MD, Lindner Center of HOPE Addiction Psychiatrist

 

 

 

Legalization of cannabis is rapidly expanding across the world. To date, 17 states (and DC) in the US have legalized marijuana for all uses, and another 19 states have legalized it for medical purposes only. The media tends to portray cannabis and its constituents, as safe, natural items that have potential to provide benefit. As medical marijuana dispensaries and CBD stores seem to be popping up all over, it is important for us to recognize the impact of cannabis on mental health and how it may affect vulnerable populations, such as young people. Clinicians and patients alike should be aware of the current state of scientific evidence and possible risks posed by cannabis use.

Cannabis is a complex plant composed of hundreds of compounds including THC (9delta-tetrahydrocannabinol, the main psychoactive component) and CBD (cannabidiol, purported to offer many health benefits). There are currently several medications approved by the FDA that are cannabis-related: dronabinol and nabilone (synthetic THC containing meds used for chemotherapy-related nausea and for appetite/weight gain in HIV patients), and recently-approved Epidolex (cannabis derived which contains CBD used for the treatment of rare childhood seizure disorders, Dravet syndrome and Lennox-Gastaut syndrome). These were extensively studied and underwent the typical FDA process for approval as effective and safe medications for these purposes. Other uses of cannabis are largely unregulated.

Using “medical” marijuana varies by state and is a much different process from taking an FDA approved medication which has been rigorously studied. Since it is designated DEA schedule I by the federal government, large scale studies on cannabis have been limited in the US. The current scientific evidence on cannabis remains mostly observational data and animal studies, rather than the gold-standard randomized controlled trials in humans. There is an ongoing need for well-designed research in this area to better understand the possible therapeutic benefits and safety profile of cannabis and to differentiate the effects of its constituents. Current evidence suggests that cannabis may help chronic pain, nerve pain, and spasticity in certain patients. There is limited and inconsistent evidence that CBD in particular may have benefit in treatment-resistant anxiety, social anxiety, and insomnia. However, other studies show that whole-plant cannabis worsens existing anxiety and mood. Notably, there IS consistent evidence that cannabis increases the risk for developing a psychotic disorder in vulnerable individuals and exacerbates psychotic symptoms. Cannabis use in anyone with a history of an addictive disorder may trigger another cross addiction or contribute to someone falling back to an old addiction.

Safety considerations must be taken into account regarding cannabis. Today’s whole-plant cannabis is generally more potent (higher levels of THC) than it was historically. How it is consumed also plays an important role—vaping allows for a higher percentage of THC to be absorbed quicker and therefore may be more likely to trigger adverse mental health reactions such as anxiety and paranoia. Edibles can cause problems for users who expect a quicker onset of action leading to higher levels of consumption to achieve a desired effect. Interactions with other medications do occur. For instance, certain psychiatric meds may alter the breakdown and elimination of THC and CBD, and vice versa.

What may be the area of greatest concern is the impact of increasing cannabis acceptance and legalization on young people. A recent study demonstrated that earlier use of all substances including cannabis was associated with increased risk for developing a substance use disorder later in life.  Cannabis use has been shown to have adverse effects on IQ and executive functioning. Moreover, younger onset of marijuana use is associated with lower overall neurocognitive functioning. Youth who engage in marijuana use, also report taking part in other risky behaviors such as using other substances like nicotine and alcohol, and driving after marijuana use. As such, there is grave concern that cannabis use in this age group could lead to significant problems.

While ongoing high-quality research is needed in this area, current available evidence does NOT show consistent benefit for cannabis (including CBD products) on mental health symptoms and it may instead exacerbate symptoms. Patients should be encouraged to use caution and to have open conversations with their mental health and medical providers about cannabis use in order to understand how this may impact their mental health. Clinicians should be aware of the risks of cannabis use particularly for adolescents and should help prevent use in this specific population.

Sources:

Dharmapuri, S, Miller, K, & Klein, JD. Marijuana and the pediatric population. Pediatrics. 2020; 146(2)279-289

Hill, K. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems, a clinical review. JAMA. 2015; 313(24) 2474-2482

Levinsohn, E & Hill, K. Clinical uses of cannabis and cannabinoids in the United States. Journal of the Neurological Sciences. 2020; 116717

Whiting et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015; 313(24) 2456-2473