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By Jennifer Farley, PsyD
Associate Chief of Psychological Services, Lindner Center of Hope

 

 

 

In many areas, autumn’s colorful trees and darker mornings are reminders of the transition from summer to winter. Evening hours just don’t feel the same compared to the long days of summer when people are more active from sunrise to sunset. While it is common to experience life differently at different times of the year, approximately 10 to 20 percent of people in the United States experience a mild depression during the darker seasons, and 4 to 6 percent of Americans experience moderate or severe depression.

Seasonal Affective Disorder (SAD) is a clinical depression triggered by seasons of the year. SAD is believed to be associated with seasonal changes in the amount of daylight. For most people with SAD, symptom onset is in the fall or early winter, and relief starts in spring. Symptoms of SAD can last up to 5 months. SAD is more common in women than men and is typically not experienced prior to 20 years old. SAD is more common among young adults and the risks of developing SAD decrease with age. People with a depressive disorder or Bipolar Disorder and people with family members with SAD or other forms of depression raises the risk of having SAD. Living in sunnier regions and closer to the equator decreases the risk of SAD, validating why many people become “snow birds” and go south for the winter.

Because SAD is a depressive disorder, individuals experience at least some symptoms of Major Depressive Disorder. These can include feeling depressed most of the day, nearly every day, having less interest in enjoyable activities, sleep problems, feeling sluggish or agitated, having low energy, and feeling hopeless or worthless. Additional symptoms can include overeating, social withdrawal, and poor concentration. It is common for people with SAD to oversleep by going to bed earlier and/or waking later. A clinical diagnosis of SAD requires a full remission of symptoms when the season ends and 2 consecutive years of episodes in the same season.

Causes of SAD include lower levels of the neurotransmitter serotonin, disruption of the circadian rhythm, increased melatonin, and a deficiency in Vitamin D. SAD is most typically diagnosed by primary care physicians, but psychiatric clinicians (medication prescribers and therapists) can also identify SAD.

Though there is not much that can be done to avoid getting SAD, symptoms can be managed to reduce their intensity. Some people start treatment or interventions before SAD symptoms start or before the season changes. Methods of treatment include light therapy (i.e., light boxes), medication, cognitive-behavioral therapy, increased Vitamin D, and lifestyle changes. Taking care of one’s body by eating healthy and getting sufficient sleep, exercising, and avoiding alcohol and drugs can help. Managing stress is important, as is being around others. Isolation and loneliness may fuel depression. Planning pleasant daily or weekly indoor or outdoor activities can be helpful to help fight “hibernation”. People also benefit from planning a vacation somewhere warmer and sunnier during the winter, and the experience of anticipating something positive helps reduce depression. Though some people use tanning beds in the winter months, this is NOT recommended due to the harmful exposure of U/V rays.

Individual therapy and/or medication treatment can be quite helpful for those with SAD, and it is especially recommended when depression is at a moderate or severe intensity. Cognitive-Behavioral Therapy in particular helps by replacing negative thoughts about winter with more positive thoughts. Discussing ways to implement lifestyle changes and planning for enjoyable activities can be helpful. Therapy can also offer opportunities to learn and practice mindfulness and to explore how to radically accept the fall and winter by “leaning in” to its opportunities. People do not have to live through darker months with dark mood.

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By Danielle Johnson, MD, FAPA
Chief Medical Officer, Lindner Center of Hope

Mood disorders have distinct disturbances in emotions. Low moods are called depression and high moods are called hypomania or mania. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) categorizes mood disorders into bipolar disorders and depressive disorders. Mood disorders include major depressive disorder, bipolar I and bipolar II disorder, disruptive mood dysregulation disorder, premenstrual dysphoric disorder, persistent depressive disorder, and cyclothymic disorder. In the U.S., almost 1 in 10 (9.7%) adults experienced any mood disorder in the past year, with past year prevalence of any mood disorder being higher for females (11.6%) than for males (7.7%). More than 1 in 5 (21.4%) U.S. adults will experience any mood disorder in their lifetime. Mood disorders are common in children and adolescents with an estimated 15% having any mood disorder. Major depressive disorder and bipolar disorder are the most common mood disorders with 8.3% of all U.S. adults experiencing at least one major depressive episode in the past year and 2.8% of U.S. adults having bipolar disorder in the past year.

When people experience symptoms of a mood disorder that do not look like major depression or bipolar disorder this can lead to a delay in diagnosis and treatment as they might have difficulty articulating their symptoms and healthcare professionals might not ask questions about other disorders. Although other mood disorders are less common and less severe, they still impact quality of life and functioning.

Persistent depressive disorder (dysthymia) was added to DSM-5 in 2013, combining some criteria of dysthymic disorder and chronic major depressive disorder. With PDD, depressed mood occurs for most of the day, for more days than not, for at least two years (one year for children and adolescents). During a two-year period (one year for children or adolescents), a person has never been without symptoms for more than two months at a time. A major depressive episode can occur before PDD, or people can experience “double depression” when major depressive episodes occur during PDD.

Symptoms can include poor appetite or overeating; insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; or feelings of hopelessness. PDD is associated with greater childhood adversity and maltreatment, childhood loss of a parent, earlier onset of depression, and higher rates of chronic depression in relatives. People with PDD also experience a higher number of traumatic events during their lifetime. The 12-month prevalence ranges from 0.5% to 1.5%.

Cyclothymic disorder consists of episodes of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder. The lifetime prevalence is approximately 0.4%-1%. Symptoms last two years, for more days than not with stability of mood for no longer than two consecutive months. Symptoms of depression can include depressed mood, irritability, hopelessness, helplessness, insomnia, fatigue, anhedonia, avolition, negativity of affect, and suicidal ideation. Hypomanic symptoms can include impulsivity, grandiosity, racing thoughts, increased sociability, excess physical activity, and increased speech production.

People with cyclothymia may experience emotional lability, hypersensitivity, recurrent interpersonal altercations, incidents of self-harming, episodes of excessive gambling, reckless sexual activity, multiple divorces, legal or financial problems, and recurrent job loss. The chronic and pervasive nature of cyclothymic disorder can lead to misdiagnosis with cluster B personality disorders.

There are no FDA-approved medications for PDD or cyclothymic disorder. Your psychiatrist or psychiatric nurse practitioner will take a thorough history including past medical history, previous medical trials, and other psychiatric diagnoses and work with you to develop a treatment plan and choose appropriate medications and psychotherapy to treat depressive and/or hypomanic symptoms.

Sekhon S, Gupta V. Mood Disorder. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558911/

https://www.nimh.nih.gov/health/statistics/any-mood-disorder

https://www.nimh.nih.gov/health/statistics/major-depression

https://www.nimh.nih.gov/health/statistics/bipolar-disorder

Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK541052/

Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK541052/

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By Angela Couch, RN, MSN, PMHNP-BC,
Psychiatric Nurse Practitioner, Lindner Center of Hope

The goal of treatment for OCD is not to get rid of the thoughts but to learn to tolerate uncertainty. For someone who struggles with OCD, the idea of this, of tolerating uncertainty, can create a lot of discomfort.  Medications will not get rid of the thoughts, unfortunately.  This is because we cannot “control” our thoughts or prevent them.  Thoughts come into our brains, often unbidden, and sometimes contain content we didn’t ask for or want, which may be scary or upsetting.  For someone who has OCD, this occurrence creates a more intense feeling of distress, which often leads to various compulsions, in an effort to relieve the distress and the uncertainty.

Medication is recommended for the treatment of OCD any time someone has a moderate to severe case of OCD. Appropriate psychotherapy is very important; generally, this is a sub-type of CBT (Cognitive Behavioral Therapy) called ERP (Exposure and Response Prevention), or sometimes ACT (Acceptance and Commitment Therapy). The combination of medication and psychotherapy is the most powerful between medication alone, psychotherapy alone or both together. Those who have completed appropriate psychotherapy also, have a lower risk of significant relapse if medication treatment is stopped.

Medication can help make the thoughts less “sticky” in the brain. It also can slow the thoughts down and somewhat reduce the level of distress caused by the thoughts. This can make it easier for someone to participate in the appropriate psychotherapy to manage the OCD.  Medication can help someone ride the waves of OCD/uncertainty more effectively. There are many treatment options, which should be individualized to the patient.

The frontline treatments for OCD are typically the SSRI (Selective Serotonin Reuptake Inhibitors) or the TCA (Tri-cyclic antidepressant) clomipramine, or sometimes an SNRI (Serotonin Norepinephrine Reuptake Inhibitors). These medications slowly build in the patient’s system after repeated administration to a steady state at which the medications begin to assert their effects. Dose increases are common because OCD typically requires higher dosing than when treating depression or anxiety disorders such as Generalized Anxiety Disorder, Panic Disorder, etc.
Sometimes, this may include “off-label” dosing (dosing higher than the FDA label for the drug). Typically, we don’t call a drug trial a true failure until the patient has taken the highest dose for up to twelve weeks because it often takes longer for the medications to impact OCD than the other disorders listed above.

Sometimes, an augmentation strategy is used in conjunction with the primary treatment. Augmentation strategies may more commonly include SDA’s (Serotonin Dopamine Antagonists, also called second-generation antipsychotics), or drugs that may impact the neurotransmitter glutamate such as NMDA receptor antagonists, certain mood stabilizers, or acetylcysteine. SDA’s or mood stabilizers are also commonly used when a patient has a concurrent bipolar spectrum illness, because treatment with an SSRI, SNRI, or TCA alone may cause mood switching.
Sometimes, when a patient has a diagnosis of OCD alone, they may very slowly taper off the medication after having a longer period of stability on the medication and psychotherapy. Sometimes this is successful for some period of time, but sometimes an individual’s brain simply needs the support to keep symptoms manageable, and that is okay, too. Patients who also have a mood or other type of disorder may need to take the medication longer term. These treatment decisions need to be tailored to the individual’s circumstances.

In conclusion, psychotherapy is a critical piece of the treatment plan, there are many medications that may provide benefit in the treatment of OCD, and treatment decisions should be individualized.

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Common Assessment Tools for Identifying and Treating OCD

By Whitney Peters LPCC
OCD Specialist, Lindner Center of Hope 

Beginning a successful journey in obsessive compulsive disorder (OCD) treatment starts with the right diagnosis. OCD occurs in people from any gender, age, or ethnicity, and happens to approximately 1 in 100 adults and 1 in 200 kids and teens. Many people think of OCD as being a germaphobe or preferring things to be organized, but the reality of OCD is far from the stereotype we think of.

People with OCD spend hours a day preoccupied with upsetting concerns that cause them feelings of anxiety and disgust, and in order to alleviate themselves or prevent those uncomfortable feelings, they must perform physical or mental acts. People with OCD can develop obsessions about anything they find to be important or valuable. This may include developing obsessions about things like their family, careers, spiritual beliefs, or identity, among many others.

For example, someone with Harm OCD might be bothered by an obsession around the possibility of having hit someone with their car.  This obsession takes over their thoughts so that they spend a lot of time driving around looking for evidence, repeating memories of their drive to reassure themselves, and frequently checking their rear-view mirror. This is all to make sure they didn’t hit anyone. People with OCD realize what they are afraid of is unlikely, but the distress they face with these concerns make it difficult to resist checking, ruminating, or looking for reassurance that they are safe. OCD symptoms can become so intrusive that a person may have difficulty functioning in daily life or attending work or school. OCD is considered one of the top 10 most disabling conditions, and the symptoms of OCD can look very different depending on the person. It is critical that a clinician the individual is working with knows how to spot it. OCD assessment tools can help us more effectively identify symptoms, specific subtypes, and assess for severity.

OCD Assessment Tools

The Obsessive Compulsive Inventory (OCI)
The Obsessive Compulsive Inventory (OCI) is a 42-item measure and screening tool for some OCD symptoms that a patient can complete independently or during a structured interview. The OCI measures some OCD symptoms, including Checking, Doubting, Ordering, Hoarding, and Neutralizing. This assessment offers check box examples that a patient and provider can indicate the severity of each prompt on mild to severe ranges and scores are added to determine the occurrence and severity of one’s OCD. The measure can also be given periodically during treatment to measure progress made in each area and help providers target treatment.

(Obsessive-compulsive Inventory (OCI) – Reproduced & adapted by permission of the authors: Foa, E.B., Kozak, M.J., Salkovskis, P.M., Coles, M.E., & Amir, N.)

Yale Brown Obsessive Compulsive Scale (Y-BOCS)
and Child Yale Brown Obsessive Compulsive Scale (CY-BOCS)
One of the most widely used assessments is the Yale Brown Obsessive Compulsive Scale (YBOCS) or the Child Yale Brown Obsessive Compulsive Scale (C-YBOCS) and is considered the Gold Standard of OCD assessments. These assessments identify the presence of obsessions and compulsions by offering examples that a patient can check independently or during a structured interview with a provider. The Y-BOCS helps providers and patients identify current and past obsessions and compulsions, and can provide structure in treatment.

(Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.” Arch Gen Psychiatry 46:1006-1011,1989; Scahill, L., Riddle, M.A., McSwiggin-Hardin, M., Ort, S.I., King, R.A., Goodman, W.K., Cicchetti, D. & Leckman, J.F. (1997). Children’s Yale-Brown Obsessive Compulsive Scale: reliability and validity. J Am Acad Child Adolesc Psychiatry, 36(6):844-852.)

Dimensional OCD Scale (DOCS)

The Dimensional OCD Scale is an assessment that breaks down OCD into four main categories, although there are some obsessions that may not fit neatly into these categories of Contamination and Sickness, Responsibility for Harm or Mistakes, Unacceptable or Taboo thoughts, and Incompleteness/Asymmetry. This assessment can be self-reported by the patient or given as an interview by the provider. The patient or provider will scale their symptoms in 5 domains, including estimated hours per day experiencing symptoms, degree of intensity of anxious distress, degree of avoidance behaviors, degree of impact on day-to-day functioning, and degree of difficulty in disregarding their compulsions. This assessment can be given at periodic intervals during treatment to measure improvements by comparing scores.

(Abramowitz, J. S.; Deacon, B.; Olatunji, B.; Wheaton, M. G.; Berman, N.; Losardo, D.; Timpano, K.; McGrath, P.; Riemann, B.; Adams, T.; Bjorgvinsson, T.; Storch, E. A.; Hale, L. (2010). “Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale”. Psychological Assessment. 22 (1): 180–198. doi:10.1037/a0018260. PMID 20230164. S2CID 7206349.)

Family Accommodation Scale
With patients who are children or live with a family, we may often use the Family Accommodation Scale, which can identify potential accommodations performed by family members that can harm progress in treatment. A family member, spouse, or guardian may complete a Family Accommodation Scale alone or assisted by a provider. The prompts ask how many days a week a person may be performing common accommodations to help identify accommodations and to measure improvement in reduced accommodations over time. They can also help a family identify which accommodations to begin eliminating and help provide structure to treatment.

(The Family Accommodation Scale for Obsessive Compulsive Disorder – Self-Rated Version (FAS-SR) Copyright © 2012 by Anthony Pinto, Ph.D., Barbara Van Noppen, Ph.D., & Lisa Calvocoressi, Ph.D. The Family Accommodation Scale for Obsessive Compulsive Disorder – Self-Rated Version (FAS-SR) includes a modified version of the Yale Brown Obsessive Compulsive Scale (YBOCS) Checklist, copyright © 1986, 1989, with permission.)

Assessments help both professionals, patients, and their families understand the specific symptoms present in a disorder and can be used to identify areas of progress in treatment by comparing previous results with current scores.

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By Shea Daniels Graham, LPCC-S, Outpatient Telehealth Counselor

One of my favorite metaphors comes from Shift Journal and describes autism as being a hair-dryer brained person in a toaster-brained world. To paraphrase: If we think about the brain as a machine made of wires and gears we inherit, there is an imaginary world where most people are born with those wires and gears turned into a toaster. In this world where most people have toaster brains there’s going to be a lot of toast—white, wheat, rye, everything bagels, cinnamon raisin bread—but it’s all toast. Making toast is almost effortless for most people in this imaginary world so it becomes an integral, expected part of existing in society. Some people, though, are born with hair dryer brains, and while they can make toast—because you can make toast with a hair dryer, after all—it is going to fundamentally take them intentional effort, time, and skill building, to do what comes effortlessly for the toaster-brained…and even with that effort, time, and skill building, someone with a hair dryer brain is never going to be able to make toast as effortlessly as someone whose brain is a toaster. Now, if the roles were reversed, society would be created around having a hair dryer for a brain and those born with toasters for brains would have trouble drying hair. But in this imaginary world there are more people with toasters for brains, so people with hair dryer brains put a lot of time and energy into simply existing.

The National Institutes of Health estimates, as of 2020, that approximately 1 in 45 adults in the United States are living with autism spectrum disorder. Various studies indicate between 20% and 50% of adults living with autism are undiagnosed. Our understanding of autism has shifted drastically since the term was first used in 1911 by German psychiatrist Eugen Bleuler to describe a form of severe schizophrenia (Bleuler 1950 [1911]), Evans 2013). It wasn’t until the growth of child psychology in the 1960s that we begin seeing anything resembling modern autism criteria, such as Victor Lotter et. al’s 1966 epigenetic study to identify prevalence of autism in Britain’s children. Their screener, which significantly mirrors current autism diagnostic criteria, included 24 items related to social and pragmatic communication; vestibular, proprioceptive, and auditory sensory differences; and, repetitive behaviors. It is interesting to note, here, that Lotter et. al’s original screening tool was based on an earlier screening tool by child psychiatrist Mildred Creak (Evans, 2013). Creak’s screening tools included reports of internal experience which Lotter et. al. excluded due to concerns internal experience was too subjective to be useful.

This trend towards excluding diagnostic criteria based on internal experiences continues even today. Compared to other mental health and neurodevelopmental diagnoses in the DSM, Autism Spectrum Disorder is the only diagnosis not to include any report of internal experiencing (American Psychiatric Association, 2013).

Going back to the example above of toaster brains and hair dryer brains: some hair dryer brains are going to be more effective at making toast than others. Some people with hair dryer brains might be able to optimize their settings, the bread they use, etc., to make toast almost as well as someone whose brain is a toaster. They might even become so effective at making toast with a hair dryer than we wouldn’t know their brains weren’t toasters, if they didn’t tell us about how difficult it is to live with a hair dryer brain in a toaster world.

The Camouflaging Autistic Traits Questionnaire (CAT-Q) is a short, reliable, accurate, valid, and current autism screener appropriate for outpatient clinical use. The CAT-Q is particularly special because it is the only such screener which measures the internal experience of autism. It includes 24 screening questions such as, “I rarely feel the need to put on an act in order to get through a social situation,” “I have developed a script to follow in social situations,” “In social situations, I feel like I am ‘performing’ rather than being myself,” and “in social situations, I feel like I am pretending to be ‘normal,’” each scored on a A-G scale from “Strongly Disagree” to “Strongly Agree.” The CAT-Q has a high internal consistency both for the total scale and for the three sub-scales of Compensation, Masking, and Assimilation. Test-retest reliability was good, as was the total stability of this screener (Jones, 2021). Results are normed by gender for women, men, and non-binary/transgender populations.

Identifying traits of autism in our patients is a crucial part of providing competent care. Regardless of whether or not a patient who scores above-threshold on the CAT-Q opts to pursue formal assessment for autism, for those patients with above-threshold results, we as clinicians can tailor our interventions to acknowledge the patient’s traits of neurodivergence.

At times, tailoring our treatment to account for diagnosed autism, or traits of autism, is simply best practices. For example, in their 2018 study Cooper et. al identified that “almost all” therapists found it necessary to adapt Cognitive Behavioral Therapy interventions due to the increased rigidity of thinking people with autism experience. Without adaptations, the CBT interventions did not produce comparable results for adults with autism compared to neurotypical adults engaged in comparable treatment protocols.

At other times, tailoring our treatment to account for diagnosed autism, or traits of autism, is not only best practices—it is a critical component of not causing harm to patients. In his 2014 presentation to the EMDR Europe Association Conference, S. Paulson explained that due to the variety complex neurological differences individuals with autism present with, trauma processing using EMDR can be more difficult, or even harmful, without appropriate modifications to the standard treatment protocol. With appropriate accommodations, however, EMDR is an incredibly effective treatment for adults with autism who have a co-occurring trauma history. Lobregt-van Buuren et. al found that after 6-8 weeks of standard therapy followed by up to 8 EMDR sessions, at a 6-8 week follow up patients “showed a significant reduction of symptoms of post-traumatic stress (IES-R: d=1.16).”

Ultimately research tells us that compared to same-age peers, people entering mental health services who are later diagnosed with autism experience higher rates of depression, anxiety, and psychosis (French et. al 2023). Not only do people with undiagnosed autism experience higher rates of troubling mental health symptoms, but a 2022 study in Britain found 10% of people who died from suicide had evidence of elevated autistic traits indicative of likely undiagnosed autism—a number 11 times higher than the rate of autism in the general population. As research tells us people with autism, or traits of autism, are unlikely to respond as well to therapeutic interventions unless those interventions are adapted appropriately, screening for traits of autism becomes a crucial best practice.

As a clinician I tend to utilize the CAT-Q screener as readily as I use a PHQ-9 or GAD-7. I use the CAT-Q any time a patient presents with a combination two or more diagnoses whose symptoms may align with autism. I also utilize the CAT-Q screener when I have a patient reporting chronic social difficulties or difficulties with sensory input, with patients who report a chronic history of ineffective mental health interventions, and with patients who report wondering if they have autism. Not every person with autism struggles with mental illness—but every person with autism who does enter mental health services has a right to high quality care tailored to their brains.
After all, if we only provide toaster mechanics, how will the hair dryers ever get a tune up?

Citations
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
https://doi.org/10.1176/appi.books.9780890425596

Bleuler E. (1950[1911]) Dementia Praecox or the Group of Schizophrenias. New York: International Universities

Cassidy, S et al. Autism and autistic traits in those who died by suicide in England. BJPsych; 15 Feb 2022;
DOI: 10.1192/bjp.2022.21

Dietz, P. M., Rose, C. E., McArthur, D., & Maenner, M. (2020). National and state estimates of adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(12), 4258–4266. https://doi.org/10.1007/s10803-020-04494-4

French B, Daley D, Groom M, Cassidy S. Risks Associated With Undiagnosed ADHD and/or Autism: A Mixed-Method Systematic Review. J Atten Disord. 2023 Oct;27(12):1393-1410. doi: 10.1177/10870547231176862. Epub 2023 Jun 21. PMID: 37341291; PMCID: PMC10498662.

Jones, N. (2020, April 21). The CAT-Q. Embrace Autism. https://embrace-autism.com/cat-q/
Lobregt-van Buuren, E., Mevissen, L., Sizoo, B. B., & de Jongh, A. (2018, August).

Eye movement desensitization and reprocessing (EMDR) therapy as a feasible and potentia effective treatment for adults with autism spectrum disorder (ASD) and a history of adverse events. Journal of Autism and Developmental Disorders

Lotter V. (1966) ‘Epidemiology of Autistic Conditions in Young Children’, Social Psychiatry 1: 124–37 [Google Scholar]

Mary. (2010, October 11). A Hair-Dryer kid in a Toaster-Brained world.
https://www.shiftjournal.com/2010/10/11/a-hair-dryer-kid-in-a-toaster-brained-world/

Paulson, S. (2014, June). EMDR with autism. In EMDR clinical practice symposium (Marilyn Luber, Chair).
Symposium presented at the 15th EMDR Europe Association Conference, Edinburgh, Scotland

Rutter M. (1998) ‘Developmental Catch-up, and Deficit, following Adoption after Severe Global Early
Privation. English and Romanian Adoptees (ERA) Study Team’, Journal of Child Psychology and Psychiatry 39: 465–76 [PubMed] [Google Scholar]

 

 

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By Nik Raju, MD
Lindner Center of Hope Staff Psychiatrist

Disclaimer: This was written for general informational purposes only and should not be viewed as medical advice. Please consult with your personal physician/care provider and/or registered dietitian for specific recommendations tailored to your individualized needs.

As the saying goes, food is medicine. While we often think of medicine as the medications prescribed by physicians and healthcare providers, the types of foods we eat on a day-to-day basis can also have an impact on our overall physical and mental well-being. Nutritional psychiatry is an emerging field within the medical specialty of psychiatry that essentially involves applying principles of nutrition to optimize brain health. Despite the tendency at times in medicine to separate the brain and the mind from the rest of the body, what is good for the body is often what is good for the brain. One of the main pioneers of nutritional psychiatry, Dr. Drew Ramsey is a psychiatrist who is a clinical professor at Columbia University as well as a farmer, and he provides his own explanation of nutritional psychiatry in this short video: https://drewramseymd.com/brain-food-nutrition/what-is-nutritional-psychiatry/. 

Nutritional psychiatry does not recommend one particular diet, though there is growing evidence that a plant-based, whole food-based diet can optimize mental and physical health, as long as some of the nutrients we usually obtain from meats and dairy products are received through proper supplementation. Given the high energy consumption and the amount of open land required to maintain cattle and livestock within our planet’s agricultural system, a whole food, plant-based diet can minimize environmental impacts while also improving our own health. This is a win-win for the planet and human health.

Dr. Ramsey and Dr. Uma Naidoo, another expert psychiatrist who is also a trained culinary chef and nutritionist based at Harvard Medical School, do not suggest that meat and seafood be eliminated completely from day-to-day food consumption but instead suggest we should be mindful of what protein sources we are eating. Regular consumption of red meats, such as beef and pork, as well as processed deli meats can produce generalized inflammation in the body, including in the brain, and inflammation in the cells and tissues that make up neural circuits in the brain is one of many hypothesized causes of depression. Unprocessed poultry meats and certain types of seafood are less likely to promote this inflammation in the brain. Shifting to foods with natural sugars, such as fresh fruit, and foods with high fiber content, including certain unprocessed grains and vegetables, can keep us full for longer periods of time, which can help us make more mindful food choices.

Nutritional psychiatry also emphasizes the gut-brain connection, as the brain cells (called neurons) comprising neural tracts in the brain communicate with cells in the gastrointestinal (GI) tract. The GI tract is actually the largest source of serotonin in the body, with approximately 90% of serotonin produced in the GI tract and 10% of serotonin produced in the brain. Serotonin is an essential (but not the only) neurochemical that regulates mood in the brain, and the SSRI antidepressants such as fluoxetine, sertraline, and escitalopram function partly by increasing the concentration of serotonin in neural circuits involved in depression. Some of the emerging research has found that maintaining healthy gut bacteria by consuming certain foods can also help reduce symptoms of depression and anxiety, and the neural networks communicating from the brain to the gut are considered to be one of the main mechanisms.

The concepts in nutritional psychiatry do not suggest foods can replace medications for mental health disorders. For conditions such as moderate to severe anxiety, depression, bipolar disorder, and schizophrenia, medication management is still usually required despite optimizing one’s diet. However, a medication regimen can at times be modified to require fewer psychiatric medications and maintained at lower doses by optimizing one’s diet and engaging in appropriate physical activity.

For further nutritional psychiatry concepts and practical information as to what foods to eat to optimize mental health, I often recommend Dr. Uma Naidoo’s This is Your Brain on Food and Dr. Drew Ramsey’s Eat to Beat Depression and Anxiety to my patients. Both books are written for the general public, and Dr. Ramsey’s book even includes recipes and meal prep ideas with optimizing one’s diet. I am also by no means an expert on nutrition, so I recommend following up with a registered dietitian to optimize your meals and food intake. Regardless, I do hope you come away from this article with general ideas and further suggestions on how to optimize what you eat to also ensure optimal brain health.

nik rajuDr. Raju is a staff psychiatrist at Lindner Center of Hope and Assistant Professor of Clinical Psychiatry and Neuroscience at the University of Cincinnati College of Medicine. All views expressed in this article are his own.

 

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Harnessing the power radical openness to enhance connection and psychological well-being.

We as humans, from a biological perspective, are meant to be vulnerable and connected beings. We aren’t the strongest or fastest species, and yet humans dominate the animal kingdom. We do this because of our ability to have and express our emotions and thoughts to others, listen to and respect the thoughts and emotions of others, and to connect and work together.

Despite this innate human characteristic, many of us struggle to let our guards down and be open to others. We often find ourselves compulsively striving for perfection or insisting our way is the right way. Somewhere along the way, we got the message that if we only try harder and be better, our life too will be better. Or we may have come to believe that showing emotions makes us weak and pushes people away. This way of coping is like a suit of armor, we might feel it protects us and makes us stronger, but it actually weighs us down and guards us from others. Remember that we are meant to live in connection with other people, and research shows that this “over-controlled” form of coping contributes to anxiety, depression, and emotional loneliness because it works against connection.

Instead of coping in this way, radical openness is the pathway to well-being. It connects us with our core, authentic human nature and involves three main components:

  • Openness and Receptivity
  • Authenticity and Vulnerability
  • Flexibility and Silliness

Openness And Receptivity.

“We don’t see the world as it is, we see it as we are.” Our unique brains and experiences contribute to how we see the world; thus we are all going to experience the world differently. Examine this inkblot. What do you see? What is the “right” answer?

There isn’t one. How often do we get so stuck on our perspective that we reject others in the process? Radical openness encourages us to acknowledge our own inner experiences, while holding space for other people’s experiences. It is being aware of our own bias and allowing ourselves to grow and learn from what the world has to offer. Doing so will help us live more harmoniously with others and in turn, enhance our own well-being.

Vulnerability and Authenticity. Despite how scary it might feel, being open with ourselves and vulnerable with others builds connection. When was mask our emotions, hide behind the façade that “all is well,” or compulsively strive for perfection, we create emotional loneliness in our own lives. Research shows that people like people who openly revel themselves, they are seen as more trustworthy, and we want to spend more time with them. When we are authentic and vulnerable with the world, others feel safer with us, and in turn we feel more connected to others. Vulnerability creates peace in our inner world and builds community in our outer world.

Flexibility and Silliness. We live in a world that is constantly changing and is unpredictable. Yet, we feel we must be in control and expect ourselves to be perfect all the time. Sometimes we take life too seriously and block ourselves from joy. Radical Openness encourages us to be flexible, to step outside our comfort zone, and have some fun. We are not production robots. We are humans with a life, and life is meaningful when we allow ourselves to flexibly participate. Having a balance between productivity and enjoyment helps sustain our psychological health.

So remember, when it comes to navigating this crazy thing called life, do so with openness, vulnerability, and flexibility. That is what it means to be human. Embrace your humanness and embrace the humanness in others. Connection is the key.

Written by Allison Mecca, PsyD

Staff Psychologist

Lindner Center of Hope

 

 

Concepts based on Lynch, T. R. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy. If you interested in learning more about radical openness and treatment for over-controlled coping, please contact the Lindner Center of Hope or visit lindnercenterofhope.org/dialectical-behavioral-therapy/.

 

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By Lauren Neiser, MSN, APRN, PMHNP-BC

Keto. Atkins. South Beach. NutriSystem. Weight Watchers. Intermittent Fasting. Paleo. Low-Carb. The HCG Diet. Raw. Jenny Craig. Slim Fast. What do all these diets have in common? They are all ineffective and potentially harmful.

We live in a diet culture driven society that celebrates thinness and is abundant with internalized fat phobia. In the United States (US), the diet industry capitalizes on our society’s obsession with thinness, generating, in 2023 alone, $90 billion dollars in profit (Research and Markets, 2024). Within the US, there is a constant captivation and fixation related to body weight, shape, and size, “healthy” eating, and exercise. This diet driven culture keeps many individuals stuck in a yo-yo dieting cycle, often leading to malnutrition, preoccupation with food, poor body image, and potentially developing a disordered relationship with food. So, if diets are effective, why is the diet industry continually growing?

 

The short answer is diets do not work and are unsuccessful because they are often very restrictive and therefore, not sustainable.

Many diets villainize whole food groups, such as carbohydrates or sugars, which is not feasible for long term health or overall well-being.

As humans, we need a variety of foods to function, including glucose and carbohydrates, for our brains to function. Our brain solely utilizes glucose, and we cannot produce glucose ourselves, resulting in a need to obtain glucose directly from food sources (Wolrich, 2021). The best source of glucose? Carbohydrates. If we completely cut out this category of food or are following a very restrictive diet, this limits our brain’s ability to function at its highest capacity. This often leads to difficulty concentrating, inattentiveness, irritability, lower mood, heightened anxiety, fatigue or low energy levels, and poorer sleep. Another often vilified food component is fat. Fat, however, is essential to many bodily functions, including absorbing micronutrients, such as vitamin D or E, forming cells, and for overall energy (Wolrich, 2021). Therefore, if we moderately or severely limit our fat intake, we may become deficient in vitamins essential for bone health and experience weakness or lethargy. Additionally, anytime we are assigning a food item or food group a label such as “unhealthy” or “bad”, we begin to appoint morality to food. This, in turn, can lead to disordered eating. The truth is food has no morality. Food cannot be “good” or “bad”, it is simply food, a collection of nutrients. We need a vast variety of foods, including fats, sugar, carbohydrates and proteins, in order to allow our body to operate at its full capacity for overall well-being, both physically and mentally.

Research has shown that less than 10% of dieting individuals are able to keep the weight they lost off for over a year (Kraschnewski, 2010). Part of this is simply due to biology because every individual has their own set point. Set point theory suggests “that body weight is regulated at a predetermined, or preferred, level by a feedback control mechanism” within the brain (Harris, 1990, p.3310). This means your body has a weight that keeps its homeostasis or “happy place” and will adjust in any way it can to maintain the weight where it feels safest. When we engage in purposeful restriction in order to lose weight, our brains cannot recognize whether this is intentional or unintentional, leading to a starvation state. This results in our body beginning to try and conserve the energy or food nutrients it currently has. This results in a slower metabolism, changes in the way your body absorbs nutrients, and storing fat to mitigate the risk of starvation (Harris, 1990). This is the science behind why 90% of individuals who diet gain most, if not all, the weight back within one year (Research and Markets, 2024).

In the end, an individual’s weight is not simply a factor of will power. Weight stems from many different, predetermined aspects, including biological, environmental, economic, behavioral, and genetics. This is a small glimpse into why diets do not work and how they are harmful for our bodies, our minds, and our relationship with food and movement. If you are struggling with body image, disordered eating, or anxiety related to food or your body, please call the Lindner Center of Hope at 513-536-HOPE to get connected with a clinician or provider who can help.

References:

Harris, Ruth. (1990). Role of set-point theory in regulation of body weight. The FASEB Journal. 4(15), 3310-3318. https://doi.org/10.1096/fasebj.4.15.2253845

Kraschnewski JL, Boan J, Esposito J, Sherwood N, Lehman EB, Kephart DK, Sciamanna CN. (2010). Longterm weight loss maintenance in the United States. International Journal of Obesity, 34, 1644-1654. https://www.nature.com/articles/ijo201094

Research and Markets. (2024). The U.S. Weight Loss Market: 2024 Status Report & Forecast. Marketdata LLC. 

Wolrich, Joshua. (2021). Food isn’t medicine. Random House. 

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An Untapped Resource in the Treatment Journey

 According to a February 2024 article in the Journal of American Child and Adolescent Psychiatry, the prevalence of mental health conditions in adolescents has been increasing worldwide, outpacing the availability of effective mental health care. More adolescents require acute inpatient psychiatric hospitalization, but do not have resources for sub-acute care after discharge. Step-down programs, often known as partial hospitalization or day treatment programs, are helpful in decreasing re-admissions but are often underutilized. These programs can also serve as a step-up from outpatient care if severity is escalating. Partial hospitalization is designed to offer this intermediate level of care between inpatient and outpatient services.

Given that adolescence is a dynamic stage of life full of transitions and a common time for symptoms of mental illness to first present, teens may have difficulty managing home, school, and social activities without therapeutic intervention. Adolescent partial hospitalization offers day treatment during weekdays, so evenings and weekends can be used for patients to test skills learned during treatment hours.

Though partial hospitalization programs primarily occur in group settings, programs should be designed in a way that meet the unique needs of each patient participating in the program.  Ideally, programing includes elements such as psychoeducation, individualized treatment planning and goal setting, a variety of psychotherapeutic experiences, psychiatric evaluation, educational support, and family involvement.

The most effective adolescent partial hospitalization programs are staffed by multidisciplinary treatment teams including a board-certified child and adolescent psychiatrist and psychiatric nurse practitioner, mental health specialist, specialized therapists, licensed social worker, psychiatric registered nurse, licensed teacher, and a dietitian.

Patients and families participating in adolescent partial hospitalization should benefit from tangible insights and skills that will foster resilience, improve communication, bolster coping skills and functioning. These tools are intended to help better navigate daily life and maximize a teen’s chances for success.

 

Lindner Center of HOPE in Mason, Ohio offers an adolescent partial hospitalization program for mental health. Learn more about the program at:  https://lindnercenterofhope.org/adolescent-partial-hospitalization-program/.

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By: Laurie Little, PsyD
Chief Patient Experience Officer and Staff Psychologist,
Lindner Center of HOPE

In recent years, there has been a growing interest in exploring alternative and innovative treatments for mental illness. Among these novel approaches, ketamine has emerged as a promising treatment for various mental health disorders. Traditionally known as an anesthetic and pain-relieving medication, ketamine has shown potential in treating mental health disorders such as depression and anxiety.

History of Ketamine

Ketamine was originally discovered by chemist Calvin Stevens in 1962 for Parke Davis Company and was Food & Drug Administration (FDA)- approved for medical use as an analgesic and anesthetic in 1970.  It is considered a “Dissociative Anesthetic” with different dosages leading to differing effects. Lower dosages can lead to a psychedelic experience and higher dosages can lead to complete dissociation or analgesia. When using Ketamine as an analgesic, researchers noticed an intriguing off-label effect: a rapid and pronounced improvement in mood and depressive symptoms in some patients. This discovery sparked interest in exploring ketamine’s potential as a novel treatment for mental health disorders.

To curb its illicit and recreational use, the United States categorized Ketamine as a Schedule III federally controlled substance in 1999, however research into its mental health benefits continued to flourish. In 2019, the FDA approved the first ketamine derived therapy, called Esketamine, as a therapy for treatment-resistant depression.

Ketamine and Depression

Ketamine’s antidepressant effects are unique compared to traditional antidepressant medications, which typically take several weeks to produce noticeable results. Ketamine often provides immediate relief to patients who are suffering. Ketamine promotes the release of Glutamate, an essential neurotransmitter that is related to cognition, memory and mood.  Traditional antidepressants often affect neurotransmitters such as Serotonin and Dopamine and take longer to notice an improvement in symptoms.

A recently published large, systematic review of published journal articles on Ketamine treatment found “support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust but suggests similarly positive and short-lived effects.“ The findings suggest that ketamine facilitates rapid improvements in symptoms among patients with major depressive disorder (MDD), bipolar disorder and suicidality, lasting up to 7-14 days after treatment. In some cases, effects last up to four weeks, depending on the number of ketamine sessions and the underlying mental health conditions.

There is also preliminary but growing evidence base supporting the efficacy of ketamine therapy for substance use disorders, anxiety disorders (generalized, social, OCD, PTSD)  and eating disorders.  However, just like its antidepressant effects, ketamine’s reductions in anxiety are also short-lived, and symptom recurrence is common after several weeks.

Patients who receive adjunctive psychotherapy appear to achieve the most long-lasting benefit compared with ketamine administration alone.

Ketamine Assisted Psychotherapy

Research shows that Ketamine is most beneficial when it is combined with psychotherapy. There is no current standard for how therapy and Ketamine should be combined. Some practitioners combine lower doses of Ketamine and engage in therapy during the treatment. Other practitioners use higher doses of Ketamine and have the patient engage in therapy either the following day or later in the week. Since patients notice an immediate improvement in their mood, they are more able to benefit from therapy and are more open and receptive to thinking about their current circumstances in a new, helpful way.

The Benefits and Challenges of Ketamine Treatment

The most notable benefit of ketamine treatment is its rapid and profound antidepressant effect. Unlike traditional medications, ketamine can provide relief within hours. This immediate response is particularly crucial for patients in crisis, who are suicidal or those struggling with treatment-resistant mental health conditions.

Moreover, ketamine treatment may benefit individuals who cannot tolerate or have not responded well to other standard treatments. Unfortunately, a significant percentage of patients do not find relief from standard therapies and it is important to have multiple treatment options available.

However, ketamine treatment does come with its challenges and risks.

  • Long-Term Data. One major obstacle is the lack of long-term data on the safety and efficacy of ketamine as a mental health treatment. While research has shown short-term benefits, the question of how long the benefits last requires additional investigation.
  • Misuse. Due to its powerful impact, Ketamine is also often misused. Research is still needed on the abuse potential of Ketamine. Interestingly, there is some evidence to suggest that Ketamine itself can be effective in the treatment of other substance use disorders such as alcohol and heroin. There is still much more to be learned
  • Insurance Coverage. Ketamine treatment is often not covered by insurance for mental health conditions, making it financially inaccessible for many patients. The cost of treatment, coupled with the need for repeated administrations to maintain benefits, raises concerns about equitable access to this innovative therapy.

Ketamine treatment represents a groundbreaking shift in the approach to mental health treatment. Its rapid and transformative effects on depression, anxiety and other mental health conditions have sparked hope for those who have exhausted conventional therapies. While ketamine shows immense promise, ongoing research is needed to fully understand its long-term safety and efficacy.

As the field of mental health continues to evolve, ketamine treatment has the potential to offer a lifeline to those who struggle with treatment-resistant conditions. It is crucial for the medical community, researchers, clinicians, policymakers, and insurers to collaborate in ensuring equitable access to this promising therapy.

Ketamine Therapy & Treatment in Cincinnati

If you’re seeking Ketamine Therapy in Cincinnati, the Lindner Center of HOPE is an excellent place to begin your mental health care journey. Reach out to explore your available options.

 

References

Banoff, MD, Young, JR, Dunn, T and Szabo, T. (2020). Efficacy and safety of ketamine in the management of anxiety and anxiety spectrum disorders: A review of the literature. CNS spectrums, 25(3), 331-342.

Berman, R. M., Cappiello, A., Anand, A., Oren, D. A., Heninger, R., Charney, D. S., & Krystal, J. H. (2000). Antidepressant effects of ketamine in depressed patients. Biological Psychiatry, 47(4), 351-354.

Feder, A., Rutter, S. B., Schiller, D., & Charney, D. S. (2020). The emergence of ketamine as a novel treatment for posttraumatic stress disorder. Advances in Pharmacology, 89, 261-286.

Krupitsky, E. M., & Grinenko, A. Y. (1997). Ketamine psychedelic therapy (KPT): A review of the results of ten years of research. Journal of Psychoactive Drugs, 29(2), 165-183.

Mia, M. (2021) Glutamate: The Master Neurotransmitter and Its Implications in Chronic Stress and Mood Disorders. Front Hum Neurosci. 15: 722323.

Murrough JW, Iosifescu DV, Chang LC, Al Jurdi RK, Green CE, Perez AM, Iqbal S, Pillemer S, Foulkes A, Shah A, Charney DS, Mathew SJ. (2013). Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site randomized controlled trial. Am J Psychiatry. 2013 Oct;170(10):1134-42. doi: 10.1176/appi.ajp.2013.13030392. PMID: 23982301; PMCID: PMC3992936.

Chadi G. Abdallah and Lynnette A. Averil

Ragnhildstveit, A., Roscoe, J., Bass, L., Averill, C., Abdallah, C. and Averillhe, L.. (2023). Potential of Ketamine for Posttraumatic Stress Disorder: A Review of Clinical Evidence. Ther Adv Psychopharmacol, Vol. 13: 1–22, DOI: 10.1177/.

Reznikov L. R., Fadel J. R., Reagan L. P. (2011). “Glutamate-mediated neuroplasticity deficits in mood disorders,” in Neuroplasticity, eds Costa e Silva J. A., Macher J. P., Olié J. P. (Tarporley: Springer; ), 13–26. 10.1007/978-1-908517-18-0_2

Walsh, Z., Mollaahmetoglu, O., Rootman, J., Golsof, S., Keeler, J., Marsh, B., Nutt, D., and Morgan, C. (2022). Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review. BJPsych Open (2022) 8, e19, 1–12. doi: 10.1192/bjo.2021.1061

Witt K, Potts J, Hubers A, et al. Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials. Australian & New Zealand Journal of Psychiatry. 2020;54(1):29-45. doi:10.1177/0004867419883341

Wolfson, P., & Hartelius, G. (Eds.). (2016). The ketamine papers: Science, therapy, and transformation. Multidisciplinary Association for Psychedelic Studies.

Zarate, C. A., Singh, J. B., Carlson, P. J., Brutsche, N. E., Ameli, R.,

Luckenbaugh, D. A., … & Manji, H. K. (2006). A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Archives of General Psychiatry, 63(8), 856-864.