By Peter White, M.A., LPCC, LICDC, Lindner Center of HOPE Outpatient Therapist

The problem during Bipolar Mood Disorders is a pattern of swings of the essential elements of mood between the two poles, like the North Pole and South Pole, of Mania and Depression. These swings are not moodiness, which are swings of mood throughout a day. A Bipolar swing is a distinct period of at least one week when the full spectrum of mood elements exhibits depressive and/or manic elements.

Although thought of as a subjective experience, mood deeply influences three areas. First is metabolism – sleep, appetite, libido and energy levels. Second, mood influences both motivation as well as the ability to experience pleasure and/or a sense of accomplishment. Thirdly, mood deeply influences interpretations within thoughts from positive to neutral to negative.

So, we can think of this first spectrum of mood disorder along an axis of depression to neutral to manic. Therefore, a depressed mood will depress metabolism. A person will have difficulty with sleep through either excessive or inadequate or disrupted sleep, loss of appetite or excessive eating despite disrupted appetite, loss of libido as well as loss of energy. Depression will hinder motivation making it difficult to experience the drive to initiate activities as well as hinder pleasure or the reward of activity. This is a very difficult cycle when it is hard to get active in the day compounded by not finding any pleasure or reward in the day’s activities. Lastly, depression will darken the flow of thoughts adding many themes of hopelessness, helplessness, worthlessness and guilt into our thought process.

Conversely, mania will elevate the same essentials. It will increase energy levels often in the face of declining sleep hours. It will increase libido, increase excessive and/or absence of appetite. It will increase motivation often leading to excessive engagement of plans or activities and will create a compounding loop of all activity feeling especially pleasurable or rewarding. Again, conversely is will paint thinking with elevated judgements of specialness, invulnerability, and inevitable positive outcomes.

The second spectrum of mood disorders, like most other behavioral health problems, is along the spectrum of severity – mild to moderate to severe. If you combine this spectrum of severity along with the first spectrum of depressive to manic, we see how varied and individualized any person’s experience with Bipolar Mood disorders can be.  Most people can relate to some degree of depression during periods of their life with perhaps a few weeks or month of low energy, noticing that they are not getting the same rewards in their regular activity as well as perhaps noticing they are thinking unusually negatively about themselves and their outlook on life. We might call this a mild, brief depressive episode. But the reality is that depression is one of the most disruptive and costly of all health conditions as recognized by the World Health Organization. This mean that depression is often moderate or severe to very severe and can disrupt functioning on every level for weeks to months if not years. A severe depression can make it difficult to get out or bed for days on end both from collapsed energy and motivation. It can destroy the pleasure and rewards of living so that all activity feels like a painful chore at best. Finally, it can turn thoughts dangerously dark with so much hopelessness, helplessness and worthless that suicidal thinking emerges nearly with a sense of relief.

Again conversely, though experienced less often by most people, Manic Episodes can present with mild, moderate, severe and very severe intensity. During a sever episode, a person with manic symptoms is often sleeping little but maintaining very high levels of energy. They are often talking very quickly and sometimes laughing excessively and outside the context of humorous things. Given the very high levels of motivation and the reinforcement of pleasure in all activities, they often initiate an excessive number of activities – starting multiple projects with little awareness of the ability to balance or complete them. They frequently initiate conversations or relationship in an open or disinhibited style very unusual for to their character. With elevated thought patterns, they might believe they have a unique or special purpose, and they are convinced that all their activities will be successful and rewarding. Give the excessive energy, motivation, pleasure and elevated sense of self and success, people in manic states will often engage in behavior patterns much riskier than typical – spending money well beyond their mean, unusually disinhibited sexual decision, reckless driving, shop lifting.

I hope it’s useful to review the way mood symptoms fluctuate along these two spectrums, because like all health care conditions, we are best off when we accurately identify what these behaviors are – symptoms. Mood symptoms are not moral challenges, personality traits or unconsciously desired behaviors. Mood symptoms are symptoms, and fortunately, there are many very effective treatments for all symptoms along both spectrums. Please know if you or a loved one or a client is experiencing any degree of Bipolar mood problems, there will be many ways to help and cope, and experience the satisfaction of effectively treating a behavioral health care condition.

 

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

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

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

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

Selective Serotonin Reuptake Inhibitors (SSRIs) Side Effects

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

Zoloft Side Effects in Women

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

Prozac Side Effects in Women

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

Lexapro Side Effects in Women

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

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs) Side Effects

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

Tricyclic Antidepressants Side Effects

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

Other Antidepressants Side Effects

Wellbutrin Side Effects in Women

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

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

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

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

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

Estrogen Levels With Antidepressants in Females

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

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

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

Lindner Center of HOPE’s Approach

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

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

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

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

By Danielle Beltz, MSN, PMHNP-BC, Psychiatric Nurse Practitioner, Lindner Center of HOPE

Pregnancy and childbirth can be one of the most rewarding and fulfilling things a woman can do in her
lifetime but can hand in hand be one of most challenging and emotionally taxing times.
A female goes through not only physical changes throughout pregnancy but also hormonal, emotional,
and psychological changes. In addition, a pregnancy can bring stress and emotional hardship to their
interpersonal dynamics.

A lot of new moms experience postpartum “baby blues” after giving birth which differentiates from
postpartum depression. Symptoms usually include sadness, irritability, moodiness, crying spells, and
decreased concentration. Baby blues usually begin within 2 to 35 days after childbirth and can persist up
to 2 weeks. When these symptoms last longer than 2 weeks this is when the mother should consider talking
to a healthcare provider.

About one in seven women develop postpartum depression. It most commonly occurs 6 weeks after delivery but can begin prior to
delivery as well. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) a major depressive episode with the onset
of pregnancy or within 4 weeks of delivery is considered postpartum depression. Five of the nine symptoms must be present nearly every
day for at least two weeks and constitute a change from previous functioning to be diagnosed. Depression or loss of interest in addition
to the following symptoms must be present:

• Depressed mood (subjective or observed) most of the day
• Diminished interest or pleasure in all or most activities
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Recurrent suicidal ideation, thoughts of death or attempts
• Diminished concentration or indecisiveness
• Change in weight or appetite (5% weight change over 1 month)

Fifty percent of postpartum major depressive episodes begin before
delivery so collectively these episodes are described as peripartum
episodes. Mothers with peripartum major depressive episodes commonly have severe anxiety and panic attacks.

The exact etiology of postpartum depression is unknown. Several factors have been reported to contribute to the development of
postpartum depression. The physical and hormonal fluctuations resulting from pregnancy influence postpartum women to develop
depression when stressful and emotional events coincide with childbirth. Some of these factors include the stress of motherhood, difficult
labor, poor financial and family support, and harmful health outcomes of childbirth. Lower socioeconomic demographic, personal or
family history of depression, anxiety, or postpartum depression, PMDD, complications in pregnancy and birth, and mothers who have
gone through infertility treatments have also all been suggested to be strong contributors.

Postpartum depression not only affects the mother’s health but also the relationship the mother has with her infant and that child’s
development. Studies have shown that children are at a greater probability of developing behavioral, cognitive, and interpersonal problems
whose mothers have postpartum depression. It can also lead to inability to breastfeed and marital conflict.

Postpartum psychosis is another severe kind of depression but is not the same thing as postpartum depression. Around 1 in 500 or 1 in
1,000 women has postpartum psychosis after delivering a baby. It commonly starts the first 2 weeks after giving birth. Women who are
also diagnosed with bipolar disorder or schizoaffective disorder are more prone to have postpartum psychosis than women who are not
diagnosed with other mental health conditions.

Postpartum psychosis is considered a psychiatric emergency with a capacity of suicide and infanticidal threat. Some symptoms include
delusions, hallucinations, unusual behavior, paranoia, and sleep disturbances. If postpartum psychosis is suspected help should be sought
immediately.

Psychotherapy and antidepressant medications are the first line treatments for postpartum depression. Psychotherapy is considered first
line for women with mild to moderate depression or if they have concerns of starting a medication while breastfeeding. For moderate to
severe depression therapy and antidepressant medications are recommended. The most common medication for postpartum depression is
an SSRI or selective serotonin reuptake inhibitor. Once an efficacious dose is reached, treatment should persist for 6-12 months to prevent
relapse of symptoms. Risk versus benefits of treated versus untreated depression while breastfeeding or pregnant should be discussed.
Transcranial Magnetic Stimulation (TMS) is an alternate therapy that can be used for women who have concerns about their child being
exposed to a medication. Although, the risk of taking an SSRI while breastfeeding is relatively low. ECT is another option for women with
severe postpartum depression who do not respond to traditional treatment. It can be particularly helpful with psychotic depression.

Zurzuvae (zuranolone) is the first oral medication approved by the FDA specifically for the treatment of postpartum depression in adults.
Until August 2023, treatment for PPD was only available as an IV (Brexanolone) and was only available at certified healthcare facilities.

People with depression especially new mothers and postpartum mothers may not identify or accept that they’re depressed. They also
may be unaware of the signs and symptoms of depression. If you are questioning whether a friend or family member has postpartum
depression or is developing signs of postpartum psychosis, assist them in pursuing medical treatment and recognize that help is accessible.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Commissioner, O. of the. (n.d.). FDA approves first oral treatment for postpartum depression. U.S. Food and Drug Administration. https://www.fda.
gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression#:~:text=Today%2C%20the%20U.S.%20Food%20
and,the%20later%20stages%20of%20pregnancy
Guo, L. , Zhang, J. , Mu, L. & Ye, Z. (2020). Preventing Postpartum Depression With Mindful Self-Compassion Intervention. The Journal of Nervous and
Mental Disease, 208 (2), 101-107. doi: 10.1097/NMD.0000000000001096.
Mayo Foundation for Medical Education and Research. (2023, April 14). “I’m happy to be a new mom. but why am I feeling
so sad?” Mayo Clinic. https://mcpress.mayoclinic.org/mental-health/im-happy-to-be-a-new-mom-but-why-am-i-feeling-sosad/?
mc_id=global&utm_source=webpage&utm_medium=l&utm_content=epsmentalhealth&utm_
campaign=mayoclinic&geo=global&placementsite=enterprise&invsrc=other&cauid=177193
Miller, L. J. (2002). Postpartum depression. JAMA : The Journal of the American Medical Association, 287(6), 762-765. https://doi.org/10.1001/jama.287.6.762
Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519070/
Postpartum depression. March of Dimes. (n.d.). https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-depression?gad_
source=1&gclid=EAIaIQobChMIqKLemfTfggMVq0VyCh3ouwGDEAAYBCAAEgKxjPD_BwE
Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S., Lichtenstein, P., Hultman, C. M., Larsson, H., & Sandin, S. (2017). The risk factors for postpartum
depression: A population-based study. Depression and Anxiety, 34(2), 178–187. https://doi-org.uc.idm.oclc.org/10.1002/da.22597
Stewart, D. E., & Vigod, S. (2016). Postpartum depression. The New England Journal of Medicine, 375(22), 2177-2186. https://doi.org/10.1056/NEJMcp1607649

 

by Dawn Anderson, LPCCS

Humans are a very resilient species. We have overcome generations of burdens to accomplish family unity, and yet this effort renews with new barriers and challenges each year. A vital component of a thriving family unit is the ability to co-regulate. Co-regulation describes the process in which a parent can identify their child’s need for help, recognize their own emotional reaction, and then help themselves cope to share that gift with their child.

Just like the airplane metaphor- you must put on your own oxygen mask before you can help others. As a parent, we are bombarded with requests for our time, resources, and attention. We have a certain amount of emotional energy in the day, and this is a renewable resource! Taking the time to take care of your own emotional health allows you to be more responsive in the ways we’d like to show up with our children. Another huge burden on parents is the one we place there ourselves- guilt. We fret about the choices to be made, the amount we’re able to give our children, and the perpetual feeling we aren’t enough. The reality is we all bring different types and amounts of skills and talents to the table.

Some of us have different capacities for stress, and that doesn’t make us good or bad. Sometimes it’s helpful to think of your stress tolerance as a cup- is yours a 12 oz picnic cup? A 2 oz bathroom water cup? An Olympic swimming pool? Whatever the size, we must take ownership of knowing where we are throughout the day, and how we are showing up in interactions with our children. We also need to be intentional about emptying said cup proactively throughout the day, so it doesn’t overflow. Overflow here is where we see the unintentional screaming at our precious ones, storming off, or being unable to play with them after our long day.

Lastly in explanation, its valuable to consider the way language impacts our thoughts, feelings, and behavior. In common language, we say things about children such as “they’re a mess,” “they’re not listening to me,” “they’re being a brat.” In all humans, we have a system in our brain that takes in information and decides if it’s safe or not, and then sends it to either the thinking part or the survival part of our brain. What our brains decide as safe depends on the person. Some of us have different themes that activate the threat systems in our own bodies, and with careful observation, you might be able to pin these down for your loved ones. If this feels difficult, a licensed clinical therapist can help.

Once the “threat center” of your brain decides something isn’t safe, we have survival reactions: our heart rate picks up, heavy breathing, we feel shaky, and/or we have a hard time thinking clearly due to the process where your brain diverts power from the thinking brain to the survival brain. That said, that’s part of why it’s hard to talk to someone who doesn’t feel safe. It’s hard for them to hear you, and hard for them to express how they feel in words. If we use compassionate language, it removes blame from the driver seat. Try “they look like they need help” or “they are having some big feelings” You and your child are a team, and teams are stronger when they work from the operating point that we win when we work together with our strengths.

That said, here are some helpful tips to regulate with your child:

  1. When you identify that your child needs help, first check in with yourself on what you need to be best able to respond to them. Its valuable to practice the breathing skills when you don’t need them, so you can use them in the moment when you do. Trying to only use them in a moment of crisis is like expecting yourself to learn to swim in the choppy ocean.
  2. Get on their level. Kneel, squat, or sit down if necessary. Looking up at someone activates the “threat” center of our brain and makes it harder to calm down.
  3. Use a low, consistent tone. If I want someone to hear me, I need to be quieter, not louder. Especially if they are yelling. Keep your messages concise and direct, such as “I want to hear you, and it’s easier when you’re at a level 2” or “Let’s take a deep breath together then we can put your toy back together.”
  4. Take a full, deep breath in your nose and exhale slowly out your mouth. Imagine feeling like you’re smelling something super pleasant and trying to cool off hot cocoa with the exhale. Even if they are not in the place to participate because they’re too dysregulated, their body will unconsciously mirror yours.
  5. If you’re not able to offer your child 1:1 proximity, or their bodies are not safe for you (i.e. hitting) consider regulating in the room by counting items together. Redirection is a powerful tool for the right moment. Again, a licensed therapist can help you catch these windows of opportunity.
  6. If appropriate, leave the room and regulate yourself before returning. Use your words to announce the intention “I need two minutes to regulate myself and I will be back to work on this with you.” Stepping away from the situation is a tool that can give teenage parents the break we need to not ground our child for the next 100 years when we’re both stuck in an argument.
  7. With any strategy, it’s important to come back together and process Use the compliment sandwich: Identify one thing that went well, offer constructive feedback, and close with another positive thing you noticed or future oriented reconnection point. “I’m proud of you for breathing with me. Next time, do you think it would help if we used the feelings chart? I’m glad I have you.”

 

 

 

 

 

 

 

 

 

 

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. 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.

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.

Lastly, 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.

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,

  1. 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.

 

By: Zachary Pettibone, MD
Staff Psychiatrist, Lindner Center of HOPE
Assistant Professor of Clinical Psychiatry
University of Cincinnati

Bipolar depression has been gaining attention recently in popular culture and the profession of psychiatry. New medications have emerged to manage this often difficult to treat illness. Bipolar depression denotes a specific type of “depression,” a distinction often unknown to patients seeking treatment and not always appreciated by clinicians. One of the most difficult challenges in clinical psychiatry is characterizing a depressive episode as falling within the diagnosis of major depressive disorder (MDD, sometimes referred to as “unipolar depression”) or bipolar disorder (BP, occasionally referred to as “manic depression”). The distinction is of critical importance because pharmacotherapy for BP and MDD differ significantly. Misdiagnosis and subsequent mismanagement can lead to years of suffering from adverse medication side effects and inadequate stabilization of symptoms.

A major depressive episode, as defined by the American Psychiatric Association (APA), is “a period of at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms): intense sadness or despair, loss of interest in activities the person once enjoyed, feelings of worthlessness or guilt, fatigue, increased or decreased sleep, increased or decreased appetite, restlessness (e.g., pacing) or slowed speech or movement, difficulty concentrating, and frequent thoughts of death or suicide.” This same definition is used for depressive episodes in both MDD and BP. Despite the diagnostic overlap, depressive episodes in MDD and BP are considered distinct entities with their own indicated treatments. This leads to the question: given the same diagnostic criteria, how does one distinguish MDD depression from BP depression?

The primary differentiating factor is the presence or absence of manic or hypomanic episodes. A manic episode is defined by the APA as “a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior: decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual), increased or faster speech, uncontrollable racing thoughts or quickly changing ideas or topics when speaking, distractibility, increased activity (e.g., restlessness, working on several projects at once), and increased risky behavior (e.g., reckless driving, spending sprees).” These behaviors must represent a change from the person’s usual behavior and be clear to friends and family and cause significant impairments in occupational and social functioning that frequently necessitate psychiatric hospitalization. Hypomania is a milder form of mania that lasts for a shorter period and does not disrupt daily functioning.

If such an episode has occurred, the diagnosis is clear: BP depression. However, depressive episodes pre-date manic/hypomanic episodes in most cases of BP. In some instances, previous manic/hypomanic episodes were overlooked. And in other cases, a patient may mistake symptoms of mania for other psychiatric diagnoses, such as ADHD, borderline personality disorder, anxiety, and drug abuse. Further complicating the picture is the fact that these illnesses commonly coexist with BP.

Laboratory tests and imaging modalities have yet to be developed for diagnosing MDD and BP. The diagnosis is based on clinical interviews and observations. There are validated self-report symptom questionnaires that can help diagnose and facilitate discussion among patients and mental health providers. One frequently used instrument is the Mood Disorder Questionnaire (MDQ). Collateral information from friends, family, and coworkers can be invaluable for supplementing a patient’s recollection of symptoms and behaviors.

Some studies suggest there may be subtle differences in the way depression manifests clinically in BP and MDD, such as more severe motor slowing and predominance of atypical symptoms (hypersomnia and increased appetite) in BP depression. Other clues from a patient’s history may help point to BP over MDD, such as early onset of depressive episodes, the presence of psychotic features, severe and frequent depressive episodes, high anxiety, episodes that have not responded to traditional antidepressant therapy, substance misuse, a history of ADHD, and suicidality. No single feature is diagnostic, however. Each piece of the history must be considered in the context of the entire presentation.

The medications used to treat each type of depression are very different, and often ineffective or even harmful if used for the incorrect type of depression. For someone seeking treatment for undifferentiated depression with no history of mania or other strong indications of BP, an antidepressant medication is typically recommended. Commonly used antidepressants include selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs). Other antidepressants with different mechanisms of action may also be used to treat MDD. There is debate among experts about the efficacy and safety of antidepressants for treating BP depression, and while antidepressants may have a place in the treatment of BP depression, the risk of precipitating manic episodes, causing rapid cycling mood episodes, and inadequately treating the illness often relegate antidepressants for use in MDD.

Medications indicated for the treatment of BP depression include second-generation antipsychotics and mood stabilizers. Lithium and the anticonvulsants lamotrigine (Lamictal) and valproate (Depakote) are mood stabilizers that are sometimes used “off label” to treat bipolar depression. Second-generation antipsychotics approved for BP depression are cariprazine (Vraylar), lumateperone (Caplyta), lurasidone (Latuda), olanzapine (Zyprexa) in combination with fluoxetine (Prozac), and quetiapine (Seroquel).

Differentiating BP depression from MDD depression represents a critical decision point in clinical practice. BP can go unrecognized or misdiagnosed as MDD for many years in a large proportion of patients seeking treatment for depressive episodes. Depression can be well managed when the appropriate treatment is chosen. Once a diagnosis is made and treatment is initiated, symptoms should be closely monitored, and the diagnosis reevaluated periodically to ensure effective treatment.

References:
Etain B, Lajnef M, Bellivier F, Mathieu F, Raust A, Cochet B, Gard S, M’Bailara K, Kahn JP, Elgrabli O, Cohen R, Jamain S, Vieta E, Leboyer M, Henry C. Clinical expression of bipolar disorder type I as a function of age and polarity at onset: convergent findings in samples from France and the United States. J Clin Psychiatry. 2012 Apr;73(4):e561-6. doi: 10.4088/JCP.10m06504. PMID: 22579163.

Fogelson, D., & Kagan, B. (2022). Bipolar spectrum disorder masquerading as treatment resistant unipolar depression. CNS Spectrums, 27(1), 4-6. doi:10.1017/S1092852920002047
Howland, M., & El Sehamy, A. (2021, January). What are bipolar disorders?. Psychiatry.org – What Are Bipolar Disorders? https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders 

Mitchell, P., Frankland, A., Hadzi-Pavlovic, D., Roberts, G., Corry, J., Wright, A., . . . Breakspear, M. (2011). Comparison of depressive episodes in bipolar disorder and in major depressive disorder within bipolar disorder pedigrees. The British Journal of Psychiatry, 199(4), 303-309. doi:10.1192/bjp.bp.110.088823

Nestsiarovich, A., Reps, J.M., Matheny, M.E. et al. Predictors of diagnostic transition from major depressive disorder to bipolar disorder: a retrospective observational network study. Transl Psychiatry 11, 642 (2021).

Perlis RH, Brown E, Baker RW, Nierenberg AA. Clinical features of bipolar depression versus major depressive disorder in large multicenter trials. Am J Psychiatry. 2006 Feb;163(2):225-31. doi: 10.1176/appi.ajp.163.2.225. PMID: 16449475.

Swann AC, Geller B, Post RM, Altshuler L, Chang KD, Delbello MP, Reist C, Juster IA. Practical Clues to Early Recognition of Bipolar Disorder: A Primary Care Approach. Prim Care Companion J Clin Psychiatry. 2005;7(1):15-21. doi: 10.4088/pcc.v07n0103. PMID: 15841189; PMCID: PMC1076446.

When someone is suffering from depression, a family member is often called upon to help make important treatment decisions.  In the midst of a major depression, your loved one may be too disturbed to make practical decisions about his or her care.

One of the most important decisions to make is the selection of the right depression treatment center to meet your loved one’s needs.  During the screening process, we recommend that you ask the following questions to potential providers:

1. Is the inpatient depression treatment program individualized?

No one wants a cookie-cutter approach to a loved one’s care.  For depression treatment, one size does not fit all. Varying levels of care and types of treatment modalities should be available. Individuals with imminent suicidal risk may require inpatient care, while others may be treated on an outpatient basis. Some patients may respond well to counseling, while others may also need antidepressant medications. The availability of a full treatment menu, with an individualized approach to care, is critical to finding the best treatment options for your loved one.

2. How involved are the patient and family with the inpatient depression treatment program?

Effective treatment programs tend to be ones that actively engage the patient and family in the assessment, planning, and treatment process. Terms like “person-centered” and “family involvement” mean that a center understands the importance of including everyone in the process – not just the professionals.  Even though they are troubled, patients with depression can contribute to an understanding of their illness and are better motivate if they are actively involved in treatment.  Family members can learn ways to better support a loved one coping with a depressive disorder, and they can also benefit from support for their own concerns and frustrations.

3.  What are the depression treatment center staff qualifications?

A professional’s best treatment tools come from a combination of training and experience.  Check the credentials of professional staff on your loved one’s treatment team.  Generally, you should look for clinical staff to have licensure in a professional field such as psychiatry, psychology, social work, marriage and family therapy, or counseling.

4.  What types of counseling and therapy for depression are provided?

When most lay people think about psychology, the first name that comes to mind is Sigmund Freud.  While he may have been a pioneer in the treatment of mental disorders, counseling and therapy have come a long way in the past century.  Many counseling techniques developed in the last few decades are designed to work with the negative feelings and self-defeating individuals with depression often have. Current therapeutic approaches considered the most effective with depression include:

  • Cognitive behavioral therapy (CBT);
  • Dialectical behavioral therapy (DBT);
  • Insight oriented therapy (IOT).

Beware of any provider that considers medication to be the sole method for treating a loved one’s depression. While modern antidepressants can have a very beneficial effect upon resistant depression, treatment should usually include other modalities such as counseling, training, or peer supports.

5.  What is the inpatient depression treatment program’s overall treatment philosophy?

A treatment center should have a clear philosophy about appropriate treatment. In discussing a program’s treatment approach, listen for terms such as the following:

  • Person-centered or patient-centered planning and care (see above);
  • Family involvement (see above);
  • Symptom management – provides patients with tools to help manage their own feelings and behaviors;
  • Least restrictive environment – provides the least intensive level of treatment necessary, while respecting the patient’s freedom;
  • Wellness and recovery – focuses on a total wellness approach to healthy living and a belief that recovery is possible.

Getting the right answers to the above questions can be a productive step in setting your own loved one on a journey to recovery.

By Jennifer Farley, PsyD,
Lindner Center of HOPE, Staff Psychologist

There are a number of reasons someone may undergo a psychological evaluation or assessment. The type of testing that is done depends on the individual’s functioning and the setting in which testing may be pursued. This article will look at the different settings of mental health assessments.

Types of Mental Health Assessment Settings

  • Outpatient
  • Inpatient
  • Residential
  • Children’s Assessments

Psychological Assessment in an Outpatient Setting

Testing from a clinical psychologist in a clinical outpatient setting can be pursued on their own or they may be referred from another clinician (such as a primary care physician or psychiatrist). This type of assessment is for patients with non-immediate mental health concerns. In this case, testing is pursued with the referral question in mind (such as whether someone has Attention Deficit/Hyperactivity Disorder, depression, anxiety, a learning disorder, dementia, cognitive problems due to a medical condition, etc). The psychologist tailors the tests to help determine the person’s functioning in the areas that could be affected by a cognitive or emotional disorder. Tests can range from intellectual assessments to personality measures to behavioral questionnaires (which can be completed by the patient themselves, parents, and/or teachers) to academic achievement measures. Clinicians such as neuropsychologists and developmental psychologists can do all these tests and then add additional measures specific to their specialization (such as when documenting problems related to a head injury or when evaluating for Autism Spectrum Disorder). The psychologist can use this information to make a diagnosis and provide recommendations for treatment of the condition. Often, such as for school-age or college-age patients, recommendations for academic accommodations are also provided.

Psychological Assessment In An Acute Inpatient Unit

Sometimes, psychological testing is completed for patients during an acute inpatient psychiatric hospitalization (when the patient is in a mentally unstable condition). In these cases, testing is often used for diagnostic elucidation to help guide decisions about types of medication to use. Recommendations may also be made about additional assessments or resources to pursue following one’s discharge from the hospital. The clinical psychologist completes these evaluations within a short time, since these acute hospitalizations last (on average) about 7 days, and there are usually just a few measures that are administered. Tests are specific to the question about the individual’s diagnosis and may only include emotional/personality measures.

Psychological Assessment in a Residential Setting

Another setting in which psychological testing may occur is within a residential psychiatric setting. This setting is for patients who are experiencing psychological distress that is not severe enough to warrant an acute inpatient hospitalization. Length of stay in a residential setting can vary from 10 days to several months, depending on the purpose of the stay (i.e., evaluation and/or treatment). The purpose of testing in a residential setting is to help comprehensively understand – by way of several different measures – one’s personality functioning, cognitive functioning (which can include neurocognitive skills such as attention, memory, and executive functioning), and other factors (such as external stressors, substance use, medical conditions, etc.) that have contributed to the patient’s condition(s). The patient’s internal strengths and weaknesses are explored, with the intention of making recommendations for how treatment can be tailored to work with the patient’s strengths to compensate for their weaknesses. The clinical psychologist works closely with the other members of the treatment team (such as the psychiatrist, social worker, and the therapists) to understand the patient, develop a treatment plan, and (if a longer stay) to begin implementing the recommendations. The patient’s progress is then monitored and, if needed, further testing can be done to help assess changes in the patient’s functioning as a result of the treatment.

Psychological Assessment in Childhood

In childhood, early observations of potential problems may come from teachers. Teachers may observe struggles in behavior such as impulsivity, talking or interrupting others during times when there is an age-appropriate expectation of silence, and/or oppositional behaviors towards others. Teachers may also be the first to wonder if a child has an underlying learning or attention disorder. If the teacher’s attempts to help the child are unsuccessful, the teacher may recommend testing in the form of a Multi-Factored Evaluation (MFE). Psychological testing may be part of this evaluation and can include intellectual testing and academic achievement testing by a school psychologist. Parent and teacher questionnaires may also be included in the MFE. Depending on the nature of the child’s observed difficulties, others (such as speech and language therapists and physical therapists) may do their own screening. If findings reveal that the student experiences problems that would make learning difficult, accommodations are then recommended and interventions and/or accommodations are then put in place through a 504 Plan or an Individualized Education Plan. It is noteworthy that clinical diagnoses are NOT made from this type of evaluation and findings and recommendations are specific to helping the child learn better.

Prior to any psychological testing, the patient (and/or his/ her family) should understand the purpose of psychological assessment and how it can be useful for guiding treatment and other recommendations.

Find out more information on what psychological assessment is here and why it is a critical step of the process towards finding a diagnosis and treatment plan.

Finding Help and HOPE

If you, or someone you know, is experiencing a mental health crisis, there is help available. The first step would be to consult with a health care provider or mental health care specialist. To see how Lindner Center of HOPE can help you decide on the best mental health assessment setting, reach out to us today. We can help you take the next steps. 

By: Sidney Hays, MSW, LISW, DARTT,

Lindner Center of HOPE Professional Associates, Outpatient Therapist

From wild parties in the massive frat houses to stories finding your soulmate in movies and television, many enter college with bright eyes and big dreams. There are expectations of melting into a friend group, dating, gaining experience, and finding your passion as soon as you get to college. All of this, stepping-stones to graduating with the dream job lined up, a group of best friends you’ll vacation with every summer, and that special someone you just might spend the rest of your life with. You’ve heard about the glory days and the football games and the spring break trips. But, what happens when you get to college and the classes are hard, friendships are complicated, partying comes with consequences, and heartbreak hits you?

Many young adults enter college with high hopes and expectations that seem reasonable Unfortunately, the movies and glory day memories from loved ones miss crucial struggles and obligations that come with college. This often leaves college students feeling like they’re “missing something” or failing, which contributes to poor mental health in an environment already rife with challenges. The struggles of large class sizes, living with strangers, easier access to drugs and alcohol, financial stress, being away from home, and lack of structure tend to tax the delicate wellbeing of young adults who have not been adequately equipped with needed skills and whose brains are not fully developed.

Most 18-year-olds step onto a college campus and it’s the first time they will be spending the majority of their time living away from home. Suddenly they are responsible for most every aspect of their life, with minimal adult supervision. Out from the safety net of coming home to parents and the guidance of coaches and teachers, college freshmen spend the majority of their time exclusively with others their same age, facing the same struggles. They navigate friendships, romantic relationships, and living with strangers as best they can, often struggling with codependency, lack of boundaries, and the pervasive anonymity and distance offered by the internet. This group tends to struggle with interpersonal skills and ability to regulate their own emotions, with little guidance on effective skills to use. Many find themselves feeling lonely and in cycles of unhealthy or unfulfilling relationships.

Accountability is a new concept for many college students. The looser structure of college settings requires more self-determination and discipline than high school. College is a place where students are generally free to make most of their decisions. While this can be liberating and a time of beautiful self-discovery, it can also lead to poor attendance, study habits, and moderation of substances and sleep. The negative physical, academic, and emotional effects of these choices tend to pile up, which is why so many college students begin to struggle with anxiety and depression.

What to tell a college student who isn’t having the best time of their life:

Know that you are not alone.

Mayo Health Clinic reported in July 22 that up to 44% of college students reported symptoms of depression and anxiety. The stressors faced by college students are underplayed and the good times overly glorified. It often takes time to make friends and friend groups naturally change; that’s okay. People are trying to understand what they want to do with the rest of their lives, becoming independent adults, and learning about the world. This will likely lead to many shifts in relationships as well.

Manage expectations.

You are in school to get a degree, learn about yourself, create relationships, and prepare yourself for the workforce. You may not find a group of friends during welcome week or even freshman year. The romantic relationships may not work out. You may not graduate with your dream job lined up. This is a step towards your goals and can still be part of a life worth living, even if you don’t get exactly what you want by graduation.

Get support and develop lasting relationship skills.

College is a great time to connect with a therapist to process the changes and have a support to help you identify your goals and live within your values. Learning skills to set boundaries, prioritize your time, communicate effectively, and regulate your emotions will make a world of difference in college and will carry on through your life.

A great option for learning these skills is Dialectical Behavior Therapy (DBT). DBT is a treatment that helps participants learn and practice skills to regulate emotions, tolerate distress, and effectively navigate interpersonal relationships.

If you are interested in learning more, for yourself or someone else, about DBT or individual therapy to help navigate this beautiful and challenging season, contact the Lindner Center of HOPE.

The Difference Between CBT and DBT (Cognitive and Dialectical Behavioral Therapies)

Stacey L. Spencer, Ed.D.
Clinical Neuropsychologist, Lindner Center of HOPE
EMDR Trained therapist
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience

 

There are many, many possible types of psychotherapy. Psychotherapy is an optimal treatment method for mental illnesses.  Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) are among the most common psychotherapies.

CBT vs DBT

What is Cognitive Behavioral Therapy?

One that has been in the public sector for decades, and that you’ve likely heard of, is Cognitive Behavioral Therapy (CBT). If you’ve ever gone to therapy, it’s very likely that the therapist you saw practiced CBT. This therapy, also called talk therapy, helps people better understand how thoughts influence our feelings. The goal of CBT is to talk through problems and help frame thoughts differently. CBT is typically time-limited and there are specific goals and homework provided. You might start out with a situation that troubles you, or one you may find troubling. With the guidance of the therapist, you identify the thoughts around the situation and work on finding alternatives and ultimately changing the behaviors in order to feel better. So, it’s thought-feeling-action-focused. Some mental flexibility is involved given that most of these thoughts are automatic and can become engrained.

Cognitive Distortions are often discussed in CBT.  CBT helps us to break up negative thought patterns or “thought traps” that can lead to feelings of anxiety, depression and cause us to avoid. A technique to help one move away from this type of thinking and often employed in CBT is “cognitive shifting”. With the help of awareness in what a person focuses on (in this case, often the negative cognition/thought/belief) the idea is that this helps us learn to shift our focus to something more helpful or innovative. There are many Cognitive Distortions under this umbrella. Examples of catastrophizing could be magnifying or minimizing. I read a good description once of this being a “billowing cloud of everything can go wrong” and believing it inevitably will.  Or in Minimizing when we downplay our successes.

A CBT-oriented therapist might give someone who tends to catastrophize events in their lives, leading to anxiety, for instance, a worksheet and walk through the process with them. This is hypothesized to have evolved as a way to help us survive during the immediate crisis. Now that we have developed higher-level reasoning skills, this can turn against us, as these negative thoughts can turn sticky.

One way to start is to help the client identify what they are currently most worried/anxious about. The client might start by specifying what they imagine will occur without using “what if” statements. Instead, the focus is on the client’s own predictions, e.g., “ I will fail the exam and get kicked out of school.” You ask the client to rate how much they believe this to be true from 0-100%. Next, the client is asked to take a step back and consider the likelihood of the catastrophe to occur. By helping the client to take a step back and assess the fear from a different perspective and re-interpret their concerns, this is called “reframing”.

Working on ways to cope with and manage these fears/anxieties by not diving into them is a strategy that CBT therapists employ. It takes practice and yet studies have shown that finding more balanced ways of managing these types of thoughts can lead to better mental and physical health outcomes. By helping the client to explore the underlying thoughts, emotions and beliefs and problematic thinking, they can work towards a more balanced view of themselves. The hope is that by helping the client change their perception to support more positive thinking, they will reduce distress and suffering and lead a more fulfilling life.

To recap, CBT features the following:

  • Treats emotional response
  • Is time-limited
  • Works best with solid therapist-patient relationship
  • Relies on the application of logic and reason
  • Employs structure to guide tailored treatment

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy (DBT) comes from dialectical theory and is actually a type of CBT.  DBT posits balance; not leaning too hard in one direction or another. This modality was originally created by Dr. Marsha Linehan in her work with people with chronic life-interfering behaviors, like self-harm and chronic suicidal thoughts. It has expanded to help with many other issues. Dialectical Behavioral Therapy techniques utilize individual therapy, group skills class and coaching. Groups emphasize learning specific DBT coping skills and there is homework given in-between to reinforce what was learned.

DBT Coping Skills

The four pillars of DBT coping skills include:

Mindfulness

Emotion Regulation

Distress Tolerance

Interpersonal Effectiveness

Mindfulness is a DBT coping skill that involves living with intentional awareness of the present moment. This includes not trying to push away or reject the moment but to notice it and not attach ourselves to it. As Dr. Linehan describes, this is by “Attending to the experience of each new moment, rather than ignoring the present by clinging to the past or grabbing for the future.” This takes practice and patience and can take many forms. Some examples of mindfulness include meditation in the form of noticing by either opening or focusing the mind. Contemplative prayer (in any spiritual form) is another mindfulness practice along with mindful movement such as yoga, martial arts, hiking, tai chi.

Emotion Regulation involves understanding and naming one’s emotions. By helping to learn to identify emotions, one can hope to gain an understanding of what they do for us. Goals of this are to decrease the frequency of unwanted emotions, the vulnerability to them and decrease emotional suffering.

Distress Tolerance are DBT coping skills for when involved in a crisis situation and the goal is to not make the crisis worse. By utilizing skills of Radical Acceptance, one can achieve freedom from suffering and being “stuck”. This can help by reducing acting on intense emotions and tolerating painful events. These are only utilized in a crisis situation, where the event or experience is highly stressful and short-term.

Lastly, Interpersonal Effectiveness skills are to help assist with either strengthening current relationships or end destructive ones, to learn to say yes/no effectively, resolve conflicts before they get overwhelming and create and maintain balance in relationships.

The Difference Between CBT vs DBT in Treating Certain Illnesses

Not all mental illnesses respond to treatment in the same way.  The difference between CBT and DBT must be taken into consideration when determining the optimal treatment method for an individual. CBT has been shown to be effective when treating depression, anxiety, obsessive compulsive disorder (OCD), phobias, panic disorder and post-traumatic stress disorder. DBT was created to help people who might be easily dysregulated and tend benefit from learning ways to self-soothe, communicate more effectively with others and find ways to reduce significant distress.

The Difference Between CBT and DBT Treatment Methods

The difference between CBT and DBT are defined. CBT focuses on the connection between thoughts, feelings and behaviors and how they influence each other. DBT emphasizes regulating emotions, being mindful and tolerating the uncomfortable. CBT guides patients to recognize troubling thoughts and redirect them, while DBT helps patients accept themselves, feel safe and manage emotions to avoid harmful behaviors.

When comparing CBT vs DBT, both therapies have aspects of how our thinking influences our emotions and behaviors but are different in their approaches and structure of the therapeutic process. Both modalities are evidenced-based, that is, much research has gone into showing whether they are effective.  When choosing a therapist, as important as it is to find someone in-network or with openings, it’s equally so to know what treatments are most effective for the reasons you’re seeking therapy in the first place. Therefore, asking about CBT vs DBT and which one might work best for you, would be an important next step in this process.  This is the best way to determine if CBT vs DBT are right for you.

Knowing your diagnosis is key to determining what therapy will be most effective for you. However, many people have more than one diagnosis, and sometimes people use a blend of therapy elements to best manage symptoms.

It can be confusing to know what techniques will best help you. CBT and DBT are some of the more common therapy practices, and have been shown to help individuals suffering from a number of mental illnesses.

Choosing to take care of your mental health is just as important as your physical health and finding providers that utilize evidence-based practices will provide you with the best outcomes possible.

For more information about DBT skills group at Lindner Center of HOPE.