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Caught in the weeds: The impact of cannabis on mental health

Christine Collins, MD, Lindner Center of Hope

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

 

 

 

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

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

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

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

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

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

Sources:

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

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

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

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

 

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Can the COVID-19 Vaccine Improve Your Mental Health?

Thirteen months ago, the world was experiencing the onset of a shared trauma … a pandemic was sweeping over the globe. The actions that were taken to keep people safe included community shut downs, stay at home orders and mandated isolation. Lindner Center of HOPE, like mental health providers around the world, began to see spikes in mental illness and addiction. Individuals who were already struggling with mental illness or a pre-disposition, saw exacerbated symptoms and an increase in severity of illness. People who were managing, saw new onset at higher levels of acuity. As time has passed since the beginning of the pandemic, the trauma has been sustained with higher percentages of people still struggling with mental illnesses and addictions. Additionally, data shows people who have experienced COVID-19 infection are also suffering with co-occurring psychiatric symptoms.

Dr. Paul Crosby, Lindner Center of HOPE

Fortunately, vaccines have been released to protect the population from the physical health threats of COVID-19. However, Lindner Center of HOPE’s President and Chief Operating Officer, Paul R. Crosby, MD, states the vaccine also offers mental health benefits as well.

“The first mental health benefit of the vaccine is simple,” Dr. Crosby said, “since the risk of COVID-19 infection diminishes significantly with vaccination, receiving the vaccine would also protect individuals from co-occurring mental illness that has proven to manifest with COVID-19 infection.”

“The second mental health benefit of the vaccine is the reduction in overall anxiety and stress, as risk and fear of infection is reduced. Vaccinated individuals can lift their isolation from other vaccinated individuals, can begin to see a return to other activities that improve mental health, like more exercise, improved sleep, new experiences through travel and more. A return to these healthier activities can hopefully also lead to a reduction in substance use, overeating or lack of participation in other things that bring joy.”

“The COVID-19 vaccine has significant potential in improving your mental health.”

For individuals experiencing symptoms of mental illness, it is critical to access help. Mental illnesses are common and treatable and no one should struggle alone.

Lindner Center of HOPE in Mason is a comprehensive mental health center providing excellent, patient-centered, scientifically-advanced care for individuals suffering with mental illness. A state-of-the-science, mental health center and charter member of the National Network of Depression Centers, the Center provides psychiatric hospitalization and partial hospitalization for individuals age 12-years-old and older, outpatient services for all ages, diagnostic services for all ages and short-term residential services for adults, and research. The Center is enhanced by its partnership with UC Health as its clinicians are ranked among the best providers locally, nationally and internationally. Together Lindner Center of HOPE and UC Health offer a true system of mental health care in the Greater Cincinnati area and across the country. The Center is also affiliated with the University of Cincinnati (UC) College of Medicine.

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Mental Health and the Environment of Connection

By Chris J. Tuell, EdD, LPCC-S, LICDC-CS
Lindner Center of HOPE, Clinical Director of Addiction Services; Assistant Professor, Department of Psychiatry & Behavioral Neuroscience
University of Cincinnati College of Medicine

At the end of the Vietnam War in 1975, 1 out of 5 soldiers (20%), returning to the United States from Southeast Asia, was addicted to heroin. It was estimated that approximately 100,000 American soldiers would be returning home, addicted to this destructive drug. Experts projected a drug epidemic, which would destroy countless lives and communities. It never happened.

Once soldiers returned home to families, friends and communities, the destructive nature of a hardcore drug, like heroin, failed to materialize. In fact, 95% of the soldiers who were once addicted to heroin, stopped using the drug almost immediately once they returned home.

For many years, our understanding of addiction was based on early research conducted in the first half of the 20th century. These studies involved rats and consisted of placing a rat in a solitary cage, providing the rat with a choice of water: plain water or water laced with cocaine or heroin. The study found that all the rats preferred the drug-laced water to the plain water. All the rats overdosed on the drug. The majority of the rats died in the study. This became our model of addiction for many years. The accepted belief became, if you are exposed to a drug, you will become addicted, and you may overdose and die.

Several years later, this original study was replicated, but with a significant difference. Researcher Bruce Alexander from the University of Vancouver, created, what was referred to as: a “rat park.” This park consisted of tunnels, multiple levels, toys, and other rat companions. Similar to the original study, all rats were given the same choice of water: plain water or water laced with heroin or cocaine. In Alexander’s study, rats preferred the plain water. Rates of overdose and death to the rats were significantly lower when compared to the initial study. How do we explain this difference in results? Perhaps, it is about the cage. Perhaps, it is about the environment.

Upon their return home, the soldiers from Vietnam who were struggling with a heroin addiction were able to re-connect with loved ones and community. A change in environment allowed for a change in connection, resulting in health, wellness and sobriety. Likewise, the environment of the rat in a solitary cage, as compared to the environment of the rat park, provided the rat with a “connection” with other rats, an environment which allowed the rat…to be a rat.

Individuals, who experience issues of mental illness and/or substance use disorders, have a natural tendency to withdraw and isolate from others. Depression, anxiety and addiction, greatly affect an individual’s ability to connect with others, let alone with one’s environment. This past year we have seen the devastating impact of COVID-19. We know that in order to maintain health and wellness, we need to maintain social distance and disconnect from one another. For now, this has and continues to be, what we need to do. It remains challenging for many of us to continue to avoid contact with loved ones and friends. We are separated from the very individuals who love us, support us, and are our sources of connection.

We have seen the rise of mental health issues during the past year. Nearly 20 percent of COVID-19 patients have developed a mental health issue (i.e., depression, anxiety) within three months of their diagnosis. During the past year, 4 in 10 adults in the U.S. have reported symptoms of anxiety or depression. Within the general population, rates of mental health issues and substance use have significantly increased across the board. In addition, the disconnection that we have witnessed has fragmented our society in general by harboring increased levels of fear, anger and animosity towards one another.

Hope on the horizon

Once “herd immunity” is achieved, the importance of re-connecting with one another becomes vital and essential to our health and mental wellness. We are social beings and need connection with one another. History has shown that the mental health impact of disasters outlasts the physical impact, suggesting today’s elevated mental health needs will continue well beyond the coronavirus outbreak.  Like the moth that needs to struggle out of the cocoon in order to develop the strength that it needs to survive in the world, we too are developing the strength that we need from the struggles we have endured.  Re-connecting with one another is an answer.  It gives us strength and it gives us hope.

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Dangers of Dieting: Why Dieting Can Be Harmful

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

 

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

What is Dieting

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

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

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

The Potential Harmful Effects of Dieting

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

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

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

 

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

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Grief During the Holidays

By Danielle J. Johnson, MD, FAPA

Lindner Center of HOPE, Chief Medical Officer

Many people have experienced loss of several types during the COVID-19 pandemic – employment, financial security, social connections, a sense of safety, and loved ones.  The way we grieve has changed because we cannot rely on our support systems to be physically there for us due to restrictions with social distancing.  With the increasing number of COVID-19 cases, the holiday season will be different this year – no holiday parties, large family gatherings, or other traditions.  It is difficult to be physically separated from loved ones, but even more difficult for those who may be experiencing their first holiday season after the loss of a loved one.

 

What are some ways that we can manage grief during this unprecedented holiday season?

  • Take charge of your holiday season: Anticipating anxiety about the holiday, especially if it is the first one without a loved one, can be worse than the actual holiday. Taking control of your plans and deciding how you will spend your time can relieve anxiety.  Do not spend time where you do not feel emotionally safe or comfortable.
  • Find nourishment for the soul: Your faith community may offer resources. Look for a support group for people who have suffered a similar loss or for those who are alone.  Due to the pandemic, many support groups are online.
  • Give yourself permission to change your holiday traditions: Some traditions may be a comfort, while others may be painful. Some traditions will have to change due to the pandemic.  It is ok to start new traditions.  Many families are finding ways to celebrate virtually.
  • Change how you give: Give a gift on behalf of your loved one to someone else or donate to a charity in memory of your loved one.  If you are spending less due to not spending the holidays with loved ones, consider giving more to charitable organizations.
  • Do not let guilt overtake you: You can enjoy the holiday without your loved one.  Celebrating does not mean you do not miss or have forgotten about your loved one.
  • Be gentle with yourself: Realize that familiar traditions, sights, smells and even tastes, may be comforting, or may trigger strong emotions. Be careful with your emotions and listen to yourself.
  • Do not pretend you have not experienced a loss: Imagining that nothing has happened does not make the pain of losing a loved one go away or make the holidays easier to withstand. It is ok to talk with others about what you have lost and what the holidays mean to you.
  • Pay attention to your health: It is often difficult for people who have experienced a recent loss to sleep. Make sure you get regular rest.  If you feel overwhelmed, talk with your health care provider.
  • Experience both joy and sadness: Give yourself permission to feel happiness and pain. Do not feel like you must be a certain way because of your loss or because it is the holidays.
  • Express your feelings: Suppressing your feelings may add to distress. To express your feelings, talk with a supportive friend or journal.
  • How can support persons help those who are grieving during this holidays season if we cannot physically be there? Be available to listen. Send cards, gift cards for meals, offer to help shop, or decorate the outside of the home.  If you are concerned about their mental wellbeing, offer to help them find a support group or encourage them to reach out to their health care provider for help.

Resources

https://www.griefshare.org/holidays

https://whatsyourgrief.com/alone-together-14-ideas-for-a-virtual-holiday/

https://coronavirus.ohio.gov/wps/portal/gov/covid-19/families-and-individuals/resources-for-parents-and-families/holiday-celebrations

Crisis Text Line, text CONNECT to 741741 for 24/7 help from a crisis counselor.

Ohio Care Line, call 1-800-720-9616 for 24/7 support from behavioral health professionals.

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When To Seek Treatment For Anxiety

 

By Angela Couch, RN, MSN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE

Anxiety is a common symptom. Anxiety is a part of everyone’s lives, we have all experienced it to one degree or another. Believe it not, anxiety serves some useful purposes. Anxiety can help give you the drive to make a change, or complete task on time.Anxiety can activate the fight or flight instinct, in a “potentially” dangerous situation, giving you the drive to get out of there, or do something to prevent harm. Anxiety can occur when you are enduring multiple stressors, or there is uncertainty, and it’s not entirely unexpected.

For instance, say you hear layoffs are coming in the company, and you’re not sure if your department will be affected. You may experience physical symptoms of anxiety (which could include racing heart, nervous stomach, sweating, tremor, nausea, shortness of breath, and more), and you might also experience worry. COVID-19…yup, that can cause some anxiety, or worry, too! Situational anxiety is a part of life, and often can be managed by rational self-talk, problem-solving, and various positive self-care strategies. (For more on that, see some of our other recent blog articles, for lots of helpful ideas!) So how do we know when the anxiety is more than just “normal” or to be expected, and when to seek help?

According to the National Comorbidity Study Replication, about 19.1% of U.S. adults will have had an anxiety disorder in the past year, and 31.1% experience an anxiety disorder in their lifetime. In other words, it’s pretty common! There are various types of anxiety disorders, and most have an underlying common thread– difficulty in accepting uncertainty in some form. So how do you know if you may need to seek further assessment or help for anxiety, if it’s really so common? If everyone gets it, is it really a problem that requires treatment? The answer is yes, it might. Some symptoms that may indicate problematic anxiety include:

* Feeling “paralyzed” by fear.

* Anxiety is causing you to avoid things you used to be able to do without anxiety, or things that are important to you (this could include social activities, leaving your house, going to your job, driving, engaging in spiritual activities, etc.).

* You have difficulty staying present “in the moment”, which may repeatedly distract you from attending to conversations, being able to complete work or school tasks because of lack of focus.

* You are having difficulty with sleep or eating due to excessive worry or anxiety.

Anxiety is causing significant physical symptoms.

* You cannot determine a cause for the anxiety and the symptoms are persistent or very bothersome.

* You worry about “everything” or “all the time”.

* The anxiety/worry you are experiencing about situations seem excessive.

* You need to engage in compulsive or repetitive behaviors, or do things in a certain way, in order to avoid significant anxiety/worry.

* Anxiety is causing you to turn to self-medication with alcohol or substances.

So you’ve determined you should seek help, now what? Psychotherapy can be helpful for anxiety, and is a very important component of treatment. Psychotherapy may include several modalities such as cognitive behavioral therapy, addressing faulty beliefs contributing to anxiety, psychoeducation about anxiety and worry, problem-solving, exercise and wellness activities/lifestyle changes, addressing sleep hygiene, skills for time management and stress reduction, or exposure therapy, just to name a few.

How do you know if psychotherapy is enough to manage the symptoms? Medication can be a helpful component in treatment of anxiety, particularly if symptoms are not improving with other psychotherapeutic interventions mentioned above. Medications alone are rarely enough to treat anxiety disorders adequately. Medication can often make it easier to engage in meaningful psychotherapy, to make those helpful lifestyle changes, or try new ways of coping with the anxiety/worry. If you are experiencing suicidal thinking or significant depression, medication should be a consideration. If the anxiety symptoms are preventing you from being able to work or do other essential tasks, medication may be indicated. If your therapist suggests a medication consultation, you should consider it.

The important things to remember are, everyone has some anxiety, not all anxiety is bad, and when anxiety does become problematic or excessive, there are evidence-based treatments to help, so don’t be afraid to reach out for help!

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Can you blueberry your way out of depression? The evidence on dietary supplements

 

By Nicole Mori, RN, MSN, APRN-BC
Research Advanced Practice Nurse, Lindner Center of HOPE

Depression is a common mental health complaint.  Although there are effective treatments available, many patients fail to experience satisfactory improvement.  There has been increased interest in nutritional supplements as an adjunct or alternative to medications in the treatment of depression.  This has contributed to the growth of the dietary supplement industry (projected to reach 230 billion by 2026).  Let’s examine the evidence for the dietary supplements that have generated interest in recent years.

Omega-3 fatty acids (EPA/DHA)

A systematic review shows mild-moderate improvement in depressive symptoms, with the best outcomes in studies where omega-3 supplementation is concomitant to standard antidepressant therapy.  There is a great deal of heterogeneity in dosing, duration of treatment and EPA/DHA content.  Products with a high EPA content appear to be more efficacious than other omega-3 supplements.    However, quality of evidence is low due to methodological flaws.  Differences in study design and methodology makes it difficult to analyze data across studies.  Omega-3 supplements have a favorable safety profile and are well tolerated.

 

B group vitamins

Folate- Possible dose dependent response in depression but level of evidence is low.  Although folate is well tolerated, it has been associated with risk for proliferation of carcinogenic cells in the colon.

L-methylfolate-Available as pharmaceutical product FDA approved for depression.  Data shows efficacy at 15mg/d.  Some studies show efficacy as augmentation strategy for depression as comparable to lithium and atypical antipsychotics.  Usually well tolerated with lower risk for proliferation of cancerous cells than folate.

Vitamin D

A 2019 systematic review of clinical trials showed improvement in depression ratings associated with supplementation.  Findings remain tentative due to paucity of studies and methodologic bias.  Vitamin D is a fat-soluble vitamin commonly found in multivitamins and other commercially available products.  In the absence of a deficiency, the recommended dose is not to exceed 600IU/day.

SAM-E (S-Adenosyl methionine)

Clinical trials show mixed results.  A 2016 systematic review suggested SAM-E was no better than placebo.  The low quality of evidence makes it difficult to draw conclusions about efficacy.  There is a need for randomized clinical trials with antidepressant comparators.  SAM-E usually well tolerated but there is a possible risk for inducing mania in patients with bipolar depression.

Tryptophan/5-HTP (5-Hydroxytryptophan)

There are few high quality studies of 5-HTP.  Two depression studies suggest 5-HTP is superior to placebo.  Overall, level of evidence is low.  Possible risk for serotonin syndrome when administered concurrently with SSRI antidepressants.  Maximum recommended dose is 50mg/kg/day.

 

Magnesium and Zinc

There is some positive data from animal studies but evidence for efficacy in humans is low quality. There is no conclusive data on the efficacy of magnesium and zinc as coadjutant therapy in depression.  Zinc and magnesium are common micronutrients and usually well tolerated.

Probiotics

Depression has been associated with poor diet and altered intestinal flora.  Research has shown a relationship between gut health and mental health.  A 2016 metaanalysis of probiotics showed an effect in reducing risk of depression in normal subjects and reduced symptoms in subjects with depression.  The effect was limited to subjects under age 60.  Clinical studies vary greatly in terms of bacterial species, dose, duration of treatment as well as the method of measuring of depressive symptoms.  Probiotic supplements are vastly heterogeneous in terms of species composition and dosage.

There is a need for further research to determine optimal composition, dosage, duration of treatment for efficacy.  Furthermore, it is important to remember that quality of diet is a major determinant in the composition of gut flora.

In conclusion, evidence for the efficacy of dietary supplements in depression remains limited.  Commercially available dietary supplements vary significantly in terms of composition and bioavailability.  Although supplements are well tolerated, it is important to be aware of increased risks for adverse events in some patients.  Supplementation with omega-3 fatty acids as an adjunct to standard antidepressant therapy seems to hold the most promise.   Further research in the area of dietary supplements is needed to determine their role in the management of depression.

For more information about Depression research studies at the Lindner Center of HOPE

call 513-536-0707 or visit https://lindnercenterofhope.org/research/

https://redcap.research.cchmc.org/surveys/?s=YKW8CE4FRF

 

References

Firth J, Teasdale SB, Allott K, et al. The efficacy and safety of nutrient supplements in the treatment of mental disorders: a meta-review of meta-analyses of randomized controlled trials. World Psychiatry. 2019;18(3):308-324. doi:10.1002/wps.20672

Martínez-Cengotitabengoa M, González-Pinto A. Nutritional supplements in depressive disorders. Actas Esp Psiquiatr. 2017;45(Supplement):8-15.

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Am I shopping too much?

 

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

Everyone needs to shop from time to time, but at what point does shopping become a problem? And is this a diagnosis? Compulsive buying disorder (CBD) is a mental health condition characterized by “excessive, impulsive, and uncontrollable purchase of products in spite of severe psychological, social, occupational and financial consequences”. While this diagnosis is not found in the DSM-V, shopping addiction was described and discussed clinically in the early 20th century by Bleuler and Kraepelin (Black, 2007). There is still much to be learned about the causes of CBD or shopping addiction, but several factors thought to be contributing include materialism, social anxiety, a general lack of social support, loneliness, or trauma history (Harnish, Bridges, Gump, & Carson, 2018). It is not uncommon for those with CBD to also struggle with anxiety disorders, mood disorders, substance use disorders, eating disorders, or disorders of impulse control.

Most consumers of goods take value and usefulness into consideration when making a decision about a

purchase and emotion is not often involved in the decision. This has also been referred to as “utilitarian shopping”, where someone only shops when they need something. Those who struggle with CBD more often make purchases in order to improve their mood, cope with stress, gain social approval, or improve their self-esteem. This has been referred to as “hedonic shopping” where the primary purpose of shopping is for entertainment, distraction, or pleasure. Research has shown that CBD has relation to reward sensitivity and the mesolimbic dopamine reward circuit in the brain (Günüç & Doğan Keskin, 2016). Over time this behavior becomes reinforced and can create a pattern similar to those seen with behavioral addictions like gambling, sexual addiction, or internet addiction (Granero et al., 2016).

Some might think that during a global pandemic with economic uncertainty people would be less likely to spend and work towards curbing unhealthy shopping impulses. For some who struggle with CBD, this isn’t necessarily the case. With the emphasis and ease of online ordering and curbside pick-up options combined with the increased stress that many are feeling related to the pandemic, coping with shopping addiction has been more challenging for some. This year credit and debit card use increased by 79% in May compared to April in New Zealand. As shops reopened in Australia over the summer there were “Christmas size crowds”. A recent study in the UK showed that those with underlying mental health conditions (primarily depression and anxiety) were more likely to resort to “panic buying” or compulsive buying in response to the pandemic (Jaspal, Lopes, & Lopes, 2020). Considering that loneliness is a contributing factor to compulsive buying as well as the need to cope with stress it really isn’t very surprising that the pandemic has exacerbated these unhealthy buying behaviors in those who struggle with CBD.

What are the symptoms of CBD?

  • Urges to make a purchase are strong and the act of purchasing creates a “high” feeling
  • Preoccupation with shopping or planning purchases
  • Making a trip to the store and purchasing more items than originally intended
  • Most purchases made are unnecessary items
  • Debt, maxed out credit cards, or spending beyond one’s means
  • Hiding purchased items from family members or friends due to guilt
  • Feeling unable to stop oneself from shopping or making unnecessary purchases

What can you do to decrease urges to shop?

  • Seek professional help. While there are few evidence-based treatments for CBD there has been interest and anecdotal success with antidepressants (SSRIs),  cognitive behavioral therapy (CBT), and habit reversal training (HRT)
  • Join a support group or surround yourself with understanding and supportive people
  • When feeling the urge to purchase something make yourself wait a minimum of 24-hours
  • Declutter your space, organize, and get a better idea of what you have and what you love
  • Identify and avoid triggering situations – for example, unsubscribe from e-mails from your favorite stores if this has led you to make unnecessary and impulsive purchases in the past
  • Be mindful of who you follow on social media and how this influences your shopping behaviors
  • When looking at an advertisement ask yourself what they are trying to sell you and how this makes you feel about yourself. For instance, does this company benefit financially from you feeling badly about yourself or wanting a different lifestyle?

 

Sources:

Black, D. W. (2007). A review of compulsive buying disorder. World Psychiatry, 6(1), 14-18. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1805733/#B1

Granero, R., Fernández-Aranda, F., Mestre-Bach, G., Steward, T., Baño, M., del Pino-Gutiérrez, A., … Jiménez-Murcia, S. (2016). Compulsive Buying Behavior: Clinical Comparison with Other Behavioral Addictions. Frontiers in Psychology7(914). https://doi.org/10.3389/fpsyg.2016.00914

Günüç, S., & Doğan Keskin, A. (2016). Online Shopping Addiction: Symptoms, Causes and Effects. Addicta: The Turkish Journal on Addictions3(3). https://doi.org/10.15805/addicta.2016.3.0104

Harnish, R. J., Bridges, K. R., Gump, J. T., & Carson, A. E. (2018). The Maladaptive Pursuit of Consumption: the Impact of Materialism, Pain of Paying, Social Anxiety, Social Support, and Loneliness on Compulsive Buying. International Journal of Mental Health and Addiction17. https://doi.org/10.1007/s11469-018-9883-y

‌Jaspal, R., Lopes, B., & Lopes, P. (2020). Predicting social distancing and compulsive buying behaviours in response to COVID-19 in a United Kingdom sample. Cogent Psychology7(1). https://doi.org/10.1080/23311908.2020.1800924

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Gratitude During a Pandemic

Tuning into the news can be a stressful and anxiety provoking experience, even in the best of times. During a pandemic, it can be downright frightening. If all of this negativity is wreaking havoc on your emotions, maybe it’s time to put your energy into building a Gratitude Practice.

Gratitude is the conscious decision to focus attention on the positive aspects of a situation and to notice feelings of joy, appreciation and thankfulness.  It is a mindset that celebrates all of the wonderful, special, and unique gifts that life has to offer every day, no matter how simple.

When the world pressures us to pay attention to things that are hurtful, dangerous or missing in our lives, it can be especially challenging to maintain a mindset of gratitude and appreciation. This year especially has brought many unforeseen challenges to us all. Cultivating a mindset of gratitude can be accomplished even in these difficult times.

Why Gratitude?

Over the last several decades there have been numerous studies that have shown countless positive effects of practicing gratitude on our emotional, social and physical health. Practicing gratitude has been shown to improve mood, and help reduce depression, anxiety and irritability. Regular practitioners of gratitude are likely to feel happier, more peaceful and do kinder things for others.

Those who practice gratitude may have stronger social relationships. Couples who regularly express gratitude to each other feel their partners are more responsive to their needs and are overall more satisfied with their relationship. This extends to the workplace as well. When gratitude is expressed at work, employees improve their felt sense of self-worth and confidence, leading to an increase in trust between colleagues and more initiative to help one another out.

Physically, people who practice gratitude regularly have a host of positive effects including improved sleep, stronger immune systems, more consistent exercise habits, fewer physical symptoms and better progress towards achieving personal goals. This is especially important in the current climate.

The act of being grateful creates a chain reaction: the more positive things you notice and give thanks for, the better you feel. As you feel better, you are likely to seek out more positive experiences for which to be thankful.

Building a Gratitude Practice

There are many ways that you can begin to incorporate more gratitude into your life. Remember that when making any change in behavior, it is best to start small and gradually build over time.

If you are just starting out, try choosing one or two times per day that you devote to being grateful. You might consider as you are falling asleep each night to think of three things that happened during that day that you are thankful for. You could also try to think of the one thing you are most grateful for. Try to be as specific as possible. Instead of saying to yourself “I am grateful for my family” think …“I am grateful my husband cleaned up the kitchen after dinner.” Or “I am grateful that my son gave me a hug before bed.”

Once you have practiced that, you might want to upgrade to a Gratitude Journal. You can spend 5-10 minutes each night or first thing in the morning, reflecting on all of the things in your life you appreciate. The act of writing it down helps to solidify in your mind the memories and experiences.

Consider incorporating your family into the practice. When sitting down to meals, ask your family members one thing that happened today that they each feel grateful for. We tend to do this before Thanksgiving dinner, but we can also do this as we sit down with our take-out pizza. Before falling asleep, tell your partner something about him or her that you value and appreciate.

Lastly, find opportunities in your day to express your appreciation for others. Consider sending an email to a colleague when you overhear a positive comment or compliment about them. A text with a thank you or heart emoji only takes five seconds but can brighten someone’s morning.

Remember that gratitude is not the same as denial or wearing rose colored glasses. It does not dismiss or deny the very real things that are not ‘ok’ in our society. Instead, gratitude helps us to collectively notice and appreciate the beauty, the kindness, the love that surrounds us every day. Sharing our gratitude allows us to work together to find solutions and to maintain hope in the face of adversity.

Practicing a grateful mindset can be challenging at first, especially when there are so many messages of negativity around us. Over time and with intention, building your gratitude practice can bring just a little more peace and joy to your world.

 

By Laurie Little, PsyD, Director of Therapeutic Services, Residential, Lindner Center of HOPE

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How to Treat Psychosis with Cognitive Behavioral Therapy for Psychosis (CBTp)

Many think that psychosis cannot be targeted with cognitive behavioral therapy, but that is not the case. There is a specific form of therapy that was developed for psychosis called CBTp. One important point to mention is that the symptoms are only targeted when they are distressing to the client and they interfere with their functioning or safety, not because one believes them to be untrue or abnormal. The main tenet is to join with the client and build rapport while not directly challenging their psychosis, which is referred to as working within their belief system. Once this is established, gradually helping them think differently about some of their experiences or beliefs is possible, but not in all cases. In some cases, the therapy is used to help them live their life and meet their goals in spite of their experiences or beliefs.

One useful technique with this therapy is to help them feel less stigmatized and normalize some of their experiences. There are specific websites out there that detail stories and list famous people out there who have struggled with psychosis, which can be very helpful for the client to read about. One such website is intervoiceonline.org.

Another very practical technique is helping them set smart and realistic goals. This can be done by asking what their goals are and developing a shared goal that can be accomplished. For example instead of “wanting the voices to stop” a smart goal could be “by the fourth session I will have learned and used two different coping strategies that reduce how much distress the voices cause from 100% to 75%”.

Other strategies that CBTp utilizes are coping strategy enhancement. First you figure out what they already are using to cope and figure out if they need to be refined or improved. Helping them figure out the time of day to use these strategies is important. They are likely to be most helpful when their voices are triggered, such as certain times of the day, a specific place, a certain smell, or certain feeling. Some strategies that can be useful to use before their voices are triggered include progressive muscle relaxation, deep breathing, and practicing mindfulness of the present moment such as identifying things in the room. Strategies that can be helpful once the voices are already triggered include: using an ipod and listening to a feel good songs playlist; playing the look, point and name; using sub vocal speech or singing under one’s breath which can interrupt the voices; focusing on voices (hearing out in order to change relationship with voice); entering into dialogue with them, and setting specific times for listening to voices.

When targeting voices in sessions, there are several main goals. One is to help the client understand how their beliefs and thoughts relate to the voices and influence their feelings, mood, and coping.  Another is to help them identify their beliefs about their voices. Helping
them explore evidence for and against their distressing beliefs is important. One can also develop behavioral experiments to test out the reality of their belief. Helping them generate alternative explanations and thoughts about their voices is also helpful. Providing behavioral interventions to reduce distress associated with their voices is key as well. Lastly, helping them change their relationship to their voices is important.

As you can see, there are many strategies that can be useful for this presenting problem.
The key it to present it in a way that is collaborative with the client and doing so in a trusting professional relationship. Meeting the client where they are at is important. It is also helpful to keep in mind that these techniques take some time to work and for the client to be able to use them, so patience is key as well.

 

 Nicole Bosse, PsyD

Staff Psychologist, Lindner Center of HOPE