Category: Mental Health

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William Hartmann, MD; Lindner Center of HOPE Psychiatrist, Medical Director, Willliams House

Navigating the realm of psychiatric medications can be challenging, often hindered by common misperceptions. Managing and understanding expectations can go a long way in ensuring treatment success. Seeking out help is often complicated by preconceived ideas. Preconceived notions about psychiatric medication often get in the way of successful treatment. Building a trusted relationship paves the way for educational opportunities, treatment adherence, and recovery.

5 Common Misperceptions of Psychiatric Medications

1 – “It’s just a chemical imbalance.” 

The advent of serotonin reuptake inhibitors (SSRIs), with their efficacy for depression and anxiety and reduced side effect risk compared to their predecessors, remains a major milestone in psychiatric care. It became increasingly commonplace to hear of the “chemical imbalance” of these illnesses. For as much as “chemical imbalance” helped spread the word that this is a brain disorder, not a moral failing, this wording unfortunately has promoted an overreliance on the power of the medication. The medications do alter brain chemistry and lead to a chain of biochemical events influencing symptom reduction and recovery. What the medication will not do is eliminate stressors, change one’s lifestyle, or cause satisfaction with an otherwise unhealthy situation. I find that those with the greatest success are those who recognize that medication helps facilitate deeper work in psychotherapy and making constructive changes to promote wellness. The medication may help substantially, but it will not do all of the work.

2 – “I don’t want to be a zombie.”

Many will fear that medication will change their personality substantially, or cause them to feel or appear sedated. The goal of treatment is to help a person function as their best self, not change who they are, or make them void of emotional response. While any effective medication has side effect potential, most patients can work with their prescriber to find the right fit for them to manage the illness with success.

3 – “I don’t want to take happy pills.”

Addressing the stigma associated with psychiatric medications, particularly antidepressants, is crucial. Depression is more than the usual sadness one inevitably encounters from time to time. Treatments for mood disorders are not instant “uppers” nor are they performance-enhancers. 

The effects of antidepressants are gradual and usually occur over about 4-6 weeks. Moreover, they will not make you “happy” so much as reduce and resolve symptoms of clinical depression. They aim to restore the capacity for contentment and joy. Treatment allows reduction of the “thought constriction” which limits one’s perspective to seeing few options. One may then see the broader opportunities to connect with core values in a rewarding way. It is about getting back to being your best self. Psychotherapy helps bring this together.

4 – “I don’t want to be dependent on a medication.”

The fear of dependency on medication is a valid concern for many. Taking medication may be a constant reminder of the illness, but the illness exists whether taking the medication or not. The majority of psychiatric medications, except benzodiazepines, do not produce true physical dependence. Turning the focus to the goals of recovery, and how the medication is part of the process, can help.

5 – “Don’t you put everyone on medication?”

There is not a one-size-fits-all approach. A common misconception is that every psychiatric patient is put on medication. Correct diagnosis is essential and, for some conditions, medication may not be the appropriate first line of treatment. A large portion of a psychiatrist’s work involves evaluating and managing the use of psychiatric medications. Most people will not come my way unless they have reached a point where medication appears necessary. A person may be experiencing sadness, grief, anxiety, milder depression, or an adjustment problem that is better suited for psychotherapy. A person might make gains in exposure response prevention for anxiety without the aid of medication. There may not be adequate or applicable evidence for medication helping a particular problem. Evidence is weaker for antidepressants in milder major depressive disorders, for example, but antidepressant treatment is recommended for moderate to severe depression. In some conditions, such as bipolar I disorder or schizophrenia, medication is crucial for the treatment and prevention of recurring episodes of illness. In opiate use disorders, prescription medications such as naltrexone and buprenorphine have emerged as a best practice, something that was not the case decades ago.

Ultimately, the decision regarding the role of medication for a given individual is between patient and prescribing clinician. Addressing attitudes and expectations early in the process can make a better experience for everyone. Empower yourself with knowledge to make the best choices for your mental health journey.

For more information and resources on psychiatric medications, contact us at Lindner Center of HOPE.

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Susan L. McElroy, MD

Lindner Center of HOPE, Chief Research Officer and Consultant to Eating Disorders Team

Borderline personality disorder (BPD) is a mental disorder consisting of a pervasive pattern of instability in regulation of emotions, impulses, interpersonal relationships, and self-image. Symptoms of BPD include frequent mood changes and excessive anger; feelings of worthlessness, insecurity, loneliness, and emptiness; periodic distortion of reality; and unhealthy social relationships.  Individuals with BPD are prone to self-harm (including suicidal ideation and behavior, self-cutting, and completed suicide), aggression, problematic alcohol and drug use, and other dangerous behaviors. The cause of BPD is unknown but thought to involve both genetic and environmental factors. Diagnosis is made clinically based on symptoms.

BPD is very common. It occurs in up to 5.9% of the general population and represents 15% to 29% of patients in psychiatric clinics and hospitals. Because the personality of children and adolescents is developing, the features of BPD do not become recognizable until late adolescence or early adulthood. Once the disorder appears, its course is often chronic. Though BPD is more common in women, a substantial number of men have the disorder as well.  There is a high comorbidity of BPD with other psychiatric disorders (approximately 85%), including anxiety disorders, mood disorders, impulse-control disorders, substance-use disorder, and eating disorders.

The present standard of treatment of BPD is psychotherapy, especially a form of psychotherapy called dialectical behavior therapy, to help individuals with tolerating distress and managing mood changes, impulses to self-harm, and relationships.  Most patients with BPD also receive psychiatric medication to target mood instability and excessive anger, impulsive and self-harming behavior, and cognitive and perceptual distortions. Small studies suggest medications that affect the dopamine and serotonin systems, particularly atypical (or second generation) antipsychotics (such as aripiprazole, quetiapine, and olanzapine), can be helpful for these symptoms. However, no medication has been approved by the United States Food and Drug Administration for the treatment of individuals with BPD.

The Research Institute at the Lindner Center of HOPE is participating in two important studies of one such medication, brexpiprazole, for treating BPD (clintrials.gov identifier NCT04100096 and NCT04186403) and is actively seeking individuals with BPD for participation. The first study is a 12-week, double-blind, placebo-controlled trial to evaluate the efficacy and safety of brexpiprazole for the treatment of individuals diagnosed with BPD. The second study is a six-month open-label trial of brexpiprazole in individuals who have completed the first study. (Open-label means all participants will receive brexpiprazole; no one receives placebo).

Otsuka Pharmaceutical Development and Commercialization, Inc., the manufacturers of brexpiprazole, is sponsoring the studies. Of note, brexpiprazole already has approval from the United States Food and Drug Administration for the treatment of schizophrenia and major depressive disorder (the later in combination with an antidepressant).

Please see the following links to get more information about the study:

https://clinicaltrials.gov/ct2/show/NCT04100096?term=Rexulti&cond=Borderline+Personality+Disorder&draw=1&rank=2

https://clinicaltrials.gov/ct2/show/NCT04186403?term=rexulti&draw=1&rank=8

https://lindnercenterofhope.org/research/

You may also contact Morgan Pond at [email protected]  or (513) 536-0704.

For further information on BPD:

https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

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Jennifer Farley, PsyD

Lindner Center of HOPE, Staff Psychologist

The holiday season can be an enjoyable and peaceful time for many of us. We adults know that this can also be a busy, tense, overstimulating, overindulgent, and overwhelming time. Any of these experiences can be triggered, for example, by holiday memories of the past, our current experiences, or worries about the future. We also may have expectations for how our holidays “should” be, which can bring about even more stress in planning them or sadness or anger if our experiences fall short of what we wanted.

Using mindfulness, or focused attention on the “here and now,” can be helpful in making the holiday season more tolerable and, hopefully, more enjoyable. Mindfulness involves being self-aware of one’s thoughts or feelings or behaviors in the current moment and without judgment. Why the current moment? Because thinking about the past can bring about sadness (and depression) and thinking about the future can bring about worry (and anxiety). Being mindful without judgment is also important – it helps prevent an emotion from being experienced more intensely. For example, telling oneself, “I’m a horrible friend for not giving them a gift,” is far different than, “I have the thought that I am a horrible friend for not giving them a gift.” Similarly, reflecting, “I’m sad that my family member isn’t here,” is experienced differently than “I have the feeling of sadness about my family member not being here.” The without judgment part also comes from not judging oneself or anyone else for having a particular thought, feeling, or behavior. Telling oneself, for example, that they’re “bad” for thinking or feeling a certain way is a judgment – having a thought or feeling simply makes one human. What we do with a thought or feeling is what matters more.

Thoughts about how the holidays “should be” can intensify people’s emotional experiences further. Many people, for instance, experience “shoulds” surrounding holiday traditions. While these can bring comfort to our holidays, “shoulds” can also weigh people down with guilt, burden, or anxiety. Family traditions are important, but so is the consideration of how a specific tradition might be unreasonable to expect – for oneself or others. Letting go of the word “should” allows more flexibility and adaptability to an experience, and as such, can bring about more joy and a lot less tension. Do you really “need” to host Christmas dinner? Or is it that you prefer it but can adapt to having someone else host?

Mindfulness can be practiced by observing and describing one’s current thought(s) or feeling(s). Mindfulness can also involve doing something with intention. Consider how you might – with focused intention – wrap a present, look at Christmas lights, drink your cup of coffee or hot chocolate, hug a loved one, sing a Christmas carol, hang ornaments on your tree, watch a favorite holiday movie, or study the fire in the fireplace. Doing something with intention helps you remain in the present moment. Be aware of how your phone or other distractions prevent you from being fully present with others. If you find yourself diving deeper into a holiday memory, try to catch yourself first, and mindfully reflect if it’s a happy or heartwarming memory or one that could bring about sadness or hurt or anger.

One classic holiday movie (A Christmas Story) features Ralphie and his myriad of Christmas-related incidents. There are two scenes that highlight mindfulness practice: 1) when Ralphie looks with amazement at the snow-covered scene outside his bedroom window on Christmas morning, and 2) when Ralphie’s parents sit together in the dark and gaze at their Christmas tree. Another movie (Elf) depicts a father making a choice to fully participate in singing a carol with his family. These pop culture references may help highlight ways you might practice mindfulness in your own ways this holiday season. As a result, may your next month or so be experienced with mindful moments that bring self-awareness, peace, and joy.

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La gratitud de un inmigrante.

Cuando pregunté por la fecha limite para entregar esta mi segunda columna me informaron tambien que saldría publicada justo antes del dia de acción de gracias (Thanksgiving) Entonces, me parecio casi obligatorio dedicar este espacio a la gratitud, y su impacto en la salud mental.

A kilómetros de distancia de nuestro lugar de origen, los inmigrantes somos también un poco huérfanos. Migrar es también una tipo de orfandad.  Y es solo atravesando ese miedo que acompaña la falta de referentes familiares al llegar a un país distinto que podemos entonces reconstruirnos y reinventarnos como ese huerfano con desesperación que busca un nuevo hogar. Hay quienes mueren (literamente) en el intento, otros que toman la decisión de ni siquiera intentarlo, y aquellos que deciden apostarlo todo en esa nueva tierra dejando atrás su historia. Es un viaje titánico imposible de transitar en solitario. Todos podemos nombrar a un familiar, un amigo, un trabajo, un colega, un vecino que nos tendio la mano o nos facilito el hilo a la hora de tejer nuestro nuevo nido. Por eso digo que no conozco a nadie mas agradecido en la vida que a un inmigrante. Y cuando escribo pienso en mi abuelo italiano que hasta el nombre se cambio para parecer mas venezolano.

No pretendo ni espero que todos nos comportemos con ese animo “rosadamente” positivo a diario, sobretodo considerando los dolores y las cicatrices que acompañan a la orfandad. Independientemente de cual haya sido la manera o la circunstancia en la que se emigró, cada uno de nosotros lleva consigo un duelo y una melancolia que nos es única e incomparable y que tiende a hacernos mas sensibles y conscientes de lo que nos falta o de lo que hemos perdido, haciendo difícil el poder conectarnos con todo aquello que vamos reinventado en nosotros mismos y a nuestro alrededor. Mi reflexión va por el lado de compartir lo que me va pareciendo son los dos elementos claves para vivir en gratitud. Primero, la posibilidad de conservar “pequeñas expectativas”, sin que eso signifique renunciar a nuestras ambiciones  y segundo, la habilidad para vivir en el presente.  Se refiere a vivir sin dar nada por sentado. Como un aprendiz o principiante que se asombra ante cualquier vestigio de progreso en la tarea que ejecuta y que no se atormenta por aquello que debe para el dia siguiente o la semana próxima. Es poder disfrutar de un dia cálido y soleado sin atormentarse porque mañana será frio y lluvioso. Es disfrutar de la visita de un familiar o de un amigo sin contar los días para la despedida.

Muchos estudios científicos afirman que vivir en gratitud es una estrategia robusta para combatir la depresion y la ansiedad. Se trata de prestar atención a cosas que podrían pasar por insignificantes o inútiles. No hace falta hacer una lista de mercado (a menos que para usted si tenga sentido). Basta con detenerse aunque sea una vez al dia a saborear un olor, un sabor, un gesto o una sonrisa inesperada como inesperado ha sido mi propio camino para llegar a ustedes.

 

Margot Brandi, MD

Medical Director, Sibcy House

Staff Psychiatrist

Lindner Center of HOPE

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Angela Couch, RN, MSN, PMHNP-BC
Lindner Center of HOPE, Pyschiatric Nurse Practitioner

Making decisions about which medication to prescribe is a complicated process.  Janicak, et al (2006, p. 1) described the complexity of the issue fairly well,

“…while improved therapies to ease a patient’s suffering are constantly emerging, the practitioner is required to continually assimilate new information about recent advances, including novel agents targeted to affect specific components of various neurotransmitter systems, combination strategies, alternative uses of existing agents, and the specialized requirements of a growing number of identified diagnostic subgroups.”

The clinician must first have identified a valid diagnosis, and determine whether treatment with medication is indicated.  In some cases, psychotherapy alone may be an adequate treatment; whereas pharmacotherapy is less frequently an adequate treatment all by itself and is often paired with psychotherapy.  Diagnosis will somewhat narrow the field of choices, and comorbid mental health conditions must be considered as well. If the patient has more than one mental illness, it is wonderful when there is a class of medication which may be able to treat all the symptoms in one drug, but often that is not the case.  Treatment of mood disorders is often prioritized, particularly if a bipolar spectrum illness is present. For instance, though antidepressants are generally a first line treatment for anxiety related disorders, giving an antidepressant to a patient with a bipolar spectrum illness can be quite destabilizing. In that case, the mood disorder should be addressed with mood stabilizing medication prior to consideration of antidepressant use.

There are potential risks and benefits to any medication, and the clinician much consider these and discuss them with the patient. Special populations require special considerations. Treating pregnant patients, children or adolescents, the elderly, or those with certain medical conditions, may pose additional risks; this may make many medications, which might otherwise be appropriate, be contraindicated due their side effects profile.  Sometimes, the potential side effects of a given medication may be beneficial to certain patients and their mental health or other comorbid symptoms, and this may help narrow the field of choices.  During treatment, the patient is continually reassessed to determine if they continue to benefit from the medication, and whether they are experiencing any side effects that should be closely monitored or may require a treatment modification.

Patients may have had prior positive or negative experiences on medications, and this can also help drive the decision making process. For instance, this may help a clinician to decide whether to try the same or very similar medication again, or to consider changing class of medication.  Sometimes, a close family member’s prior response to medication may be considered.

Pharmacogenetic testing is a recent advancement in pharmacotherapy.  There is a lack of consensus about the value of this genetic testing.  It would be misleading to state that the genetic testing results can indicate the medication to which a patient will respond favorably.  However, it can identify whether patients may metabolize various drugs that pass through the CYP P450 system in different ways, which may impact outcomes or suggest dose modification. Also, there a limited number of medications for which the FDA has specific labelling regarding recommendations for certain types of metabolizers. So it is possible that pharmacogenetic testing would be a consideration in the decision making process, but not a required one. It is not often covered well, if at all, by insurance, and the out of pocket portion can be cost prohibitive for some patients.

Practice guidelines can be very beneficial. For instance, the APA has been developing practice guidelines since 1991, and these cover a wide range of topics, which undergo periodic updates. The guidelines are formed by work groups of actively practicing psychiatrists who are selected based on their experience in various topic areas.  Recommendations are based on evidence that includes research studies and clinical consensus.

Last but not least, cost is a factor that unfortunately must be considered for many patients.  For those that have high deductible insurances, or no insurance, many drugs may be out of reach including those that may add an extra layer of medical monitoring such as frequent laboratory testing.

In summary, decision making regarding medication choice is complex process.

References:

APA Practice Guideline Development Process (n.d.) Retrieved from:  https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/APA_Guideline_Development_Process.pdf

Janicak, P.G., Davis, J. M, Preskorn, S.H., Ayd, F.J., Marder, S.R. & Pavuluri, M.N.  (2006). Principles and practice of psychopharmacotherapy (4th ed.).  Philadelphia, PA: Lippincott Williams & Wilkins.

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Lo que fui es lo que soy….

(“What I was is what I am”. An article addressing the challenges and consequences of immigration from a social and psychological perspective and how this process ends up shaping us in multiple and unexpected ways while trying to maintain and cultivate original roots.)

Soy venezolana. Soy psiquiatra y psicoanalista. Le debo a mi país la esencia de mi formación como professional y mi Corazon latino. Finalmente, luego de mucho esfuerzo  tengo una practica solida como psiquiatria y psicoterapeuta en Mason, Ohio. Volver a estudiar fue un requisito inevitable para poder recuperar un pedazo de mi identidad perdida que no cupo en mi maleta a la hora de emigrar y que alimentaba de forma negativa a la nostalgia que no he podido sacudirme desde que llegue a los Estados Unidos de America. Desde que empece a trabajar formalmente siempre había querido encontrar una manera que me acercara a la comunidad latina y desde donde pudiese compartir mis ideas y experiencias en relación a distintos temas relacionados a la salud mental. Es una deuda pendiente con mi raiz latina. Mi intención es abrir un espacio que considero indispensable para abordar la salud mental sin tapujos ni prejuicios hasta ahora muy ligados a la manera como nuestra cultura tiende a referirse a cualquiera que sea la enfermedad mental. Todos podemos hablar con comodidad y compartir nuestra experiencia y nuestro sufrimiento físico cualquiera que este sea pero cuando se trata de nuestro sufrimiento psíquico tendemos a esconderlo o a avergonzarnos y sin darnos cuenta terminamos aislándonos y de esta forma empeorando nuestra padecer.

Así que entre mis resoluciones de ano nuevo estuvo darle inicio a esta columna y como seguramente les ha pasado a ustedes tambien con sus propias resoluciones me ha costado arrancar y con mucha suerte estarán ustedes leyéndome antes de que el ano termine…. Es decir casi con un ano de retraso en mi calendario de ilusiones.

He decidido titular mi columna “Lo que fui es lo que soy”. Es el nombre de una de mis canciones preferidas y recoje lo que a mi manera de ver es una utopia porque no es posible negar los efectos del tiempo, el espacio y la distancia en la identidad de todo emigrante pero a la vez es tambien un ancla que me permite estar atenta a la necesidad de preservar y cultivar mi identidad Latina.

No hay duda que al pisar otro pais con el proposito de emigrar se produce una division, una ruptura entre lo que dejamos atras y lo que empezamos a construir. Sin duda las redes sociales, las llamadas telefonicas, el facetime o el whatsapp sirven de cuerda que intenta mantener cierta continuidad entre estos dos mundos. Eso contando con que el internet y las telefonicas esten de nuestro lado, cosa que no es lo usual en paises como el mio.  Es una cuerda que a veces se siente floja o muy tensa dependiendo el dia y el interlocutor y caminar en ella da mucho susto por no decir vertigo y es entonces cuando empezamos a evitarla o a caminar en puntillas para que no se rompa. Nos comunicamos menos con los que quedaron del otro lado, o decimos menos omitiendo asuntos importantes por aquello de no preocupar al otro y asi sin darnos cuentas vamos perdiendo gente querida muchas veces ignorando por que.

Hace poco lei que “la emigracion distorsiona las leyes de la fisica. Es todo alucinante y un poco incomprensible”. “ Todo el que emprende el largo y azaroso viaje de la migración —que te cambia como persona, que siempre te somete a toda clase de sorpresas, que te arroja a orillas inesperadas— se convertirá en otra persona más rápida e imprevisiblemente de lo que espera y de lo que hubiera pasado en lugar de origen. Todos cambiamos, queramos o no, a medida que vivimos, pero ese cambio se dispara si nos mudamos de ciudad o de país o de continente. Así que irse implica siempre, en cualquier contexto, que te harás otra persona más pronto que tarde, y por tanto irás dejando de tener cosas en común con quienes te rodeaban en tu mundo anterior.”

Esta columna es mi intento por mantener esa cuerda firme a sabiendas de que las consencuencias de la migracion son muchas, y algunas irreversibles.  No me queda otra que hacer el intento. Tratar de dibujar en este espacio maneras de navegar entre estos dos mundos y revisar sus consecuencias en lo psicologico. En mi proxima columna explorare el tema de el duelo como proceso inevitable en toda migracion.

Margot Brandi, MD
Medical Director, Sibcy House
Staff Psychiatrist

 

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By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief
of Adult Psychiatry

 

Innovations in Mental Health Treatment

By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief
of Adult Psychiatry
The past year has brought exciting innovations in treatment options for people with attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), and obsessive-compulsive disorder (OCD.) The U.S. Food and Drug Administration (FDA) approved the marketing of two devices which offer non-medication alternatives for the treatment of OCD and ADHD.  In August 2018, the Brainsway Deep TMS (Transcranial Magnetic Stimulation) system was approved for the treatment of OCD.  Deep TMS uses specially designed magnets to stimulate specific larger volume areas of the brain beneath the surface of the skull.  It is a non-invasive treatment that involves five 20-minute sessions per week for six weeks while sitting in a chair wearing a helmet with a sensation of tapping during the treatment.  Patients can continue medication and psychotherapy while receiving deep TMS.  According to the National Institute of Mental Health (NIMH), the lifetime prevalence of OCD among U.S. adults is 2.3% and 50% of these have had serious impairment.  Having another treatment option will bring hope to many people with severe OCD.

In April 2019, the Monarch eTNS (external trigeminal nerve stimulation) system was approved for the treatment of pediatric ADHD as monotherapy in children ages 7 through 12 years old who are not currently taking prescription ADHD medications. The Monarch eTNS System is intended to be used at home under the supervision of a caregiver when the child is sleep. The cell-phone sized device generates a low-level electrical pulse that feels like a tingling sensation and connects via a wire to a small patch that adheres to a patient’s forehead, just above the eyebrows. The system delivers electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. The NIMH reports that the prevalence of ADHD is increasing, and severe ADHD is being diagnosed at an earlier age. This can be a treatment alternative for parents who prefer to avoid medications at an early age. Clinical response is expected in four weeks.

The mechanism of action of most antidepressants involve the neurotransmitters serotonin, norepinephrine, and dopamine. In March 2019, two antidepressants with novel mechanisms
of action were approved. Zulresso (brexanolone) was the first drug specifically approved for postpartum depression. Postpartum depression affects about 15% of women. Zulresso modulates the neurotransmitter GABA. It is administered as a 60-hour intravenous infusion in a registered healthcare facility. Symptom improvement was seen at the end of the infusion and at the end of 30-day follow-up. There has never been a medication that treats the symptoms of postpartum depression so rapidly, so this can significantly improve the quality
of life for the mother, infant, and her support system.

Spravato (esketamine) nasal spray was approved for treatment-resistant depression in conjunction with an oral antidepressant. Patients must have tried at least two antidepressant treatments at adequate doses for an adequate duration in the current depressive episode before trying Spravato. The spray must be administered in a certified medical office where the patient can be monitored. Spravato is taken twice a week for four weeks then once a week for a month, then once a week or once every two weeks. It is an antagonist of the NMDA receptor, a type of glutamate receptor. Approximately 30% of people with MDD are considered to have treatment-resistant symptoms and have the potential to benefit from esketamine.

For more information about these treatment options: https://www.brainsway.com/treatments/obsessive-compulsive-disorder 

http://www.monarch-etns.com/ 

https://www.zulresso.com/ 

https://www.spravato.com/

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By Jen Milau, APRN, PMHNP-BC
Lindner Center of HOPE,
Psychiatric Mental-Health Nurse Practitioner

 There’s no denying it: the advent of social media has changed the way we connect with one another. In some ways, these programs have offered an opportunity to locate and reconnect with lost friends or family members – a phenomenon that was not even fathomable until recent decades. However, this near-immediate accessibility of information, coupled with the rapid growth of social media sources, has not been accompanied by a “user guide” or an algorithm for appropriate and healthy incorporation into our daily lives. Instead, the technology has been thrust upon us as a society, and we have been left with the task of “figuring it out as we go.” In the field of psychiatry and mental health, we are seeing the repercussions of this in a number of unexpected ways, and those who have been hit the hardest are among our most vulnerable – children, adolescents, and young adults.

As a clinician working primarily with this population, I have been struck by the stark and abrupt increase in suicidality and mental health concerns within the last five years. According to the Centers for Disease Control, in 2017, suicide stood as a leading cause of death for individuals aged 10-34, second only to accidental injury. Just this year, the American Psychiatric Association (APA) published data Continued from page 1 which cites that “more U.S. adolescents and young adults in the late 2010s (vs. the mid-2000s) experienced serious psychological distress, major depression, and suicidal thoughts, and more attempted suicide and took their own lives… These trends are weak or nonexistent among adults 26 years old and over, suggesting a generational shift in mood disorders and suicide-related outcomes rather than an overall increase across all ages.” The specific data presented within this report reflect a 40-122% increase (depending on specific age range) in suicidality and psychological/mood disturbances among individuals age 12-25. So the question stands: why have young people been so disproportionately affected?

The answer to this is complex, and certainly not yet fully understood. It is important to first consider what we know: Adolescence is a period of significant neurochemical and biological transformation. With these physiological changes comes the development of a sense of identity – a process fueled by social interactions, sexual exploration, experimentation with interests, exposure to information, and individual expression. These facets of development have not changed by any means. Rather, the way in which today’s youth is exposed to these experiences has shifted from primarily organic, physical, human interactions to online exchanges through a variety of social media and communication apps available with a simple tap of a finger. Since this happens behind a screen, kids are not faced with the immediate implications of their words or actions, as they do not witness the non-verbal cues accompanying a person’s response, and do not experience the inevitable feeling of anxiety that goes along with confrontation or conflict in a real-time situation. They have the opportunity to carefully calculate their responses over time, or blatantly ignore a person with whom they do not want to interact, rather than being placed into a situation that requires problem-solving and relational abilities in the immediate moment. This has led to a generation of individuals who have largely avoided natural social responses; in turn, we are seeing a serious rise in the prevalence of social anxiety and kids who are devoid of many vital interpersonal skills.

Additionally, within the world of social media, we are offered the opportunity to customize our “online identities” to mirror whichever characteristics we choose to share with others. Due to our human need for acceptance and attention, this usually results in the meticulous formation of an “ideal self” – one which typically is not reflective of our inherently flawed (and beautifully unique) personalities and instead represents a false utopian identity used to highlight those traits of ourselves and our lives that we feel may be most desirable to others. As this practice becomes typical of an entire society, we begin to unconsciously accept these “pseudo-selves” as reality, leading to the habit of comparing our actual lives to those that are portrayed on the internet. This can result in significant issues with self-esteem, increased self-doubt, shame, body image concerns, and social isolation – problems which, for an individual predisposed to mental illness, could trigger a major mood episode or exacerbation of anxiety symptoms.

Further, the immediate accessibility of information to which we have become accustomed has unfortunately led to an expectation for instant feedback and gratification that is simply not applicable to most real-life scenarios. Studies suggest that the neurochemical response to “likes” on a post or picture actually mirror that which is experienced with illicit drug use or other behavioral addictions. This, then, leads to further desire to obtain more likes, and the consequent sense of disappointment and desperation when posts do not receive the attention that we were expecting.

When we view these ideas in the context of an adolescent who is developmentally tasked with the goal of exploring and forming a sense of self while also battling the physical and emotional implications of rapid growth and hormone changes, this becomes extraordinarily problematic. Many patients that I see describe feelings of worthlessness and hopelessness due to their perception that they are not as “successful” as others they see online. For a child who has endured trauma, the ability to form harmful connections with ill-intentioned adults is too readily accessible, leading to exploitation and further exacerbation of trauma-related symptoms. Children with attention issues are experiencing insomnia due to being constantly stimulated by their devices into the nights, resulting in reduced academic performance and mood dysregulation. And most importantly – families are not connecting in the ways that are imperative for fostering well-adjusted and cognitively flexible young adults.

This being said – there is certainly hope for change moving forward. As we adapt to the presence of technology within our lives, we are learning more and more about the importance of moderation in regards to screen time and devices. As a clinician, I preach to my patients and their parents about the risks of social media and unlimited time with technology and encourage open conversations regarding limits and expectations for its use. I challenge parents to model what it looks like to balance screen time and “real” time, and recommend the implementation of rules for all members of the family, not just children or adolescents. By increasing the number of organic experiences and social interactions that our children have, we are preparing them to be able to adjust to the unexpected, unpredictable twists and turns.

 

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By Anna I. Guerdjikova, PhD, MSW, LSW

“Mens sana in corpore sano” is a Latin saying from the Satires of Juvenal (ad c.60–c.130) , literally translating to ‘a healthy mind in a healthy body’ and widely used nowadays to describe the concept of wellness – the need for both physical and mental wellbeing to be present for a person to be healthy. When raising children, paying attention to both aspects of health is indeed critical to ensure their bodies and minds grow and develop to the best of their potential. The mnemonic below (BE SAFE) can help with remembering the key concepts of how to parent healthy children.

B– Build sense of belonging. Ensure that your child socializes with an appropriate peer group, that they participate in activities suitable for their age and that they learn to develop nontoxic friendships. Spending time with relatives and family friends fosters sense of security and belonging and teaches children how to nurture meaningful relationships.

E– Educate and encourage. Encourage children to develop age appropriate competencies, both social and academic. Be their role model in teaching them respect, acceptance of diversity, responsibility, accountability and kindness. Reinforce positive behaviors and decision making, encourage them to help others by setting an example (like volunteering as a family).

S– Enough sleep is absolutely critical for wellness (9-13h/ night for ages 3-12; 8-10h/ night for teenagers).1 More than 70% of children in a contemporary family get less sleep than recommended, thus improving sleep hygiene for everyone in the household can significantly boost family wellness. Help them establish and keep a regulated schedule (even on weekends and during vacations) by setting an example and discussing the benefits of good sleeping habits.

A –According to the U.S. Department of Health and Human Services guideline issued in 2018, children 6 to 17 years of age can “achieve substantial health benefits by doing moderate-and vigorous-intensity physical activity for periods of time that add up to 60 minutes or more each day”.2 Unstructured play in the park, biking, walking, and sports, both recreational and competitive, they all count.

F –Appropriate food choices with up to 5 servings of fruits and veggies per day and at least a few family meals a week. Frequent family meals increase the odds of child positive social skills and engagement in school, and decrease the likelihood of child problematic social behaviors3; they also have protective effect on the mental health of adolescents, particularly for depressive symptoms in girls. 4

E -Limit use of electronics. In 2016, the American Pediatric Association issued recommendations regarding screen time use and while they vary by age group, the overarching idea with older children is to “balance media use with other healthy behaviors”. 5 For children younger than 18 months the use of screen media other than video-chatting, should be altogether avoided.

Raising healthy children is hard. Raising healthy children when the parent struggles with mental illness can be particularly challenging; it is of paramount importance for them to seek professional help, but to also solicit support for daily logistics from friends and family. The old African proverb “It takes a village to raise a child” is especially relevant when one or more members of the family are suffering with mental illness, thus actively requesting help, practicing self-care and knowing one’s limitations can improve the wellness of the entire family.

  1. https://edubirdie.com/articles/american-academy-of-pediatrics-announces-new-recommendations-for-childrens-media-use/
  2. J Fam Psychol. 2014 Aug;28(4):577-82. doi: 10.1037/fam0000014. Frequency of family meals and 6-11-year-old children’s social behaviors.Lora KR, Sisson SB, DeGrace BW, Morris AS
  3. J Nutr Educ Behav. 2017 Jan;49(1):67-72.e1. doi: 10.1016/j.jneb.2016.09.002. Family Meals and Adolescent Emotional Well-Being: Findings From a National Study. Utter J1, Denny S, Peiris-John R, Moselen E, Dyson B, Clark T.

120 Tools and Tricks to Protect Your Kids Online

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 Innovations in Mental Health Treatment

By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief
of Adult Psychiatry

The past year has brought exciting innovations in treatment options for people with attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), and obsessive-compulsive disorder (OCD.) The U.S. Food and Drug Administration (FDA) approved the marketing of two devices which offer non-medication alternatives for the treatment of OCD and ADHD.  In August 2018, the Brainsway Deep TMS (Transcranial Magnetic Stimulation) system was approved for the treatment of OCD.  Deep TMS uses specially designed magnets to stimulate specific larger volume areas of the brain beneath the surface of the skull.  It is a non-invasive treatment that involves five 20-minute sessions per week for six weeks while sitting in a chair wearing a helmet with a sensation of tapping during the treatment.  Patients can continue medication and psychotherapy while receiving deep TMS.  According to the National Institute of Mental Health (NIMH), the lifetime prevalence of OCD among U.S. adults is 2.3% and 50% of these have had serious impairment.  Having another treatment option will bring hope to many people with severe OCD.

In April 2019, the Monarch eTNS (external trigeminal nerve stimulation) system was approved for the treatment of pediatric ADHD as monotherapy in children ages 7 through 12 years old who are not currently taking prescription ADHD medications. The Monarch eTNS System is intended to be used at home under the supervision of a caregiver when the child is sleep. The cell-phone sized device generates a low-level electrical pulse that feels like a tingling sensation and connects via a wire to a small patch that adheres to a patient’s forehead, just above the eyebrows. The system delivers electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. The NIMH reports that the prevalence of ADHD is increasing, and severe ADHD is being diagnosed at an earlier age. This can be a treatment alternative for parents who prefer to avoid medications at an early age. Clinical response is expected in four weeks.

The mechanism of action of most antidepressants involve the neurotransmitters serotonin, norepinephrine, and dopamine. In March 2019, two antidepressants with novel mechanisms of action were approved. Zulresso (brexanolone) was the first drug specifically approved for postpartum depression. Postpartum depression affects about 15% of women. Zulresso modulates the neurotransmitter GABA. It is administered as a 60-hour intravenous infusion in a registered healthcare facility. Symptom improvement was seen at the end of the infusion and at the end of 30-day follow-up. There has never been a medication that treats the symptoms of postpartum depression so rapidly, so this can significantly improve the quality of life for the mother, infant, and her support system.

Spravato (esketamine) nasal spray was approved for treatment-resistant depression in conjunction with an oral antidepressant. Patients must have tried at least two antidepressant treatments at adequate doses for an adequate duration in the current depressive episode before trying Spravato. The spray must be administered in a certified medical office where the patient can be monitored. Spravato is taken twice a week for four weeks then once a week for a month, then once a week or once every two weeks. It is an antagonist of the NMDA receptor, a type of glutamate receptor. Approximately 30% of people with MDD are considered to have treatment-resistant symptoms and have the potential to benefit from esketamine.

For more information about these treatment options: https://www.brainsway.com/treatments/obsessive-compulsive-disorder 

http://www.monarch-etns.com/ 

https://www.zulresso.com/ 

https://www.spravato.com/