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

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

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

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

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

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

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

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

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

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

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

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

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

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by Dawn Anderson, LPCCS

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

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

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

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

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

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

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

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Learn what residential treatment facility is like and when is residential treatment necessary.

What is Residential Treatment?

A loved one is experiencing mental health problems – or perhaps you are dealing with mental illness yourself.  As you look into treatment options – outpatient, inpatient, etc., one option that may be recommended is a residential treatment center.

Residential treatment is a specialized form of inpatient care. It typically includes 24-hour supervision and monitoring within a non-hospital setting, often aimed at providing an intensive therapeutic environment for clients with mental health and/or substance use issues. This type of care provides an extended stay with personalized, clinically informed interventions and services that can often be more beneficial than traditional outpatient care.

Additionally, residential treatment programs can offer a variety of activities designed for both the physical and emotional health of clients, ranging from recreational activities to individual and group therapies. Residential treatment is highly individualized to meet each person’s specific needs, helping them build life skills as they work on their emotional stability and overall well-being.

What is a Residential Treatment Center?

A residential treatment center provides intensive, comprehensive assessment and care for individuals dealing with complex mental health and/or addiction issues.

But is this type of program right for you or your family member? After all, any type of treatment approach isn’t right for everyone.  Consider the following information before you make a decision about whether residential treatment is the best choice.

Who Is the Best Candidate for Residential Treatment?

While a variety of individuals can benefit from the structured and supportive environment of a residential treatment center, some of the best candidates are those who:

  • Have complex diagnostic or treatment issues;
  • Need a more structured environment or do not have a natural environment ideal for supporting their treatment;
  • Have not responded sufficiently to previous treatments;
  • May have a higher risk of decompensation. (While stable, they may need a greater degree of watchful oversight to address potential suicidal risk, “acting out” behaviors, etc.).

When is Residential Treatment Center Necessary?

Residential treatment centers can be an important lifeline for those struggling with mental or emotional health issues and are in need of additional support for wellness. These establishments, providing short-term 24-hour care and a safe environment, often benefit those at risk of self-harm or suicide as well as those with severe emotional trauma that can’t be handled without a structured program.

It is often recommended to individuals when more traditional treatments such as therapy or medication have not been successful. A residential treatment center can also act as a bridge to prevent the person from having to go into a higher level of care such as hospitalization or long-term into the institution if their mental health condition worsens.

If you believe that you or someone you know might need residential treatment assistance, contact your healthcare provider who is best suited to assess the current level of care needed and guide you through this process.

What is Residential Treatment Like?

For an individual who meets one or more of the above criteria, a residential treatment center can provide many benefits, such as the following:

  • A supportive environment. The community and therapeutic milieu provided in a residential treatment environment can be treatment approach themselves. Many individuals with mental illness do not live in a naturally supportive environment and may easily become socially isolated or frustrated after an acute treatment episode.  Others lack the life skills necessary to function productively, and the therapeutic environment of a residential program provides a safe place to learn and practice them. It helps foster more responsible behavior, greater self-esteem, and positive relationships.
  • A greater degree of structure.  Residential treatment centers provide structured and stabilizing routines throughout the entire day.  These can be beneficial to individuals with impulsivity, compliance issues, medical problems, or high-risk behaviors.
  • More intensive, longer-term care. If a behavioral health problem is particularly severe or complex, outpatient treatment is not sufficiently intensive, and inpatient treatment is not long enough to help patients develop new coping and social skills. Ten- or 28-day programs are an increasingly popular option in many residential treatment centers today.
  • More extensive diagnostic assessment process and tools.   An estimated 85% of individuals with addiction are also dealing with a mental illness. Additionally, individuals with one type of mental disorder may also have other mental health issues.  Proper assessment and diagnosis is important to guide the best treatment plan possible.  Residential treatment programs typically provide more extensive assessment, often using sophisticated tools and technologies such as psychological tests, brain scans, and even genetic testing. Find out more about psychological assessments here.
  • Broader range of treatments. A residential treatment center typically offers a broader “menu” of services than other settings. Once assessment is completed, residential program offer a robust selection of therapies, from traditional psychotherapy to recreational therapy. The fact that the environment is more structured and supervised makes some treatments, such as medication adjustments, more feasible. The logistics of obtaining therapeutic assessment and high-tech treatments are also easier when services are provided literally under one roof. Finally, this environment is also ideal for implementing detailed protocols for specific disorders, such as obsessive-compulsive, substance abuse, and eating disorders.

There are many benefits to residential treatment. One way to remember the overall benefits is to think of the “4-S” approach to treatment: Supportive, Structured, Safe, and Sophisticated.

Alternative Options to Residential Treatment

Residential treatment is not appropriate for everyone.  Patients with short-term or milder disorders may benefit sufficiently from outpatient treatment, while individuals with critically acute problems or significant suicidal risk may need inpatient care.

But for many individuals, the “happy medium” provided by an effective residential treatment center offers the best head start on regaining a productive and enjoyable life. For more information about residential mental health and addiction treatment, view our in-depth guide.

There is HOPE. For more information, call 1-888-537-4229.

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

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

History of Ketamine

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

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

Ketamine and Depression

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

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

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

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

Ketamine Assisted Psychotherapy

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

The Benefits and Challenges of Ketamine Treatment

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

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

However, ketamine treatment does come with its challenges and risks. One major obstacle is the lack of long-term data on the safety and efficacy of ketamine as a mental health treatment. While research has shown short-term benefits, the question of how long the benefits last requires additional investigation.

Due to its powerful impact, Ketamine is also often misused. Research is still needed on the abuse potential of Ketamine. Interestingly, there is some evidence to suggest that Ketamine itself can be effective in the treatment of other substance use disorders such as alcohol and heroin. There is still much more to be learned.

Lastly, ketamine treatment is often not covered by insurance for mental health conditions, making it financially inaccessible for many patients. The cost of treatment, coupled with the need for repeated administrations to maintain benefits, raises concerns about equitable access to this innovative therapy.

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

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

References

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

Berman, R. M., Cappiello, A., Anand, A., Oren, D. A., Heninger,

  1. R., Charney, D. S., & Krystal, J. H. (2000). Antidepressant effects of ketamine in depressed patients. Biological Psychiatry, 47(4), 351-354.

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

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

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

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

Chadi G. Abdallah and Lynnette A. Averil

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

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

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

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

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

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

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

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People often wonder what “psychological evaluation” is, what it is used for, and how it can help.

This blog post is written by Jennifer L. Farley, PsyD, Lindner Center of HOPE, Staff Psychologist. We’ll dive into the varying answers to those questions, learn more about referral questions, testing settings and why psychological evaluation is important.

What is psychological assessment?

Psychological assessment is the process of evaluating an individual’s mental health and behavioral functioning through the use of standardized tests, observations, and other methods. It is typically conducted by a mental health professional, such as a psychologist or psychiatric nurse practitioner, and is used to diagnose mental health conditions, determine appropriate treatment options, and measure progress in treatment.

Most broadly, psychological evaluation involves an objective manner in which one’s “psychological functioning” is assessed. An “objective” way of testing involves comparing one’s responses to standardized measures (in which every respondent is given the same measure or responds to tests that are administered in the same way) to normative group (usually based on the person’s age) to see how well they are functioning compared to their age peers. (Think of the standardized testing that students complete in school or with college preparatory examinations such as the ACT or SAT.) “Psychological functioning” is also a broad label, since many different abilities are assumed within this. More specifically, when people refer to “psychological functioning,” it helps to understand if they are referring to intellectual abilities and some other cognitive skills (such as attention), emotional functioning, and/or personality characteristics.

Types of psychological evaluation and what is included in testing?

There are different types of evaluations that can be pursued, depending on the purpose of the testing.

Psychoeducational evaluation

First, a psychoeducational evaluation is one in which the patient typically undergoes testing for a learning-based disorder. Often, this testing centers around intellectual testing and academic achievement measures (such as tasks involving math, reading, and written language). Comparisons are then made between one’s intellectual abilities and his or her academic skills; if there is a large discrepancy between one’s intellectual skills and academic skills in any particular area (in which the academic ability is significantly lower than what would be expected for the patient’s intellectual abilities), this helps form the basis of diagnosing a specific learning disorder.

Psychoeducational evaluations are often performed within schools when there is a concern about a child having a cognitive or learning-based disorder that is interfering with their learning. These types of evaluations are also often done “privately,” meaning that individuals pursue these evaluations in a clinical (i.e., not academic) setting with a licensed psychologist. Often, other measures (such as classroom observations or parent and teacher questionnaires of observations of behaviors or emotional functioning) may be included in these types of evaluations. Though school psychologists cannot diagnose specific disorders (such as Attention Deficit/Hyperactivity Disorder), what matters most is that regardless of the testing setting, the findings help guide interventions and/or accommodations that can be implemented into a 504 Plan or into a more formal, Individualized Education Plan (IEP).

Emotional and/or personality functioning evaluation

Some may seek evaluations to help understand a patient’s emotional and/or personality functioning, especially because the testing helps learn about the individual in a more comprehensive way in a shorter amount of time (instead of over several therapy sessions). Results from these measures can help with recommendations for mental health treatment, such as with use of medications and/or for therapy (such as which strategies can be most helpful to teach the patient). Findings can also help guide other referrals, such as to other specialists (such as a psychiatrist or a neurologist). Depending on the age of the patient, these measures may include questionnaires that are only completed by the patient themselves (this is particularly the case among adult patients).

Assessments in children

When assessing a child, parents often complete questionnaires that ask about what they observe (behaviorally and emotionally) in their child. When the patient is an adolescent, it is more common that a combination of emotional and personality questionnaires are included that involve the adolescent responding to self-report measures and the parent(s) or primary caregiver(s) responding to their own measures involving observations of the child. Parent or caregiver responses are particularly helpful (and often necessary) when assessing children and adolescents, as most children and many adolescents lack enough insight or awareness into their difficulties, and often parents are the ones to observe problems or concerns first. These evaluations are conducted in clinical settings such as outpatient practices and sometimes inpatient hospitals in which obtaining such information is necessary to guide a clinician’s diagnostic impressions and treatment recommendations.

Neuropsychological evaluation

Another type of psychological assessment is a neuropsychological evaluation that helps measure more detailed aspects of cognitive functioning, such as executive functioning abilities (i.e., one’s ability to plan, organize, and inhibit cognitive, emotional, and behavioral responses), attention, learning, memory, and even motor coordination and/or strength. Individuals who specialize in these types of assessments are required to have completed more thorough post-doctoral training. Often times, referrals may come from physicians or therapists who are concerned about a patient’s functioning in these areas, whether it be related to a neurological condition (such as a seizure disorder, a head injury, or dementia) or to a psychiatric disorder (in which it is common for mood states or anxiety to negatively affect one’s cognitive functioning). Neuropsychological assessments are most often conducted in medical-based settings. Yet, they can also be conducted when a more comprehensive evaluation is sought after (such as in psychiatric residential settings). When this is the case, a neuropsychological assessment battery can capture one’s functioning more globally with measures of intelligence, academic achievement, neurocognitive abilities, and personality and emotional functioning.

Why is psychological testing important?

There are several reasons why psychological testing is important:

  • Psychological assessment is important because it can help identify mental health conditions and other issues that may be impacting an individual’s thoughts, feelings, and behaviors.
  • It can provide a more complete understanding of an individual’s strengths and weaknesses, which can be useful in making decisions about treatment and support.
  • Psychological assessment can help diagnose conditions such as depression, anxiety, bipolar disorder, and attention deficit hyperactivity disorder (ADHD), among others.
  • It can also be used to assess an individual’s cognitive abilities, such as memory, problem-solving skills, and intellectual functioning.
  • Psychological assessment can help identify the underlying causes of an individual’s symptoms and provide a basis for developing a treatment plan that is tailored to their needs.
  • It can also be used to monitor an individual’s progress in treatment and make any necessary adjustments.
  • Psychological assessment can help individuals and their families better understand the nature of their struggles and the options available for addressing them.

A final consideration for any kind of psychological assessment is this: while testing is often sought after to diagnose a condition or to understand one’s possible difficulties in any area of functioning, it is also important to learn what someone’s strengths are. Everyone has strengths and weaknesses relative to their own abilities; it is helpful to inform individuals from testing of what their strengths are and how to use these to compensate for any documented weaknesses they may have. Information helps empower people to develop and grow, and results obtained from psychological assessment can help people be more informed as to how to proceed with utilizing their cognitive and/or emotional strengths to help improve their mental health overall.

There is HOPE. For help, call 1-888-537-4229.

If you or a loved one is suffering from mental illness or addiction, contact us for information on our residential treatment programs for mental health in adults.

Read more about Lindner Center of HOPE’s assessment programs.

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What is Panic Disorder?

Panic Disorder is an anxiety disorder that occurs when someone experiences recurrent, spontaneous, unexpected, and untriggered panic attacks. This leads to preoccupation with and fear of experiencing another attack. Panic attacks occur when there is an intense physical surge of symptoms that quickly reach their peak, usually in a few minutes. A panic attack can be felt very differently from one person to another. A combination of the following symptoms is typically experienced during a panic attack:

  • Heart palpitations, pounding heart, or accelerated heart rate
  • Sweating/perspiration
  • Trembling or shaking
  • Sensations of shortness of breath or feeling smothered
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizziness, unsteadiness, light-headedness, or faintness
  • Chills or feeling over-heated
  • Numbness or tingling sensations
  • Feelings of depersonalization (unreality)
  • Feelings of derealization (being detached from oneself)
  • Fear of losing control or “going crazy”
  • Fear of death or dying
  • Sense of impending doom or danger

At least one of these panic attacks is followed by one month or more of persistent concern or worry about having another attack and/or a significant change in behavioral pattern (typically avoidance of certain places or situations).

Panic attacks can be viewed as a “false alarm” related to a fight-or-flight response to a mis-perceived threat. Fight-or-flight is a natural human reaction that prepares us to defend ourselves or flee the situation. When someone becomes hyperaware of their body’s sensations, they may interpret a sensation as a threat when there’s not one.

Panic disorder affects 2-3% of Americans and is affects women roughly twice as frequently as it affects men. The onset of Panic Disorder typically occurs in adulthood, but can also affect children and teens.

What is Agoraphobia?

Agoraphobia occurs when someone persistently avoids situations in which they might become embarrassed or have difficulty escaping. This is often the result of fear of having a panic attack in public. This can manifest in fear of using public transportation (such as planes, buses, trains), being in open spaces (such as parking lots, malls, or stadiums), being in enclosed spaces (such as elevators, stores, or cars), being in crowds or standing in line, or even being outside the home alone.

Panic Disorder can be present with or without Agoraphobia, but these disorders commonly present together. When they occur together, Agoraphobia usually develops following an adverse experience, such as having a panic attack in one of these places/situations in which the person feels trapped, embarrassed, or fearful. Over time, avoidance of these situations and places reinforces one’s fear, leading to further avoidance.

How are Panic Disorder and Agoraphobia treated?

People with Panic Disorder often present to emergency departments or their physician’s office due to their uncomfortable physical sensations (often fearing that they are suffering from a heart attack). While it is important to rule out any physical cause for these symptoms, repeated trips to the ER and doctor visits can also reinforce the symptoms. Instead, it is important to receive appropriate mental health treatment for Panic Disorder and Agoraphobia.

Treatment for Panic Disorder and Agoraphobia typically includes of a combination of medication and psychotherapy. Medications commonly used to treat Panic Disorder and Agoraphobia include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), beta blockers, and benzodiazepines. SSRIs and SNRIs are a category of antidepressants that are also useful in treating anxiety disorders such as Panic Disorder and Agoraphobia. Beta blockers can be used to help control some of the physical symptoms of panic attacks such as a rapid heart rate. Benzodiazepines are useful to provide temporary relief of acute anxiety symptoms. These medications can be very helpful, but they should be used with caution due to their potential for dependence. Benzodiazepines can also interfere with the ability to habituate or learn that situations are safe. Only your health care provider should determine whether these medications are appropriate for use and you should not discontinue any medications without consulting with your provider.

Cognitive-Behavioral Therapy (CBT) is an evidence-based type of psychotherapy that is helpful in treating Panic Disorder and Agoraphobia. This therapy helps people to change their behavior and their way of thinking. Various CBT techniques are useful in treatment of these anxiety disorders. Interoceptive exposures involve purposely provoking uncomfortable physical sensations (heart pounding, shortness of breath, dizziness) to desensitize oneself to them. This should be done with the guidance of a trained mental health professional to ensure that it is done correctly. Similarly, gradually limiting avoidance of circumstances and places (such as driving or going into stores) that are typically avoided allows someone to become comfortable and gain confidence in these situations. Breathing and relaxation exercises can help to lower someone’s overall level of anxiety to prevent them from having a panic attack. And finally challenging faulty beliefs, such shifting from thinking “I’m in danger” to “my body is telling me that I’m in danger, but I’m actually safe” can be helpful in lowering related anxiety. Other helpful interventions include biofeedback and mindfulness. Additional lifestyle changes such as reducing one’s intake of caffeine, sugar, nicotine, regular exercise and sleep, and limiting checking vital signs can be helpful in lowering anxiety.

If you believe that you or someone you know is suffering from Panic Disorder and/or Agoraphobia, it is important to seek the help of a mental health provider. These disorders can become debilitating without proper treatment but can become manageable if properly treated.

by Jennifer B. Wilcox, PsyD
Staff Psychologist, Lindner Center of HOPE

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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By: Heather Connor, LISW-S

At times it can feel like it’s impossible to have a positive relationship with our body image. We are inundated with ads that encourage us to lose weight via this supplement or that diet/wellness program, guaranteed to give you results. Diet Culture is a multibillion-dollar industry and it’s been around for generations. However, a fact to consider is that diets do not work. In a large-scale 2015 study of 278,000 people, it showed within 5 years, 95-98% regained all the lost weight (or more) (Fildes et al, 2015). Diets are designed to fail and instead of taking responsibility for that failure, they turn the blame onto the dieter. The reality too, is that even when the weight is lost, most of us still don’t feel confident in our bodies. Fatphobia is a driving force for the diet culture industry. The more afraid we are of fat bodies, the more we subscribe and pay into the thin ideal. Fatphobia is woven into the fabric of our culture, and it’s become so commonplace, we may not even notice when it’s present. For years we have rarely seen fat bodies on television or in ads and when we do, these characters are shown as the butt of the joke, the silly friend, or the lazy one who is always eating but almost never the main character or the one who finds love. We live in a world in which certain seats or devices do not accommodate larger bodies. We have until very recently, forced those in larger bodies to shop at specialty stores or online for clothes that can accommodate their size.

 

It’s become commonplace to gab to our friends about which “program” we are trying this week and we might even find community in joining along. We regularly talk negatively about our bodies or praise others for looking “great” after some noticeable weight loss without stopping to consider how this weight loss was achieved. We make unprovoked comments about other people’s bodies and children and even adults are often bullied relentlessly if they exist in a larger body. And with each time we make these comments we reinforce the narrative again and again that fat is bad and thin is the goal.

And it’s not just our culture that contributes to our unhappiness with our bodies. With our healthcare system waging war on obesity, it’s no surprise that many of us will search out any means to lose weight in the name of health. The BMI continues to be used to determine who is at risk even though BMI only accounts for our height and weight and no other measurement of health. While thin is often promoted at “healthy” for a large portion of the population, working tirelessly to achieve this goal, is anything but health-promoting. If we consider the steps we often take to achieve the thin ideal, we have to acknowledge that most of these involve hurting our bodies. These include everything from denying ourselves basic needs like nutrition to invasive surgeries, all in the name of health. Not to mention the shame and ridicule we often experience not only from others but from our own internal dialogue as well.

“While it is well established that obesity is associated with increased risk for many diseases, causation is less well-established. Epidemiological studies rarely acknowledge factors like fitness, activity, nutrient intake, weight cycling, or socioeconomic status when considering connections between weight and disease. Yet all play a role in determining health risk. When studies do control for these factors, increased risk of disease disappears or is significantly reduced.” (Bacon & Aphramor, 2011) In other words, living in a larger body does not automatically mean that one is “unhealthy”.

While we are on the topic of health, let’s also consider that dieting is a major risk factor for the development of eating disorders. The National Association of Anorexia Nervosa and Associated Disorders (ANAD) reports that 9% of the US population will develop an eating disorder in their lifetime and only 6% of those who are diagnosed are considered “underweight”. Eating disorders also have the highest mortality rate of all other mental health disorders, 2nd only to opioid overdoses and this is true for people, regardless of their size.

As a result of these experiences, we all have certain internalized biases surrounding weight which also contribute to our body image. We might make assumptions of someone’s health, intelligence, willpower, or overall lifestyle based solely on their body shape and size. The reality is however that we cannot determine any of these above traits just by looking at someone.

So if we can accept that all bodies are not meant to be thin and thinness does not equal health, then perhaps we could forge a different relationship with our bodies. When we focus on listening to our bodies instead of on external rules, we naturally lean into behaviors that are health promoting. Such behaviors include eating a variety of foods, engaging in joyful moment, and practicing a relationship with our bodies that prioritizes taking care of ourselves in the way we might care for a good friend. When we are not focused on losing weight, we are able to make decisions based on trust and our own internal wisdom.

The following are some strategies one might consider to begin the journey of moving away from diet culture and fatphobia and into a place of peace, trust, and an overall more friendly relationship with our bodies.

  1. Grieve the “ideal” body. In order to improve your relationship with your body, we have to first begin to let go of the “ideal” and accept the wonderful body you have. This may involve some of the phases of grief such as denial, anger, bargaining, and depression, before achieving acceptance.
  2. Ditch the negative self-talk. Every time you notice yourself calling yourself names and making negative comments about your appearance, stop, put your hand on your heart, and give yourself a compliment, body-focused or otherwise. You might even consider writing a few compliments down and posting them up as easy reminders that you are more than your body. A good rule of thumb here is begin to talk to yourself in the same manner you would a good friend.
  3. Practice Body Gratitude. Take 5 minutes each day, find a quiet place, close your eyes, and scan down through your body. Notice any sensations, thoughts, or feelings that you notice as you bring awareness to your body. If you are finding a lot of negative energy around one or more parts of your body, begin to shift that focus to what that part of your body does for you. Begin relating to your body as a good friend who trying to take care of you.
  4. Listen to your body and start rebuilding body trust. Start making it habit to begin to check in with your body regularly. This is a practice that is often lost for those that have been chronic dieters because dieting relies on rules rather than our body for what we can eat or how to move. As you check in, begin to respond according to your body’s signals such as eating when you are hungry, moving when you feel restless, or resting when you are tired.

If you continue to struggle with your relationship with your body, consider talking to a therapist who has experience with body image and who is familiar with Health At Every Size (HAES) or the practice of Intuitive Eating in order to help guide you even further in your journey towards body acceptance.

References:

Anorexia Nervosa and Associated Disorders (n.d.) Eating Disorder Statistics. https://anad.org/eating-disorders-statistics/

Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 9.

Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A.T., &Gulliford. M.C. (2015). Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. Am J Public Health, 105, 9, e54-9. doi: 10.2105/AJPH.2015.302773. Epub 2015 Jul 16. PMID: 26180980; PMCID: PMC4539812

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One of the greatest challenges in the treatment of bipolar disorder (BD) is the significant weight gain associated with psychotropic medications.  Mood stabilizer medications with antimanic activity, which include lithium, valproate as well as atypical antipsychotics, remain the mainstay of treatment despite being associated with different degrees of significant weight gain.  This is particularly notable for antipsychotic medications, which are furthermore associated with metabolic disturbances.  Accelerated weight gain is concerning because it is associated with increased cardiovascular risk, and particularly important in patients with BD because of their increased risk for cardiac and metabolic disease.  Furthermore, excessive weight gain is distressing and often plays a role in dissatisfaction with treatment and early discontinuation.  A growing body of evidence suggests that weight gain, weight cycling, and central obesity are linked with exacerbation of bipolar symptoms and less favorable course of illness.  A comprehensive treatment plan for bipolar disorder should include interventions to prevent or mitigate excessive weight gain.  Let’s examine the available options and identify areas for further research.

Until recently, interventions for weight gain were mostly limited to lifestyle interventions.  Inactivity and dietary choices are significant contributors to metabolic abnormalities seen in patients with BD, and although dietary and lifestyle changes have the potential for improving the overall quality of life, the results from these interventions often fail to keep up with the accelerated weight gain seen with psychotropics.  Clinicians have also attempted to select medications with lesser potential for metabolic dysfunction and increased appetite, but this is not always a viable option.  Bariatric surgery has the greatest potential impact as an intervention for obesity in BD.  Although there is evidence that weight loss resulting from bariatric surgery is associated with improvements in mood, there is no data specific to patients with BD and this is only an option for stable, euthymic patients.

The use of off-label adjunctive medications for mitigating weight gain has had mixed results:  Weight mitigation has been modest, efficacious medications have produced significant adverse events leading to discontinuation or the cost to the patient has been prohibitive. Topiramate and zonisamide are antiepileptic drugs with data suggesting efficacy in weight mitigation.  Topiramate has shown significant efficacy in weight mitigation (3.1kg over 6-26 week, according to a meta-analysis), but it is poorly tolerated and is associated with significant cognitive adverse events and paresthesia.  The estimated cost for a month’s supply of topiramate ranges from $40-$250.  Data suggest that zonisamide also has a significant effect on weight gain mitigation with similar, but milder adverse events.  Opioid receptor antagonists like naltrexone and samidorphan have demonstrated modest efficacy in mitigating weight gain associated with olanzapine.  Samidorphan, the best-studied opioid antagonist, is associated with modest weight mitigation (1kg with olanzapine), is well-tolerated and is available on the market as part of a proprietary combination with olanzapine with an estimated cost of $1000/month.

Antidiabetic drugs like metformin and glucagon-like peptide-1(GLP-1 RA) receptor agonists have  potential for weight mitigation and improvement of metabolic parameters such as dyslipidemia and insulin resistance.  Metformin is a popular option for medication-induced weight gain.  In patients treated with atypical antipsychotics, the estimated weight mitigation with metformin is 2-3kg and it is generally, well-tolerated.  The average estimated monthly cost of Metformin ER 2000mg/daily ranges from $27 to $50.  GLP-1 RAs and similar drugs have the potential for significant mitigation of weight gain associated with psychotropics, and in some cases, weight loss.  These drugs are better tolerated than topiramate but additional research on the effects of these drugs on patients with BD is needed to determine efficacy and safety.  GLP-1 RAs decrease glucagon secretion, have the potential for decreasing insulin resistance and delay gastric emptying, therefore decreasing appetite.  In addition, GLP-1 RAs have been shown to improve glucose regulation, lipid levels, and reduce cardiovascular risk.  Although GLP-1 agonists have demonstrated effectiveness in inducing weight loss and improving metabolic parameters in type 2 diabetes mellitus and obesity, data shows that only 10% patients eligible for treatment do not take these medications due to the high cost.

As we have seen, there are a few options for treatment of excessive weight gain associated with psychotropics, which can be used in addition to lifestyle interventions.  Limitations the modest results seen with some interventions, intolerable adverse events with more effective options or high cost.  Additional, affordable treatment options are needed.

For more information about Bipolar Disorder research at the Lindner Center of HOPE:

https://lindnercenterofhope.org/research/clinical-trials/#1619574722103-ad16b647-fc35

Works consulted:

Laguado SA, Saklad SR. Opioid antagonists to prevent olanzapine-induced weight gain: A systematic review. Ment Health Clin. 2022 Aug 23;12(4):254-262. doi: 10.9740/mhc.2022.08.254. PMID: 36071739; PMCID: PMC9405627.

Mangge H, Bengesser S, Dalkner N, Birner A, Fellendorf F, Platzer M, Queissner R, Pilz R, Maget A, Reininghaus B, Hamm C, Bauer K, Rieger A, Zelzer S, Fuchs D, Reininghaus E. Weight Gain During Treatment of Bipolar Disorder (BD)-Facts and Therapeutic Options. Front Nutr. 2019 Jun 11;6:76. doi: 10.3389/fnut.2019.00076. PMID: 31245376; PMCID: PMC6579840.

Wang Y, Wang D, Cheng J, Fang X, Chen Y, Yu L, Ren J, Tian Y, Zhang C. Efficacy and tolerability of pharmacological interventions on metabolic disturbance induced by atypical antipsychotics in adults: A systematic review and network meta-analysis. J Psychopharmacol. 2021 Sep;35(9):1111-1119. doi: 10.1177/02698811211035391. Epub 2021 Jul 27. PMID: 34311625.

 

By Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner

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Obsessive-Compulsive Disorder (OCD) is a debilitating psychiatric disorder that presents in many forms. OCD is comprised of obsessions, which are persistent and unwanted intrusive thoughts, images, or urges. In OCD, these intrusive thoughts are considered ego-dystonic, meaning they are inconsistent with someone’s self-image, beliefs, and values. Therefore, these obsessions cause significant distress, anxiety, and worry and can greatly interfere with one’s life. To reduce or eliminate this distress or discomfort, OCD sufferers begin to engage in compulsions, which are ritualized behaviors or mental acts that serve to reduce their discomfort and anxiety. Unfortunately, engaging in compulsions reinforces obsessive thinking. Some subtypes of OCD include fears related to contamination, scrupulosity (religious-based fears)/morality, fear of harming others (aggressive or sexual), ordering and arranging, repeating, and checking. It should be noted that not all compulsions are outwardly observable and may include avoidance of triggers or mental compulsions.

Recommended Questions for Assessing OCD

Exposure and Response Prevention (ERP) is a type of Cognitive-Behavior Therapy (CBT). Cognitive-Behavior Therapy varies from other types of talk therapy in that it is focused on changing thinking patterns and behaviors. It tends to be directed at the present, rather than the past and is goal-oriented and solution-focused. ERP aims to change behavioral patterns, allowing someone to confront their fears and therefore, reduce their OCD symptoms. ERP is widely considered to be the “gold standard” therapy for Obsessive-Compulsive Disorder.

Exposure refers to the direct confrontation of one’s fear through voluntarily taking steps towards their fears and triggers. Response Prevention refers to someone voluntarily agreeing to reduce their usual rituals and compulsions. It is very important for someone that is working on doing exposures to simultaneously refrain from engaging in compulsions. Without reducing or refraining from the related compulsions, the person cannot learn that they can tolerate the exposure or that the compulsion is unnecessary.

How is ERP done? 

ERP is done by working with a therapist to examine the person’s specific obsessions and compulsions, generate a fear hierarchy, and begin to work on exposures while limiting engagement in compulsive rituals. A fear hierarchy is a personalized list of exposures. This list is created collaboratively by the person with OCD and their therapist. Exposures include situations, stimuli, or thoughts that evoke a strong, negative emotional response and to which the person has a fear or an aversion. Exposures on the fear hierarchy list should be very specific and can include variations of the same exposure (such as touching several different places on an object and for varying amounts of time). People with OCD often engage in avoidance of triggering stimuli to prevent unwanted distress as well. Much of the fear hierarchy can be generated by examining situations and stimuli that the person avoids. A Yale-Brown Obsessive-Compulsive Symptom (Y-BOCS) Checklist may be completed to help generate ideas. It can also be helpful to gather ideas from family members as well. The goal of exposure work is to slowly and carefully work to approach each of these triggers in a strategic manner.

In vivo exposures refer to confronting one’s fears “in life” or through direct confrontation. This type of exposure is appropriate for things that can be directly approached or confronted. Imaginal exposures refer to mentally imagining being exposed to one’s fears. This type of exposure is utilized for exposures not appropriate for direct confrontation (fear of hitting someone with one’s car). Similarly to in vivo exposures, imaginal exposures are done in a gradual manner and should always be done voluntarily. A SUDS (Subjective Units of Distress Scale) is used to communicate the person’s perceived level of distress, generated by engaging in exposures while refraining from compulsions. The fear hierarchy is arranged to allow someone to work from lower-level exposures to higher-level exposures.

The central premise of OCD is intolerance of uncertainty, with the goal of ERP being to increase the level of tolerance to uncertainty, rather than working to disprove the fear or find ways to become certain. Although it is very common for families to accommodate compulsive behavior or give reassurance when they see a loved one in distress, accommodation and reassurance exacerbate OCD by not allowing the person to learn to tolerate their discomfort. Instead, it is helpful to allow the person to gradually learn how to tolerate their distress with the help of a trained therapist.

How does ERP help with OCD symptoms? 

Exposure and Response Prevention is accomplished through gradual behavioral change, which occurs in the form of habituation and extinction. Habituation occurs with repeated exposure to a particular stimulus. This happens when we become numb or desensitized to things that we see, hear, or do on a regular basis. For example, if we live next to a noisy highway, we might initially be very aware of the noise. However, after living there for a while, we become accustomed to this constant sound, and we learn how to “drown it out.” Habituation in ERP works in a similar manner by repeatedly exposing a person to their feared triggers. Over time they habituate to those triggers and the strong emotions associated with their fears disappear. Extinction occurs when a reinforcer (something that influences behavior) is no longer effective at bringing pleasure or reducing distress. In the case of ERP, by reducing the compulsive behavior that reinforces the anxiety or distress, the obsessive thoughts decrease over time.

If you believe that you or someone you know might be suffering from OCD symptoms, it’s important to reach out to a professional with specialized training in OCD treatment. With the proper treatment, OCD can be a very manageable condition.

By: Jennifer B. Wilcox, PsyD