Do Not Take On An Empty Mind

Medications A-Z: The Prozac Family (SSRIs)

2009-08-30T12:41:00.003-05:00

The most commonly prescribed class of antidepressants today are the selective serotonin reuptake inhibitors (SSRIs), the so-called "Prozac family" of medications, of which Prozac was the prototype, but which also includes Zoloft, Paxil, Luvox, Celexa, and Lexapro. They are widely prescribed because they are very safe and generally well-tolerated, and they are highly effective at improving a person's mood and reducing symptoms of tearfulness, hopelessness, irritability and also anxiety, including panic attacks, obsessions, and compulsions.

Because they all share the same mechanism of action--increasing the bioavailability of the neurotransmitter serotonin--they are all remarkably similar with respect to how they help, as well as in regard to their side effect profiles. This is because, by and large, it is the increase in serotonin itself that is responsible for both the beneficial effects on the brain as well as the bothersome physical effects that occur elsewhere in the body, such as the GI tract. Various types of serotonin receptors are widespread throughout the body and wherever serotonin acts upon one of these receptors, you get an effect, sometimes a desired effect, but also more often than not, a side effect. In this respect the SSRIs are remarkably similar; differences are usually a matter of degree. Where these medications tend to differ more so is in relation to their effect at other, non-serotonergic, receptor sites, such as acetylcholine or histamine receptors, which is what accounts for the differences in their side effect profiles and hence, their tolerability for a given patient.

Practitioners are fond of saying that the choice of SSRI is an empiric one: starting an SSRI for the first time, making dosage adjustments, resuming therapy and/or switching to a new and different medication in this class is essentially a trial-and-error process, they explain, but that doesn't mean that it is completely arbitrary or haphazard (although some prescribers tend to want to approach it that way). Educated guesses can be made before a medication trial is undertaken, if not regarding how useful a medication's effect on an individual's mood will be, then at least with regard to how well or how poorly it will be tolerated. This mindfulness on the part of the prescriber, as well as the person agreeing to subject himself to a trial of this type of medication, can avoid wasted time and an unpleasant experience.

So, how best to choose among this family of medications? Well of course your doctor will be the one making the final recommendation, but with regard to treatment with an SSRI there is never only one option for a patient (unless she's tried them all). This article explains what considerations should go into that decision-making process; there is no reason why, armed with a little information, you cannot be an active participant in that process. It is you who will be taking the medication, after all. Why not help your doctor save you some trouble and/or wasted effort, if you can?

Assuming this is the best class of medication from which to choose, there are two main considerations: 1) selecting a medication that is likely to work and 2) selecting the medication that will best be tolerated by the patient. Because the SSRIs are more-or-less equally likely to work, the ultimate decision is more often based on the second consideration.

Selecting an SSRI that is likely to work. Assuming that the diagnosis is correct and that medication management is indicated in the first place and that the target symptoms in question indicate that an SSRI would be the best initial option (agitated, irritable depressions and/or anxiety states), I have already stated that there is little to predict beforehand whether one or another SSRI will ultimately have the desired effect; unless there is prior history to indicate one way or another, they all start out with the same likelihood of helping. Although in general we can expect that certain symptoms will be significantly reduced on these medications as a person's threshold for tearfulness or irritability or feeling overwhelmed is raised with increasing serotonin levels, in terms of overall efficacy--in terms of remission--it is never possible to predict with 100% accuracy whether a given compound will "work" on a person's depression. Likewise, while panic attacks can always be stopped with these medications if taken properly, residual, sometimes unacceptably high levels of generalized anxiety may fail to completely resolve despite treatment with one or another SSRI, necessitating a switch of medication.

The lesson here is that, while some people respond better to one SSRI over another, to a large extent this is unpredictable. Differences in efficacy are idiosyncratic; that is to say, they depend largely upon the individual who is taking them, and they do so for unknown biological reasons. And so we try one medication to see if it works, and we ensure that a good therapeutic trial is completed before trying something else, if necessary. However, what I have found in my practice is that switching from one SSRI to another is not usually because of a lack of effectiveness, but instead due to tolerability issues. By anticipating these tolerability issues (which is more methodical than anticipating efficacy), time and frustration can be saved.

Selecting the SSRI that will best be tolerated by the patient. While the reasons for differences among individuals in terms of the efficacy derived from medications in this class is a mystery, differences in tolerability can often be explained, and even predicted, by the relative affinity of one SSRI versus another for certain receptor types. If you reviewed the complete prescribing information for any of the following medications, you would be left with the impression that all of them can cause all of the same potential side effects, which is true, but the clinical reality is that some of them are much, much more likely to cause certain side effects than the others. All you need to know as a patient is that one SSRI tends to cause more diarrhea or constipation or dry mouth than another, or that a given SSRI tends to cause more weight gain or more sexual dysfunction than the others, etc.

Likewise, if you read the pages and pages devoted to each medication in the Physician's Desk Reference (PDR), you would come to realize that nearly every side effect known to man has been reported at one time or another or associated in some way or another with every known medication, rendering an encyclopedic book like the PDR practically useless to the individual who just wants to know which side effects are likely, not which ones are possible. Of the 1001 potential side effects listed for any given medication, there are only a handful of truly common problems.

When I first started routinely prescribing these medications in the mid-nineties there were only four available SSRIs in the United States, but even then I had no idea how Prozac would be different for a patient than Zoloft, or Paxil versus Luvox. Now, after having prescribed these medications for more than a decade, although they all share the same general side effect profile, it has become clear to me which SSRIs are more likely to induce which unacceptable side effects, and to what degree. (Remember that, often, it is simply a matter of degree to which the medications differ.) For example, while they all induce sexual dysfunction, some are simply worse offenders in this regard. Similarly, while they all can cause weight gain, some unequivocally have a greater propensity to do so. What follow are some general profiles, what you might expect from treatment with one SSRI versus another.

All of the SSRIs tend to cause diarrhea, headaches, queasiness, restless legs/body, sexual dysfunction (delayed orgasm, decreased libido), sweating/hot flashes, lethargy, yawning (not related to feeling tired), waking up in the middle of the night, jaw clenching, and weight gain. Sounds terrible, but any list of potential side effects does. The fact is that many of these side effects, if they present themselves at all, are mild and resolve over time. Given that the above-listed are all common SSRI side effects, the side effects mentioned below are not being highlighted because they are in any way exclusive to the medication in question. Rather, the medication in question is simply especially prone to inducing those particular side effects. Given that they are all equally likely to help, carefully consider which unwanted effects you would most like to avoid.

The following blurbs are not at all meant to be comprehensive. They are not even highlights; they are highlights of the differences of each medication with respect to its sister medications. The last thing I'll say here is that there are always exceptions, of course, and you may be that one rare person who actually gets more diarrhea on Paxil than on Zoloft, but otherwise these guidelines will prove true, time and again.

Prozac (fluoxetine). Still the most famous, in part because it was the first, Prozac truly revolutionized the pharmacologic treatment of depressive and anxious mood disorders when it was released in 1987. It was far safer than the first-generation antidepressants available up to then, particularly in overdose, and induced far fewer side effects.

One of the things that distinguishes Prozac from the other SSRIs that followed is that it has an exceptionally long half-life. A drug's half-life is a measure of how long it takes the body to metabolize it away. The longer the half-life, the longer the drug remains in circulation in its original form. Once drug levels have reached steady-state, it takes five half-lives to clear 97% of the drug. The half-life of most SSRIs is approximately one day, so stopping them means they will be cleared by the body in about one week. Fluoxetine, on the other hand, has a half-life of 4-6 days with chronic dosing, and its active metabolite norfluoxetine has a half-life of 1-2 weeks. Compared with most other drugs, this is extraordinarily long. The practical implications are that, because a drug's half-life also affects how quickly it builds up to steady-state levels in the body with regular dosing, 1) it takes longer for Prozac to reach therapeutic levels, possibly delaying the onset of action even more so than what is typical for these types of medications (typically around two weeks) and even more significantly, 2) when you stop taking Prozac, it can take 5 or more weeks to fully exit your system, although the clinical effects of the medicine will begin to wane long before that. One advantage to this is that Prozac withdrawal is not seen; you can abruptly stop taking the medication and it tapers itself out of your system (abruptly stopping any psychotropic medication is generally frowned upon, however). One disadvantage would be a delay in switching to a different medication or starting a new medication that cannot be co-administered with Prozac, such as the MAOIs (monoamine oxidase inhibitors).

Prozac is also known to be among the more "activating" of SSRIs. It tends to cause jitteriness and motor restlessness (akathesia) more so than some of the others. Prozac may not be the best choice if you are already troubled with restless legs syndrome or the general inability to sit still for very long periods of time due to motor restlessness.

Prozac is also famous for what is affectionately called the Prozac "poop-out." It is not at all uncommon for any SSRI, after a time, to not work as vigorously as it did initially, or even to stop working altogether. Usually a simple dose adjustment is all that is needed to jump start the treatment, but sometimes a medication switch becomes necessary. I have certainly seen many cases of "Prozac poop-out," although it is difficult to say based on anecdotal evidence alone whether Prozac is truly more prone to this disappointment than the other SSRIs. Why a medication stops working or stops working as well over time is a complicated issue that may have a lot to do with extra-pharmaceutical factors as well.

Fluoxetine (the generic preparation) is also marketed in the U.S. under the brand name Sarafem. Sarafem was approved by the FDA for the treatment of symptoms associated with premenstrual dysphoric disorder (PMDD) in adult women, but it's just fluoxetine; a generic preparation would work as well. In fact, any of the SSRIs are useful in lessening the emotional lability some women experience due to hormonal shifts that occur mid-cycle. SSRIs are well-indicated for both PMDD as well as milder premenstrual syndromes.

Prozac Weekly. When pharmaceutical companies lose their patent on brand-name medications and other companies are allowed to sell generic preparations of the drug, the original company will often rebrand the medication in order to hold on to some of the market share for their product. This was the case with Sarafem. A more aggressive strategy involves obtaining a new patent for a medication by either slightly tweaking the molecule (so that legally it is now a "new" compound) or else revamping the delivery system by pairing it with a different vehicle or placing it in a new type of capsule. Although the pharmaceutical companies spend many hundreds of millions of dollars developing and marketing these novel preparations, many times it amounts to nothing more than a marketing ploy. The most common scheme is to take a drug and place it in an extended-release capsule.

Prozac Weekly is just that: 90mg of good old fluoxetine in a fancy, enteric-coated capsule that dissolves more slowly and thus releases the medication more slowly, but that's not what allows for once-weekly dosing. It is fluoxetine's exceptionally long half-life that facilitates once-weekly dosing, and there's nothing new about the half-life. As a psychiatrist, I never recommend once-weekly dosing of any anti-depressant; the only reason to dose once a week instead of every day is apparently a matter of convenience, although this is arguable, since it may actually be more challenging to remember to take your medication if you only take it once a week, as opposed to every day. When Prozac Weekly was first released, the manufacturer touted the fact that once-weekly dosing would allow individuals to feel "less daily dependence on theneed for medication" that many patients find stigmatizing, but this does not change the fact that individuals who are clinically depressed do, in fact, require daily levels of the medication that the long half-life allows, even when it is not being taken every day. Marketing ploys aside, my own preference is to be completely upfront with my patients and to educate them regarding the exact nature of their need for treatment, whatever that may be, and to encourage destigmatization in other, healthier and more honest ways. The last thing I would ever want to do as a psychiatrist is to downplay the physical nature of a patient's major mood disorder and lull that person into a false sense of security by promoting the idea that his illness is not so serious because he "only needs to take medication once a week." Too many patients who truly need medication to function and remain safe already underestimate their need for treatment and eventually disregard their regimens, often with disastrous results. But, if I ever were to recommend once-weekly dosing, a patient could just as easily take generic fluoxetine once a week and save a lot of money.

Zoloft (sertraline). Zoloft was the next SSRI to be developed, and it was just as effective across the board and just as well tolerated as its predecessor, with subtle differences that varied from individual to individual. In my experience, Zoloft is not as overtly activating as Prozac, although akathesia is common enough. Zoloft is also one of the SSRIs that is especially prone to produce diarrhea. And again, while the other SSRIs also frequently cause loose stools--at least initially--the diarrhea that Zoloft brings on is often more pronounced, and often endures for a longer period of time, than the others.

Unlike Prozac, which is often started at the target dose of 20mg, Zoloft is started at 25mg, a subtherapeutic dose for the vast majority of people, thus it requires more of a titration to reach the recommended dose, which could eventually be as high as 200mg for some. With each adjustment, side effects like diarrhea can reappear even after they had previously resolved (although this effect becomes attenuated over time as well; in general, the more dosage is tolerated, the less increasing that dosage further will renew old side effects).

Plenty of patients have noticed weight gain on Zoloft, but in my experience it is not the worst in this regard (see Lexapro, and especially Paxil).

Paxil (paroxetine). Paxil is the most potent inhibitor of serotonin reuptake in vitro. Clinically, I have found it to be the most aggravating in terms of sexual dysfunction. Many patients report complete anorgasmia on even starting doses (10mg or less). This makes low-dose Paxil an excellent treatment for premature ejaculation, but something of a problem in treating depression and anxiety, particularly at the higher doses recommended for those conditions.

Paxil is unusual among the SSRIs in that it is highly anticholinergic; that is, it blocks one subtype of receptor that is normally bound by the neurotransmitter acetylcholine. The result is side effects such as dry mouth, constipation, and blurred vision for close-up objects (e.g., text on a page). Anticholinergic effects can also include a subtle impairment in short-term memory. For this reason, Paxil is usually a poor choice for an elderly person, who may already be experiencing significant problems with constipation, presbyopia and noticeable short-term memory loss.

And while all of the SSRIs can potentially lead to weight gain, Paxil is one that I consider notorious for doing so. I avoid it in patients for whom this is a particular concern.

Unlike Prozac, Paxil is also one of the SSRIs that is associated with a peculiar discontinuation syndrome. I call it a "discontinuation" syndrome, as opposed to "withdrawal" purposely, to avoid the notion that Paxil is in some way addicting. In the classic sense it is not. However, because of its particular neurochemistry, abruptly stopping this medication or abruptly lowering the dosage--or even for some people taking it a few hours later than scheduled--can lead to dizziness, flu-like symptoms and paresthesias that feel like tiny, lightening-fast "electric shocks" in the brain. These paresthetic jolts do not represent seizure activity and they are more uncomfortable than painful; they are not harmful and they eventually subside, but they are very unpleasant.

SSRI withdrawal paresthesias (also commonly experienced upon the abrupt discontinuation of Luvox and Effexor, which has an SSRI component) are exacerbated by rapidly turning or moving the head, which can bring one on, and by stimulants. Conversely, they are reduced in intensity or blocked entirely by mild tranquilizers and do not wake people up from sleep. The way to avoid them is to avoid abruptly stopping the medication, which is always ill-advised. The recommendation is always to lower the dose gradually over several days under a doctor's supervision before stopping the medication entirely. If you are going out of town you want to take extra precautions not to leave your Paxil behind, and you want to avoid getting caught between refills for the same reason.

With all of its extra tolerability issues, Paxil is often clinically superior to the other SSRIs in certain conditions that require a truly potent serotonergic medication. I have seen it outperform the other SSRIs, even at maximal doses, in generalized anxiety disorder and obsessive-compulsive disorder in particular. Paxil definitely has its place.

Luvox (fluvoxamine). Luvox is not as well-recognized among laypersons, due in large part to the fact that it was originally approved and marketed for the treatment of obsessive-compulsive disorder, which is not as common as other anxiety disorders and major depression. But as repeatedly stated above, all of these medications are useful for all of the same types of depressive and anxious mood disorders.

Like Paxil, Luvox is associated with a pronounced "withdrawal" syndrome if not gradually tapered before discontinuation. Like Zoloft, Luvox typically has to be titrated from a starting dose to a significantly larger final dose and is more likely to cause GI disturbances than the others, either loose stools or alternately, constipation. Weight gain is another not uncommon issue with Luvox.

Celexa/Lexapro (citalopram/escitalopram). Whereas Paxil is the most potent selective serotonin reuptake inhibitor, Celexa and Lexapro are the most selective, referring to their relative effect on serotonin receptors versus other receptor types; i.e., among SSRIs, their action is the most specific to serotonin receptors. Lexapro (escitalopram) is the left-handed stereoisomer of Celexa (citalopram). Escitalopram is the biologically active molecule; the right-handed enantiomer is not only inert with regard to blocking the reuptake of serotonin, but actually competes with the left-handed enantiomer, so that by removing it from the mix, both potency and efficacy are increased. Lexapro can therefore be thought of as a "purified" form of Celexa that works better on a milligram-per-milligram basis because the active component is not competing with the inactive component for receptor sites.

If Paxil has the worst sexual dysfunction, Lexapro typically has the least. However, like Paxil, Lexapro is notorious in my book for causing significant weight gain. I have also noticed (and this of course is purely anecdotal) more "rebound" symptoms between doses in anxious patients taking Lexapro. I have had several cases in which panic attacks and symptoms of social anxiety seemed to do worse at various times of the day despite consistent dosing and even with divided dosing.

Effexor (venlafaxine). Effexor is actually a dual-acting agent: it was the first commercially available (non-tricyclic) serotonin-norepinephrine reuptake inhibitor, or SNRI. SNRIs can be advantageous over SSRIs based on their dual mechanism of action and indeed have been shown to be somewhat more efficacious with respect to depression. They may also have a more rapid onset of action, which I have certainly seen with Effexor in some cases.

I include Effexor in this discussion because at low starting doses, Effexor is essentially an SSRI. The affinity of venlafaxine for serotonin reuptake is many orders of magnitude greater than that for norepinephrine and noradrenergic reuptake does not occur until higher doses are reached. Effexor's side effect profile is very similar to the other SSRIs, with significant sexual dysfunction and a marked discontinuation syndrome. In my experience, I have seen a lot more temperature dysregulation (sweating and hot flashes) in patients taking Effexor, but no weight gain, which is rare with Effexor.

Other considerations that come into play in choosing one SSRI over another may be practical: cost, for example, or whether or not the medication is supplied in liquid form, for those patients (children, usually) who are unable to swallow a capsule. Most of the SSRIs are also available in extended release (XR) or controlled-release (CR) preparations, which, although their development may have been prompted by corporate financial interests, can nonetheless be very useful at reducing immediate side effects by prolonging absorption and simplifying a regimen to once-a-day that you might otherwise be taking in divided doses throughout the day.

Family History. One other point bears mentioning in any discussion regarding psychotropic medication selection. Importantly, if you have a blood relative--particularly a first-degree relative, such as a parent, sibling or child--who responded favorably to a particular medication, you have a statistically higher probability of responding favorably to that medication yourself, so inasmuch as selecting a psychotropic medication can be a trial-and-error process, be sure to mention that to your prescribing doctor if you know about it.

Tip: Ask for samples. If you are trying a medication for the first time, your doctor will often be able to provide you with free samples or a coupon for a free month's supply.

How to Engage in Meaningful, Successful Psychotherapy

2009-08-23T18:39:00.004-05:00

More people than ever before are seeking professional counseling services. Thankfully, the stigma of seeing a mental health professional is waning and people are becoming better educated regarding the various options available to them. Needless to say, psychotherapy can be extremely helpful and--assuming there are no major contraindications (see below) and the client-therapist relationship is a good fit--it is almost always a good idea if a person is at all interested in it. Unfortunately, a trial of psychotherapy can also result in disappointment and/or even greater confusion. This article discusses how to embark upon meaningful, successful psychotherapy by setting goals, avoiding pitfalls and engaging your therapist.

Pick the right therapist. Because the start of a successful psychotherapeutic endeavor begins with the therapeutic relationship itself, selecting the right therapist is of paramount importance. This not only gets you off to a good start, but will prove absolutely vital to your ultimate success. It is a complicated issue, and there are no guarantees, but it is the sine qua non of engaging in successful therapy. It is also one of the most uncertain tasks, especially when practical considerations such as geographical location, availability and cost come into play.

A therapist is not a friend. Therapists and clients do not, and should not, socialize outside of scheduled appointments. While many clients want to become friends with their therapists and even understandably consider themselves to be on friendly terms, it is never appropriate for a degreed professional to seek personal validation and social enjoyment by dropping his professional role and adopting the client as a friend. This is not only counterproductive, it is unethical. Similarly, a therapist is not a parent, a therapist is not a policeman, and a therapist is not a personal savior.

A good therapist is well-trained, experienced, non-judgmental, empathetic, unbiased, open to feedback, transparent (honest, upfront and sincere), and directive when you need it or ask for it. She is there to facilitate your growth and to help you help yourself and solve your own problems; she is not there to take charge or solve them herself. See my previous article, "How to Pick a Good Therapist", for some general guidelines in making this selection.

More specifically, the type of therapist you choose to see may depend upon your particular concerns. There are therapists who specialize in a host of specific conditions, such as chemical dependency counselors and other addictionologists, relationship counselors, therapists who specialize in eating disorders, forensic psychologists, and others. Within these groups there may be further differences, as various therapists subscribe to various forms of therapy, based on one school of thought or another. For example, there are cognitive-behavioral therapists, interpersonal therapists, psychoanalysts and other psychodynamic therapists, group therapists, hypnotherapists, faith-based counselors, etc. A discussion of all of the available forms of talk therapy is well beyond the scope of this article, but see below for some links to organizations that can provide additional information.

Manage your expectations. The degree of satisfaction we come to derive from any given venture depends in large measure upon our expectations going in. When expectations are excessively high, this can be a setup for disappointment. Conversely, when expectations are unreasonably low, this can sabotage the process by preventing us from adequately investing of our time and energy. Decide what you are looking for and identify any reservations you might have, and discuss this openly at your first visit. Managing expectations involves being in touch with why you are seeking counseling in the first place. Perhaps you were referred by someone else, but in that case you should especially do some soul-searching and ask yourself why (or even whether) you agree that professional assistance is the best next step.

Once you have reconciled yourself to the notion of conferring with a professional counselor, ask yourself: are you needing someone who is going to employ a highly directive approach, an active therapist who will ask a lot of close-ended questions, challenge your previously held assumptions, supply expert advice and give you "homework assignments?" Or are you more interested in someone who will mainly listen, someone to whom you can reveal and with whom you can discuss things you might not yet be able to share with family and friends, a person who can remain objective and who can provide you with a safe forum in which to explore how you truly feel about your situation, as well as give you time to weigh your options in a non-threatening environment? Both approaches are valid and alternately warranted, depending upon the given circumstances. A good therapist is flexible and can provide both.

Frequency. At your first visit you will also need to determine the frequency of visits. Once-a-week, hour-long sessions are standard, but in some cases your therapist may initially recommend twice-weekly sessions, until the crisis has passed and your situation has stabilized somewhat. Rarely, if ever, are more frequent visits called for (traditional psychoanalysis is an exception, but the goal of analysis per se is not really what this article is about). If a person needs to see a mental health professional more than twice a week to function and to stay safe, a brief course of hospitalization is often indicated.

Duration. Therapy can be brief, short-term or long-term. Certainly some individuals have done well to remain in therapy for years with one or more providers, but most practitioners agree that a principal goal of psychotherapy is to foster autonomy and to sufficiently improve a client's situation and symptoms such that she no longer requires frequent, ongoing sessions. To the extent that this is so, from the beginning there is at least the implication of an eventual endpoint, although the exact duration of treatment is not typically discussed or determined at the outset (with the exception of some forms of highly structured brief therapy).

In some cases in which a client has developed a good working relationship with a certain therapist, he may resume weekly or biweekly sessions only during difficult or particularly symptomatic periods and otherwise suspend regular sessions in the interim. Other clients may graduate to monthly visits and remain on that "maintenance" schedule over the long term, to stay on track; this is particularly appropriate for individuals who are in the later phases of recovery from substance abuse or some other form of addiction as a means of relapse prevention, to compliment involvement in a community-based twelve-step program.

Once you have voiced your preferences and agreed upon a general plan for treatment, the next order of business is to focus on what needs to be "fixed." Enrolling in professional psychotherapy is not a casual decision for most people, and so the reason for investing what could be a significant amount of time, money and energy needs to be made explicit. If you are not exactly sure, then this is an excellent opportunity to have that discussion with your new therapist and it will also give you something to report back to the person who initially referred you.

Identify target symptoms. Sometimes the goal of therapy involves understanding and controlling specific target symptoms, such as panic attacks, crying spells, or feelings of hopelessness, helplessness and/or worthlessness. Identifying target symptoms early on is especially important when therapy is a means by which to determine whether or not you should consider a trial of psychotropic medication. One of the things an experienced therapist can tell you is whether or not she feels you might be suffering from a physical condition the cause of which is biological and that you would benefit from a consultation with a doctor who can prescribe medication.

Or, when therapy is part of a multidisciplinary approach in which you are already taking a psychotropic medication, focusing on the reduction or the elimination of your target symptoms in therapy is an effective way of making sure your treatment is well-rounded. Sometimes medications reduce symptoms to the extent that you are then able to accomplish the work you need to do in psychotherapy. Conversely, psychotherapy can always go beyond what the medications are designed to do by assisting you in taking personal inventory and effecting change that ensures your long-term well-being in a way that has more to do with your environment, your relationships, your attitude and outlook on life, and your lifestyle choices. There is a lot of research that indicates that patients do better with a combination of medication and psychotherapy than with medication alone.

Set goals. Beyond defining your immediate needs, the best way to evaluate the outcome of therapy in the long-run is to establish concrete, realistic goals that you hope to achieve and setting a timeframe for reaching (or at least reexamining) those goals. Timeframes, of course, should be flexible and subject to adjustment, as becomes necessary; although certainly in real life, decisions may have to be made and certain problems dealt with in a timely manner, there are never any "deadlines" in therapy beyond which personal growth cannot occur. And while you will want to have thought this through a bit before your first consultation with a new therapist, determining all of your goals is not something you have to have accomplished prior to that first visit. Proper goals evolve over time and your therapist should actively engage you in determining what they are and modifying them as you go along, as appropriate. Whatever else, don't be shy about discussing the treatment plan. How will progress be measured?

Seek to understand. Concrete goals are a good idea, but remember also that the lasting benefits of therapy involve more than having simply put out fires and surmounted specific obstacles. Life is full of trials and there will always be something else to negotiate. What enduring lessons has therapy taught you? For example, one goal might be: "Deciding by the end of the fiscal year whether or not to offer my resignation at work," but this decision could also be paired with gaining a broader, further-reaching insight, such as, "Understanding why I become so frustrated at work and why I resent my supervisor," and ultimately, "Am I satisfied with my chosen profession and will I feel fulfilled doing this for the rest of my career?" Or, alternately, a person might be confronted with the decision, "Do I want to try to salvage my marriage?" and at the same time come to consider questions like, "Have I approached my current and previous relationships in a healthy and compassionate manner? If not, why not?" and, "What do I really need in a long-term companion?"

A perfectly valid, if somewhat more ambiguous, goal for therapy is to answer questions such as these and to come to know oneself better in the process. Of course, with questions like these, it may be that at the outset of therapy you won't even know which ones need answering. Often one of the long-term benefits of psychotherapy is discovering the important questions in your life, and working to resolve them is one of the rewards, even when some of them do not necessarily have definitive, absolute answers, because life circumstances do change, and we evolve as individuals.

Be honest with your therapist. There are many ways to sabotage your efforts in therapy, both purposely and inadvertently. Perhaps the most common is not being completely honest with your therapist. There are two ways to be dishonest in treatment, and thereby to cheat yourself of the full benefit of therapy. One way is to lie or distort the truth. This we do on purpose, and there are many reasons for it, all of which seem like a good idea at the time, but of course lying only detracts from the usefulness of therapy. But examined logically, lying to your therapist is pretty pointless. Remember that your therapist is like your lawyer; she is your advocate, and is not there to judge. She is also bound by the ethical guidelines of her profession, which includes strict confidentiality. There are only a few instances in which confidentiality can be violated (see clients' rights, below), so unless you know for a fact that "anything you say can and will be used against you in a court of law," the urge to deceive your therapist is at best irrational, at worst self-defeating.

The other way to be dishonest is through blatant omission: holding back the truth or the whole truth, often due to feelings of guilt or embarrassment. Sometimes what we don't reveal is more misleading than the little white lies we are apt to tell. Though it may be difficult, do yourself a favor and try your best to tell the whole truth and nothing but the truth. I promise you will get so much more out of therapy! Not having to worry about censoring yourself with your therapist is one of the great benefits of the professional therapeutic relationship; it is one of the things that makes it so unique and that gives it the power to be so helpful to you.

Being completely honest and relaxed can be incredibly liberating and highly therapeutic in itself, but understandably this may be something you will only slowly gain comfort with over time, as you come to better know and trust your therapist. That's perfectly natural. Just don't be afraid to admit to your therapist when the time comes that you may have failed to mention something important early on, or even that you gave an untruthful answer before, because you were unsure. Many times a client will come to feel comfortable fully confiding in his therapist, but then worries about courting the therapist's disapproval because he was not honest the entire time. Believe me when I say that a compassionate, competent therapist will not take it personally and would much rather prefer knowing what she needs to know to best counsel you as soon as you are comfortable enough to reveal it. Better late than never. Unfortunately, when it is part of a client's avoidant personality, sometimes a client feels so guilty about having lied that he can't bring himself to set the record straight, and therapy is then corrupted by an unnecessary tension and the added stress of having to avoid what may be at the heart of the matter.

If this happens to you, trying writing your therapist a brief note explaining why you felt you couldn't be entirely honest before and ask for her assistance in moving through this unexpected roadblock. Remember that in therapy everything is fair game and, inasmuch as it provides added insight into the nature of the way in which you tend to relate to other people and what it says about your emotional sensibilities, many times the therapeutic process and relationship itself needs to be the focus of the discussion for a while to achieve the personal growth that is one of the goals in therapy.

Be honest with yourself. Sometimes you can't be honest with your therapist because you're not being entirely honest with yourself. Denial, rationalization, and intellectualization are some of the defense mechanisms we use to protect ourselves from the sometimes unpleasant truth. Being honest with oneself is perhaps more easily said than done, but like seeking to understand, it is a valid work-in-progress and something an astute therapist will encourage and remind you to do from time to time. As clients, we rely upon the professional's objectivity and impartiality to help us see ourselves more accurately.

Engage your therapist. Therapy is not a monologue (again, with the exception of classical psychoanalysis; Freudian analysis is a form of therapy with many extremes). Instead, psychotherapy should be a dialogue between client and therapist, so don't be shy about asking questions, providing critical feedback, and even challenging your therapist's assumptions if they don't make sense to you or you fundamentally disagree. Your therapist may have training and experience and some measure of objectivity on his side, but he is not infallible. Not only that, but it is in the exchange of ideas with a therapist that some of the most important discoveries take place. Remember that neither you nor your therapist know everything that is going on with you at the start of therapy, or for that matter, at any point along the way. An active, vibrant discussion keeps the lines of communication open, prevents misunderstandings, spontaneously gives rise to new hypotheses worth exploring and at the very least, assures you that you are being heard.

Don't sabotage treatment. I've already talked about how anything less than complete honesty can detract from and even derail treatment, and I mentioned how low expectations and skepticism can sabotage you before you even get started, but nothing wrecks the entire process more completely and permanently than abruptly walking away from therapy because of a momentary flash of emotion. Sometimes it's anxiety, usually it's anger or hurt feelings, but it's always a bad idea if you do it without first signaling your intention and scheduling at least one final session to discuss your reasons for doing so. It could be that you are justified in your decision, and that terminating therapy is actually the right thing to do, whether you take a break from it completely or find a new therapist with whom to work, but if you act impulsively and you don't process it with your therapist before you abandon treatment, you might miss the opportunity to either clarify a simple misunderstanding, or else, at the very least, speak your mind and leave the therapist with something to think about for his next client. Especially if you are motivated by anger to "fire" your therapist, give yourself some time to calm down and give your therapist the opportunity to refer you to someone else so you can continue to work on your issues. Remember that therapy is for your benefit, not your therapist's, and you should never make decisions about your treatment based on hard feelings aroused in you by something your therapist said, or something he did or didn't do.

The other possibility is that you are feeling vulnerable or threatened precisely because you are getting somewhere in treatment. Therapy is not always comfortable, and it can actually be a bit stressful or even daunting at times, depending on the strength and nature of your defense mechanisms. Particularly if you want to quit altogether, ask yourself if you are not avoiding moving through and dealing with something difficult or painful.

Know your rights. Because getting the most from psychotherapy requires a certain piece of mind (for example, regarding the legal limits on confidentiality), familiarizing yourself with y our rights as a therapy client can be an important part of committing to the process, especially if you are new to it.

Confidentiality. The law in all 50 States protects the privacy of communications between a client and a psychotherapist, but there are limited situations in which a therapist is permitted or required to disclose information without your consent. These are situations involving certain court proceedings when a judge issues a subpoena, if you file a complaint or lawsuit against your therapist and the therapist has to defend herself, specific diagnostic and treatment information as requested by your insurance company in order to authorize payment for services rendered, situations involving the potential abuse of a child, or an elderly or disabled person, or if you make a serious threat of homicide against a specific person, and you have every intention of actually carrying out that threat, the therapist may be required to notify the potential victim directly and contact law enforcement. Depending on the law, minors who are not emancipated may also have their treatment record subject to review by their parents; it is best for teenagers to come to a clear understanding with their therapists regarding what information, if any, will be shared with their parents without their explicit prior consent. Parental involvement in therapy is extremely important, but a therapist should also be sensitive to the fact that a lack of confidence can seriously undermine the therapeutic process as well.

Protected Health Information. You have the right to examine and/or receive a copy of your clinical record, if you request it in writing and pay for it, but your therapist has the prerogative to refuse the request on clinical grounds, or to release to you a redacted copy of her notes, whose decision you then have the right to appeal. This is based on the fact that professional records can be misinterpreted and/or upsetting to untrained readers and can actually do psychological harm to the client.

Although you have a legal right to request a copy of your therapy record, I generally advise against it on therapeutic grounds. I myself frequently make observations and other notations in a patient's chart that would not necessarily be therapeutic for him to read verbatim himself, and that in a few cases might actually be detrimental to progress in therapy, or even downright psychologically harmful. Any helpful observations, insights and interpretations that should be communicated will be brought up by a deft therapist in session when the time is right, and in such a manner that is measured and most appropriate, with the client's well-being and best interests in mind.

If you need records sent to your doctor or another provider, it is best to sign a release of information form and have your therapist mail or fax the records directly to that professional. In some instances where it was necessary for me to release records directly to a patient and I had concerns about what the patient or the patient's family might read there, I sat down with the patient to review specific portions of the record with him. A debriefing session of this kind can easily be incorporated into your final visit if you are moving or terminating treatment for some other reason and you need direct access to your record.

Contraindications. Finally, there are a few circumstances in which engaging in psychotherapy is not a good idea at the time. These all involve periods during which the potential client is too sick to engage in healthy, conducive talk therapy, including periods of detoxification from drugs or medicines, episodes of acute psychosis (when a person’s reality testing is impaired), and during a severe major mood episode. Acutely manic individuals do poorly in therapy and therapy should be deferred or suspended until symptoms come under control on medications. Similarly, if an episode of depression is especially severe, talk therapy is relatively contraindicated until medical treatment has a chance to work. A seriously disturbed mood will contaminate the therapeutic process; patients who are deeply depressed are often incapable of formulating positive interpretations and of envisioning a better future. All therapy may accomplish for these individuals at these times is to induce a great deal of painful, mood-congruent and ultimately harmful ideations and helpless conclusions. It is better to wait until the client is physically capable of fostering hope and of feeling empowered before proceeding to introspect and problem-solve.

International Society for Interpersonal Psychotherapy

National Association of Cognitive-Behavioral Therapists

American Psychoanalytic Association

American Psychological Association

Read this: Current Psychotherapies

How to Pick A Good Therapist

2009-08-19T09:08:00.006-05:00

More people than ever are seeking professional counseling services in one form or another. Thankfully, the stigma of seeing a mental health professional is waning and people are becoming better educated regarding the various options available to them. Needless to say, psychotherapy can be extremely helpful, and it is almost always a good idea if a person is at all interested in it, assuming there are no major contraindications (see Part II) and the client-therapist relationship is a good fit. Unfortunately, as many people have experienced, a trial of psychotherapy can also result in disappointment and/or greater confusion. As is the case with medical malpractice between doctors and patients, it is a fact of life that some therapeutic alliances between professional counselors and their clients go terribly awry. In some cases this is because of the relative inexperience of an otherwise well-intentioned therapist; in other instances it may be due to a therapist's gross negligence, or his or her own psychological morbidity; in still other cases, it’s simply due to a poor match: some client-therapist alliances just aren't meant to be.

Because the start of a successful psychotherapeutic endeavor begins with the therapeutic relationship itself, selecting the right therapist is of paramount importance. It is also one of the most uncertain tasks, especially when practical considerations such as geographical location, availability and insurance requirements come into play. The topic of selecting the right therapist could fill a book. This article will briefly touch upon a few things to consider when making that selection. Part II, to be published separately, will discuss how to embark upon meaningful, successful psychotherapy by setting goals, avoiding pitfalls and engaging your therapist.

Because there is no practical way of comprehensively screening a potential therapist before therapy actually begins (it is often not until therapy is well under way that both the client and the counselor begin to develop a true sense for the other person), you will probably have to settle for an empiric, trial-and-error process, but the following guidelines should improve your chances of success without encouraging you to "therapist-shop." We'll see that, while it is reasonable to "interview" a potential new therapist on the first visit before committing to weekly sessions, you will want to resist the urge to shop around for someone who is only going to tell you what you want to hear, enable your maladaptive behaviors, or just validate you without asking you to really examine yourself and take a critical look at your choices in order to effect real change. It's not always a comfortable, pleasant experience, but if you invest in it fully, the rewards can be great.

Credentials. In searching for a good psychotherapist, you will certainly want someone with acceptable credentials, which involves four things: schooling, training/experience, certification, and more experience. None is more important than experience.

There are various types of degreed professionals who engage in psychotherapy, primarily social workers, clinical psychologists, and some psychiatrists. Although psychiatrists are medical doctors whose formal education and training is the most extensive of the group, M.D.s and D.O.s are not necessarily any better at providing professional counseling than social workers or psychologists. In fact, doctors may be significantly less prepared in that respect. This is because physicians of any specialty are licensed to conduct therapy, despite the fact that they are not required to take any psychology or sociology courses as part of their pre-med curriculum and likewise, they are not schooled in psychotherapeutic principles as medical students (graduate students may take a brief, basic course in behavioral health before their psychiatric rotations in their third or fourth year). As for psychiatric training, the trainee may or may not spend a significant amount of time practicing counseling under supervision, depending upon the specific residency training program, but in any case this is not the primary focus of residency training. Psychiatrists are medical doctors first and foremost, so they concentrate on diagnosing mental illness, ruling out treatable physical causes and managing symptoms with medications. Some residents in psychiatry receive surprisingly little in the way of formal instruction regarding psychotherapy. Do not assume that, because doctors have endured a rigorous and lengthy program of education, it makes them better therapists.

Psychiatrists. The only distinct advantage to having an M.D. or a D.O. as a therapist, beyond the fact that a doctor is able to bring the full breadth and depth of her medical knowledge to bear in diagnosing any physical conditions that may be present (as well as ruling them out) is that your therapist then also has prescriptive authority, in the event that you need or would benefit from a trial of psychotropic medication. A therapist comes to know you very well with the typical, once-weekly hour-long sessions, so if and when it becomes necessary to prescribe or adjust a medication, such an arrangement places the prescribing physician at an enormous advantage in terms of being able to consider, in-depth, the psychosocial factors relevant to your situation before deciding what to recommend regarding the medication. Even if you are meeting only every other week, you are still spending far more time, far more often with your psychiatrist than you would otherwise. Imagine the advantage of having up to a full hour to discuss medication issues and your various treatment options, as opposed to the standard 15-minute "medication check" every few weeks or months that is currently the industry standard.

Because psychiatrists and independent therapists are not always easily able to coordinate the care of the many patients they see and whom they may treat in common, having a therapist who is also your psychiatrist (and vice-versa) can definitely be an advantage, assuming that your psychiatrist is adept at therapy. To reiterate: the combination of seeing your psychiatrist for therapy practically guarantees that you will receive better psychiatric treatment (diagnosis and medication management), but it does not necessarily mean you are getting the best psychotherapy.

LPCs. As for social workers and psychologists, all licensed professional counselors (LPCs) in Texas must have a master's or doctoral degree in counseling or a counseling-related field from an accredited college or university. Here again, a Ph.D. will not necessarily make a better therapist for a given client than someone with a master's degree, because the ability of a particular therapist to help you depends on a number of factors, least of which is whether or not that therapist completed a dissertation as a graduate student.

When it comes to credentials, check for the minimum requirements (although if the therapist is licensed, the State in which the person is practicing has already done that for you), but beyond that, don't base too much of your first impression on how advanced the degree is, or which institution of higher learning granted it. There is absolutely nothing to indicate that a Harvard or Stanford graduate is going to do a better job working with you than the therapist who spent the first few years earning his degree at a local community college. Therapy is an art, not a science; many aspects of it cannot be learned except through direct experience, and some people are just naturally more gifted with regard to practicing it. Also, therapy is a collaboration, and the right fit often has little if anything to do with how accomplished the therapist's academic career was before sitting down to meet with a client for the first time.

Certification. That said, there are subspecialties in which LPCs can become certified, and inasmuch as these certifications indicate additional experience in a given area, they are certainly a source of added confidence. If you are seeking treatment for drug dependency, for example, you probably want to see an LPC who is also an LCDC: a licensed chemical dependency counselor. (And although not a requirement by any means, still…if substance abuse is the focus of treatment, you might even consider a therapist who is also a recovering addict herself; there is no greater teacher than direct personal experience, and these individuals are especially equipped to guide you through the process of your own recovery in a way that others who have never personally dealt with addiction simply are not.)

Other counseling subspecialists include cognitive and behavioral therapists, child and adolescent therapists, couple, family, and group therapists, and psychoanalysts, to name a few.

Definitely beware the "life coach" with absolutely no official credentials whatsoever. There are State laws governing the way in which these unlicensed individuals are allowed to advertise their services, but claims can be misleading. (Some practitioners may refer to themselves "life coaches" and be schooled, trained and properly certified; I'm only referring to individuals with no formal training whatsoever).

Experience. Do pay attention to how many years a therapist has been in practice. It bears repeating that the best credentials are not diplomas and certifications, but actual experience (the formal training that qualifies for State licensure always includes a significant amount of supervised experience). This is not to discriminate against those therapists who are just starting out, but as with medical doctors, the more time a practitioner has spent in practice and the more clients she has treated, the more opportunity she has had to master her own strengths and weaknesses and to learn from her mistakes.

Seek the best fit. A fully credentialed, Board-certified brain surgeon is going to do the best job she is capable of doing, regardless of what type of person the brain belongs to, but when it comes to engaging the mind, even the most seasoned clinician with one of the most well-honed techniques may not be the best suited to you, if that technique does not meet your particular needs. Someone who may be a wonderful therapist for one type of client may turn out to be a disappointing choice for someone else. Again, therapy is an art, not a science, which is why M.D.s and Ph.D.s--even those extensively trained in psychotherapy--are not necessarily better equipped to counsel you through your particular problems than someone with less formal training but who is perhaps culturally and ideologically a better fit (or simply someone with more innate talent).

The problem, as already mentioned, is that it is difficult, if not impossible, to know from the outset who is going to have the best approach for you and with whom you are going to relate the best over time. You won't know if you are going to clique with your new therapist until it starts to happen. Sometimes you get a good feeling on the first visit, but the therapeutic alliance is a relationship--a special kind of relationship, but a relationship nonetheless--and as in real life, meaningful and rewarding relationships build over time, with the establishment of trust and the building of familiarity. The more your therapist comes to know and understand you, the better able he will be to help you help yourself, and the better your initial choice in therapist will prove to be. Alternately, as you continue working together, differences in philosophy and approach may lead you to realize over time that you are not making as much progress as you would like.

Despite this limitation, it is reasonable to screen a potential therapist at your first appointment. Although the clinician will be performing a formal interview and will have many questions for you, one of them should be what you expect to gain from therapy, and in the context of discussing that, a good therapist will welcome inquiries from you regarding her therapeutic philosophy, experience and style. It's a start.

Give it time. Ultimately this is the only way that you are going to be able to make an informed decision. It may take several visits to get comfortable with a new therapist and to fully determine whether or not therapy is going to work between you. Unless you are immediately put off, you won't really appreciate whether or not you will be able to build a good working relationship until you both have had time to build one, so be patient, but ask questions and reserve some time early on to find out as much as you can about the person with whom you will be sharing and confiding your most important personal information.

The following are some specific qualities to look for in a therapist. Some of these you can ask about, but most you will have to discover for yourself, and the way to begin is to be aware of them.

Empathy. Does the therapist seem to care? Is he engaged with you, does he ask a lot of probing questions that invite you to stop and consider and reveal yourself a little in the answers? And when you go to answer, is he listening, or is he just waiting to ask the next question? Body language and eye contact are things a competent therapist is going to be evaluating in you, but you will also take your cues--consciously or unconsciously--from the therapist's demeanor, so take note if your new therapist seems distracted or disengaged. I've heard plenty of sad stories from patients about therapists actually yawning and looking bored in the middle of a session and yes, even falling asleep! One patient described to me how put off she was by the therapist's slurping his coffee when he met her for the first time. (It wasn't just the fact that he was drinking coffee, of course; it was the disaffected tone in his voice and the way he peered at her dubiously over the rim of his cup.)

It may be tempting for the sake of convenience to simply dismiss a really bad first impression, but this is a professional you have come to see: if your counselor seems indifferent or spends a lot of time quickly asking rote questions that she obviously asks everybody, with no real interest in your answers and no follow-up questions that are tailored to your responses, and she doesn't bother to look up much from her notepad during that first interview (a good therapist takes notes on the first visit, by the way), take these as precautionary signs.

Client-Centered Therapy. There is an entire school of thought built around the notion of empathy for one’s client. Carl Rogers' Client-Centered Therapy (CCT), developed in the 1940s and 1950s and later rebranded as Person-Centered Therapy, was the founding movement in the humanistic school of psychotherapies. It relies heavily upon the notion of "unconditional positive regard" that a therapist should demonstrate for his client. Rogers' belief was that people naturally tend to move toward personal growth and healing if merely allowed the opportunity, and therefore the principal aim of therapy should be to allow that spontaneous process by fostering a comfortable, non-judgmental environment and demonstrating "the utmost respect and regard" for the client. Chief among the therapist's tasks is to listen and try to understand how things are from the client's point of view.

CCT is a non-directive approach in which the beneficial effect of therapy is believed to ensue from a client's ability to feel accepted and valued, which occurs in the context of a properly fostered therapeutic relationship. It is the relationship itself, as a model for what other relationships in the person's life can be like, that is considered instrumental in alleviating a person's symptoms. It is a simple but powerful philosophy, and although most modern therapists (myself included) adopt a more eclectic approach to psychotherapy, drawing what works best from various disciplines and judiciously applying the various principles and tactics to individual cases based on the patient’s ability to benefit from a given technique, I do believe that the Rogerian principles of unconditional positive regard, empathy and openness should underlie every psychotherapeutic relationship. It is a solid, and I think necessary, foundation from which to proceed and build.

On a side note, the opposing ideology of the time was Behaviorism, an experimental approach which rejected notions of introspection and approached psychology on a strictly empirical basis. All behavior can be explained and predicted as a result of mindless conditioning, it argued. Behaviorism gave way to modern cognitive theory, which to be sure includes some of the most useful and effective techniques utilized in modern-day treatment, but even when we, as therapists, opt to focus on extinguishing or reinforcing behavioral responses as opposed to delving more deeply into our shared humanity, there is no reason those techniques cannot be taught and applied with due compassion for their subjects.

Compassion and wisdom. These may sound like fairly lofty qualities--and they are--but they are also necessary virtues for anyone who is serious about practicing the art of psychotherapy and truly helping people. Meaningful, well-administered therapy is a growth process for both the clinician and the client, which is why experience over time is the best guru for a dedicated counselor who truly loves the work. Teachers learn from their students, and therapists learn about the human condition, and about themselves, from their therapy subjects. So if it seems to you that the person who is supposed to be serving as your advocate and guide is narrow-minded, rigid, intolerant or embittered--and this does happen--move on.

Good boundaries. A proper therapist respects appropriate professional boundaries. This ranges from availability issues (see below) to issues such as whether your therapist calls you by your first name and encourages you to do the same, to actual touching. With regard to whether you and your therapist should be on a first-name basis, this is largely a matter of personal preference. With the exception of doctors and their patients, most clients and their therapists seem to be on a first-name basis, as it fosters a more comfortable and intimate therapeutic relationship, but if you have a particular preference regarding what your therapist should call you--and this is entirely your decision--make it known.

With regard to touching, it is accepted that a light hand on the shoulder or in some cases even a comforting or congratulatory hug are within the limits of propriety, but with hugs in particular it is also generally accepted that the client should be the one initiating or asking for that type of gesture, not the therapist. It is generally frowned upon for a therapist to routinely hug his patients, or to ask for hugs, although some therapists would disagree with that, and if a patient asks me for a simple hug, I have found that it is usually okay to grant the request. But if you find yourself wanting to hug or touch your therapist at every visit, that's something you may want to discuss in therapy (cf. transference). Whatever else, a therapist should never make you feel uncomfortable by touching you. If he does, this is something you will need to address.

I learned a valuable lesson once when I extended my arm in an offer to shake hands at the end of my first visit with a patient who was a young, unmarried female Muslim. Despite the fact that she had been reared and educated in the United States, her culture did not permit her to feel at all comfortable making that kind of physical contact with her male treating physician. Although this intelligent young woman was an adult who had lived and worked independently as an engineer before becoming seriously ill, she came to my office in traditional dress, always chaperoned by her mother, and I learned that at the end of subsequent visits, a warm smile and a simple nod conveyed all the politeness and graciousness that any offer of a handshake could have. More, in fact. By being mindful and respectful of her personal boundaries and modifying my overtures accordingly, I earned her trust and respect.

Cultural sensitivity. Entitled, self-righteous, ethnocentric individuals (bigots) are poorly suited for this line of work. Thankfully, few apply! But, particularly if you are a non-native resident who was reared in a different culture, you want your therapist to be interested in and sensitive to the differences that exist between you. Many clients who belong to a minority class perfectly reasonably prefer to see a member of their own ethnic group, to obviate the possibility of cross-cultural misunderstandings. Moreover, if English is not one’s first language, one may do better conducting insight-oriented psychotherapy in one’s native tongue.

Along the same lines, many lesbian, gay, bisexual and transgendered individuals prefer therapy offices that are likewise owned and operated, or at least recommended, by members of the LGBT community, and the same can be said for any minority group that is subject to discrimination. A decent therapist, regardless of his own personal demographics, affords all human beings the respect and dignity they deserve.

One alarming exception to this seen today that bears mentioning because it is so pernicious is the example of "gay conversion" therapy, which is destructive and unnatural in my professional opinion, and unethical and immoral in my personal opinion. Thankfully it is not a mainstream movement in modern-day mental health treatment.

Adaptability. Inasmuch as the typical therapist will see a wide array of individuals in the course of a work week, she cannot demonstrate the same persona with all of them if she has truly mastered the art of psychotherapy. A truly capable therapist, no matter his theoretical persuasion, adapts himself to accommodate the intellect, culture, communication style and symptomatic limitations of the person seeking services. We do not relate to our spouse or partner the same way we relate to our parents or the way we relate to authority figures; we adapt our style to suit the situation and the expectations of the other person. Why would a therapist relate to every patient in the same manner?

If your new therapist uses language you cannot understand and fails to express herself more clearly when you indicate your confusion, or else makes you uncomfortable in the manner and style with which she addresses and interacts with you, despite voicing the hesitation and concern you may be feeling, that may be an indication that the therapist is not a good fit for you, especially if she seems out of touch with the fact that you are not entirely at ease. A therapist must be able and willing to adjust her personality to accommodate the client’s social vulnerabilities, whether they are inherent or whether they are the result of a temporary episode of illness. This is not to say that a therapist’s job is to make sure the client is always comfortable; that may not be possible, or even desirable. It is merely to say that a skilled therapist notices and adjusts the rate, tone and volume of his speech and gestures accordingly.

Openness. A good therapist is not only sensitive to your comfort level at all times, but is likewise continually open to feedback, including criticism; she will not take things personally or become defensive when you point out your dissatisfaction or discomfort with some aspect of your therapy. A truly experienced therapist will carefully consider what you have to say, and either accept it at face value if it is a valid criticism, or else explore it further with you if there are questions or concerns about a possible misunderstanding. Often a client's disillusionment or frustration with the therapeutic process is an opportunity for further introspection and interpretation that neither of you would want to miss. A therapist who remains transparent, honest and genuine in his emotional responsiveness to a client (a quality Rogers called "congruence") encourages the client to do the same, greatly facilitating the therapeutic process and leading to greater satisfaction for both client and practitioner.

Spiritual alignment. Some clients specifically seek faith-based counseling services, which includes pastoral counseling, and in these cases obviously a person would seek a minister, rabbi, priest or guru as appropriate to his religion. If you are atheist or agnostic, it may or may not be important to you to find a like-minded therapist, but an evangelical counselor who specializes in faith-based therapy with a heavy emphasis on prayer would obviously be a poor fit, so keep that in mind.

Also realize that, while some licensed counselors incorporate their own faith in their work and specialize in faith-based psychotherapy, pastoral counselors (clergy) are not licensed therapists. In Texas, theology is not considered a "counseling-related field" by the Department of State Health Services, and so students of theology are not eligible for licensure based on seminary work alone. Absent formal training in providing professional counseling services, pastoral counselors rely more on wisdom and simple compassion than do their professional counterparts, whose philosophies are not dependent upon church doctrine and who are trained in specific therapeutic techniques and interventions that have been tested by research.

Little can go wrong when compassion is the guiding principle, surely, but when compassion fails to refute dogma, suffice to say that not all religious doctrines are necessarily conducive to the mental health of a given individual. If you are a person of strong faith and it is important to incorporate God in your treatment, perhaps it is better to seek a licensed professional counselor of the same religious affiliation as yourself who advertises faith-based services than to simply discuss your problems informally with your clergyperson, although discussing any problem with as many caring individuals who might help is always a good idea, even if you are bound to receive contrasting points of view.

My own personal opinion is that I consider a strong spirituality an invaluable asset for a therapist to bring to bear in the therapeutic context, when it comprises humility and altruism, whereas adamant religiosity, on the other hand--especially of the arrogant and self-righteous variety--only exacerbates real-life struggles in a way that fails to preserve the autonomy and dignity of the individual who suffers…but that’s just my personal opinion.

Thus far I've discussed important qualities and characteristics inherent to the personhood of the therapist, qualities that cannot be taught, but that can be cultivated with a sincere effort and interest in the art of psychotherapy. One question you might ask your new potential therapist is why she chose counseling as a profession in the first place. The answer might give you a good idea about how interested in and dedicated to the practice she is. The following considerations are likewise a testament to the type of professional you will be relying upon, but have more to do with the practical aspects of your treatment.

Availability. Being on-call and available to clients for after-hours emergencies and consultations is an unavoidable part of any health profession. The question is: how badly does your therapist try to avoid it? Therapists who flat-out tell their prospective new clients up front that they don't normally make themselves available after hours are sending a very clear message, one you should hear for what it is. I personally find the practice of broadcasting such a thing in such a manner a bit distasteful. I want my patients to understand that they can rely upon me in an emergency, not that I don't want to be bothered. Posted signs and other communications from your therapist's office that warn that you may be charged extra for after-hours services are one indication of where the therapist's priorities lie.

On occasions when you do have to contact your therapist outside of your usually scheduled appointment time for more routine matters, how easy is it to leave a message and how long does it take to get a callback? If you call during normal business hours, it is customary to get a call back by the end of the day, unless you call late in the afternoon.

Confidentiality. This almost goes without saying, but your therapist is required by law to maintain the privacy of your protected health information, and should provide you with a copy of her office's privacy practices. Just as you would never want your therapist to casually discuss your case with others, your therapist should never discuss the treatment of her other clients with you, except in the most general of terms, for illustrative purposes that pertain to your situation and that have to do with her experience in dealing with the issue at hand. It is very bad form to overhear a therapist discussing his cases with other professionals, and if your therapist is fond of gossiping in session with you directly, think seriously about the implications that has on your own treatment. I have witnessed these types of behaviors myself, and so while I hesitate, I have to mention it here.

Other therapist variables depend on you: do you have a gender preference? It's okay if you feel more comfortable with someone of the same gender, for example, especially if your issues are gender-specific or involve sexuality. Age can be another preference; many adults prefer a therapist who is at least their age, if not older. Whether or not your therapist has ever been married might also be a consideration if you are seeking couples' counseling, although don't discount divorced therapists, who may have even more valuable insights into marriage--as well as the process of extricating yourself from one that isn't healthy--because of having lived through it.

Finally, it's okay to "fire" your therapist if things aren't working out, but before you terminate the client-therapist relationship be sure to discuss your concerns openly and honestly. A good therapist welcomes constructive feedback, which might salvage the therapy if offered sincerely and early on, or if not, at least provides the therapist the opportunity to improve for the next client.

Also, sometimes a person will become disenchanted with her therapist or with therapy in general because the therapeutic process has become difficult or anxiety-provoking. This may actually indicate that progress is being made, albeit uncomfortably, and that therapy should definitely not be interrupted. Having one final debriefing session to discuss your reasons for wanting to quit or switch to a different therapist prevents sabotaging perfectly good therapy when it gets stressful and helps to avoid "therapist shopping."

Less commonly, a therapist might suggest or even insist upon the need to terminate the therapeutic relationship and that you find another provider. There are only a few situations in which this is professionally appropriate. In every instance, adequate referrals should be offered to you, as well as instructions as to how to have your medical records forwarded to your next provider.

Of course, people "graduate" from therapy all the time, and since that is generally the goal, even with longer-term therapies, it is an occasion to celebrate, indeed.

It's good to have many advisors in your life, some of whom may be licensed professional counselors, but most of whom will be the people in your life: family, friends, colleagues, a member of the clergy, a teacher, a mentor, or any of a number of other role models. Perhaps you consult regularly with a fitness instructor or a dietician, or a home health nurse. Maybe you look up to a supervisor at work. Perhaps you are particularly impressed by the works of your favorite author, or inspired by the imagination of a great artist. Anywhere you encounter wisdom and compassion and a desire to be helpful, assistance can be found. And if you go through life with a healthy outlook and the right attitude, at the right time and with the right persons you may be that altruistic guiding influence.

Side Effects A-Z: Avoiding Weight Gain (Hyperphagia)

2009-08-17T09:10:00.003-05:00

One of the most alarming and universally unacceptable of medication side effects is that of permanent weight gain, and it is not an uncommon one. This article focuses on weight gain as a side effect of psychotropic medication, which falls under the area of my expertise, but the general principles are applicable to weight gain from any medication or substance--including, for example, the recreational drug marijuana.

Weight changes due to the routine ingestion of a chemical compound, be it a prescription medication, an over-the-counter preparation, or some other substance, could be due to three primary mechanisms.

1. Water retention or loss. The composition of normal body tissues is largely aqueous; at least 70% of our body weight is attributable to the weight of water. Water weight is not, however, what people worry about when they think about weight change due to medication. Although the bathroom scale can register sometimes rather impressive shifts due to this mechanism, and bloating due to water retention can feel uncomfortable and make your clothes fit more snugly about the waist, this is a relatively modest effect that is seen mostly with prescription hormone therapies. It waxes and wanes depending on the dosing schedule and is not the kind of weight gain that involves an increase in the actual size of fat cells. Similarly, but in the opposite direction, diuretics which are used to lower blood pressure may also result in a rapid and pronounced weight change according to the scale, but no actual permanent change occurs with regard to a person's girth.

2. A change in metabolism. A few commonly prescribed medications directly impact a person's metabolic rate, increasing it (medications that significantly lower a person's metabolism, such as those used in anesthesia, are administered in highly controlled settings for brief periods of time and are not generally prescribed to outpatients). Thyroid hormone, for example, stimulates the metabolism and is prescribed in hypothyroid conditions and also as an adjunct in treating medication-resistant major depression. Drugs that increase sympathetic arousal--that is, stimulants--increase metabolism by virtue of the fact that they increase the activity of the central nervous system and stimulate the heart rate, both of which consume extra energy.

But, again, medication-induced weight change is not typically accomplished by this particular mechanism. Patients taking stimulants lose weight because those medications strongly suppress the appetite, not because the autonomic nervous system is activated, and certainly weight gain due to a medication or substance is never the result of a metabolism that has ground to a halt. Other, more serious and life-threatening problems would result! No, although many patients are not typically aware of it at first and will honestly deny that they have changed their eating habits, virtually all weight change that occurs due to medications and other substances is due to:

3. A change in appetite. By far, the weight gain seen as a side effect of psychotropic and other medications is due to this process: a change in the drive to eat. That is, a change in eating behavior. Understanding this is key to preventing and foregoing continued weight gain.

Just as the anorexia that is induced by stimulant medications is responsible for the vast majority of the weight loss that is seen with those medications (even though they also slightly increase metabolism), the weight gain that is seen with many antidepressant and antimanic and antipsychotic medications is due to overeating, including binge eating. The medical term for this side effect is hyperphagia.

As stated, it is not uncommon for people to swear that they are not eating any differently or any more than usual, leading them to believe that their metabolism has somehow shifted dramatically because of the medication, but in such cases individuals are simply not noticing that they are, in fact, snacking more than usual, or that they have, indeed, increased their portion size or else have shifted their dietary preferences in favor of sweets and starches (see below).

So…what to do?

Be mindful. The simplest, though not often the easiest, thing to do is to guard your eating habits closely and look for behaviors such as increased snacking or the tendency to go back for seconds. Because weight gain--even relatively rapid weight gain--occurs over time, there will be ample opportunity to curb it, and then reverse it, if you notice it in time. Often patients who are not cautioned about the potential for weight gain will be oblivious to it until they have put on an extra 10 or 20 pounds, seemingly overnight. So, simply put: be cautioned. If it is a major concern for you, and since it is relatively common, always ask about the potential for weight gain, especially with psychotropic medications. Some medications are notorious for it. In psychiatry, these include SSRIs (especially Paxil and Lexapro), mood stabilizers (especially lithium and Depakote), and the newer, so-called atypical antipsychotic agents (especially Zyprexa and Clozaril), among others.

Remember that, although the weight gain may seem to occur overnight, it doesn't, quite. That is to say, it takes many days to weeks to gain more than a couple of pounds (real pounds of fat, not water), so the first thing to do is to be aware of the possibility and to pay attention. That said, the other thing to know is that the urge to eat more (and that's more than your typical urge to overeat, which almost all of us already experience to some degree or another at our baselines) may not be able to be overcome with sheer willpower. In other words, merely paying attention may not help you regain the control over your eating that the medication takes away from you, particularly if you already struggle with this issue, but at least it will keep you from gaining an unacceptable amount of weight before you are even aware of what is going on, early enough to discuss switching medications with your doctor, if necessary.

Beware carbohydrates. Hyperphagia as a medication side effect is not indiscriminant. Instead, it is rather specific to sweets and starchy foods like bread and pasta. You are not going to suddenly begin craving steak under the influence of a medication; rather, you will crave potatoes. Likewise, you don't feel like munching on green leafy vegetables under the influence of marijuana; instead, you develop an acute hankering for ice cream, cookies and chips! In fact, one way to distinguish substance-induced hyperphagia from an increase in appetite due to other factors (such as a depressed mood, for example) is that substance-induced cravings are specifically carbohydrate cravings. Unfortunately, as many of us already know, we naturally tend to crave carbs whenever we crave anything to begin with, so it is not unusual to develop a sweet tooth for other reasons (such as mood or stress) and therefore it is not always obvious from this alone that it is a given medicine that is making us overeat.

Another clue is the intensity of the craving. Carb cravings due to a substance or medication are intense, and if you pay attention, you will notice not only an increase in craving cakes, cookies, ice cream and candy, but a sharply increased pleasure in their consumption. Certain foods taste better when the brain is amenable to them. When this effect is due to marijuana intoxication it is colloquially called "the munchies," and is essentially the same phenomenon as the overeating that is due to treatment with certain antidepressants (albeit as a result of different molecular mechanisms).

Of course, many patients do notice the increase in their appetites. In fact, many will report feeling "hungry all the time." But hunger per se is not increased in hyperphagia. It is good to keep this fact in mind, because it may help you to resist unplanned meals. Weight gain occurs precisely because you are eating when your body does not require it. Just because you are eating more--even when it's because your brain is telling you to eat more--doesn't mean you are actually feeling hunger. Hunger is the discomfort felt by your brain when your stomach is empty and your blood sugar level is falling. Medication that causes you to gain weight will signal to your brain that it's a good idea to eat, even when your stomach is not empty and your blood sugar level is fine, but it's a different signal. It's not a hungry, you're-getting-low-on-fuel signal; it's a gee-that-looks-good, "Let's eat!" signal. The medication is not making you hungrier, in the strict sense of the word, but you may actually have to remind yourself of that.

Avoid temptation. The drive to overeat may be irresistible while on a medication, and so if you don't want to change the medication, another strategy is not to place yourself in situations that will tempt you. The only way to overcome a temptation that you cannot resist is to avoid it altogether, and this is doable: because you are not actually hungry all of the time, you will not necessarily seek out food that isn't there, the way you might if your stomach were actually rumbling and you were overdue for a meal. But, if the snack is in front of you already, and your appetite is in overdrive because of a medication, you will likely succumb to the temptation to "taste just a little." But even if you are only sampling a little here and there, the cumulative effect is one of certain weight gain over time. This is one of the ways in which people don't necessarily notice a major change in their eating habits despite putting on a lot of weight: they are constantly "grazing" and the pounds add up.

Don't enable yourself. This is just another way to say: avoid temptation. The problem is that we keep snack food handy--at our desks, on the coffee table in front of the TV, on our nightstands, in the car, etc. Food is usually within sight and often within reach, which enables the compulsive snacking that is seen with certain medications. When you are prone to overeating for whatever reason, hanging out in the kitchen is an example of risky behavior. So is opening the refrigerator just to see what's in there. Under any circumstances, if you wander into the kitchen because you're bored and you aimlessly open the fridge, you are much more likely to eat something as a reward for your curiosity. On the other hand, if you are already prone to overeating or if you are under the influence of a medication that compels you to overeat, then to do so is practically to ensure that you will have a meal you don't need.

So, the rule to follow when you are susceptible to binge eating is to stay away from temptation if you can't resist it, whether the inability to resist is relative or absolute, and whether this is due to a medication, bulimia nervosa, or some other neurological condition. Take your cue from alcoholics, who know to stay out of bars. Of course, you can't (and shouldn't) avoid three square meals a day, so you will still have to watch meal choices and portion size at other times for as long as you remain affected by hyperphagia.

Will you develop tolerance to medication-induced hyperphagia, the way tolerance is usually developed toward other unwanted medication side effects? It is certainly reasonable to surmise that, over time, the brain might lose some or all of its sensitivity to the appetite-stimulating effect of a given medication. Clinically, I have certainly seen this with medications that suppress the appetite: over time, individuals become insensitive to the anorexigenic effect of stimulant medications and their appetites return to normal, so it is plausible that the same thing happens with medications that stimulate the appetite. This has been difficult for me to confirm in my practice, however, because by the time such a tolerance were developed (weeks or months into treatment, at the least), a patient has either already gained a significant amount of weight, or else in many cases has asked to be switched to something different to avoid further weight gain. And while it is true that an individual does not go on gaining weight indefinitely and at some point a person's weight will plateau, it is difficult to say whether this represents having developed resistance to the appetite-stimulating effect of the drug, or whether the new weight merely represents a new steady state for the hyperphagic individual.

Switch medications. When all else fails, a medication change may be in order. Unfortunately, dosage adjustments are typically ineffective. While many side effects occur when a medication dose reaches a certain threshold level and will wax and wane in intensity depending upon the corresponding dosage, in the long run weight gain (which, remember, occurs over time) tends to be an "all or nothing" phenomenon, such that an individual either will or will not tend to gain weight on a particular medication, regardless of the actual dose s/he is exposed to. At the end of the day, lowering the dose rarely if ever corrects the appetite; at best it may slightly decrease the total amount of weight gained, or else delay the maximum weight reached by a few weeks or months, but you get there regardless. Switching to a different medication in the same class is the best first option. The sooner you identify a problem and the sooner you and your doctor change course, the less you will ever gain and have to worry about losing later.

An ounce of prevention… What can also be said is that discontinuing the medication will not necessarily result in weight loss all by itself. While returning to one's normal weight will be much easier off the medication (indeed, losing weight can be impossible on certain medications), even after one's appetite normalizes, weight loss is typically a purpose-driven, labor-intensive undertaking that can be quite a challenge.

Weight gain will occur over time, so catching it early and either modifying your eating habits accordingly or else discontinuing the medication (check with your doctor) will prevent any long-term gain. For this reason you should not rule out trying a medication that is likely to help you, based upon the risk of weight gain alone. There's always the possibility that you may not be affected, or else that you will be successful being mindful and/or compensating with exercise, and you wouldn't want to miss out on a life-saving antidepressant or mood stabilizer that you truly need.

Understanding Addiction

2009-08-11T08:53:00.006-05:00

The notion of addiction is one that includes more than just chemical dependency. Today we are aware that a person can be physically or psychologically addicted to a number of things; drugs, food, sex, and gambling are among the most common. What all addictions have in common is impulsive thrill-seeking. In neurological terms, this involves stimulating the brain's dopaminergic pleasure center. Even highly specific, inherently problematic behaviors, like stealing or setting fires (kleptomania and pyromania, respectively) can be thought of as addictive behavior. But what, exactly, do we mean by "addiction"? Are all addictions the same? What are the defining components of addiction? Are addicts weak and immoral, or are they ill? This article addresses some of these questions and defines what professionals mean when they diagnose abuse and dependency in the context of substance use.

As a lay term, "addiction" can mean any number of things. Clinicians do not use the term officially, and so it has not been operationally defined. Instead, diagnosticians refer to abuse or dependence, the latter including both physical and psychological dependency. Classically these terms have been used to describe substance abuse and chemical dependency, so for illustrative purposes I will use abuse of and dependency upon intoxicants as my example, but keep in mind that the following principles apply equally well to food addiction, or sexual or gambling addictions, et al.

Use…abuse…dependence. Such is the progression, where abuse represents a recurrent pattern of problematic use and marks the beginning of the need for treatment and dependence involves some degree of losing control. Just as not all occasional users become habitual abusers, not all abusers become physically or psychologically dependent. Many factors come into play, including what exactly is being used or abused (some substances have a much higher abuse and dependency potential than others), as well as precisely how it is being abused (smoking cocaine is more addictive than snorting it, for example), how often and for how long. These variables aside, we know that genetics plays a huge role: most people are just inherently--biologically--predisposed to abusing or becoming dependent upon a given substance or they're simply not, such that oftentimes little more than brief exposure is required to set off years and years of severe and debilitating addiction, whereas in other cases a person seems to be more-or-less immune to the perils of dependency, despite frequent and repeated exposure to the drug in question.

Use vs. Abuse. Depending on the substance, use is not necessarily abuse. Many people can use alcohol and not abuse it, and there are millions of people who say the same thing about marijuana, and other recreational drugs. But what if a person drinks too much, experiences a blackout and gets sick? Is that abuse? Or what about heroin? If a person sticks a needle in her arm and injects herself with heroin, is that always abuse, even if she doesn't get sick and never does it again?

This is where clinicians, because they are tasked with identifying those individuals who require treatment from among those who've simply exercised poor judgment, make the distinction that clinical abuse per se involves a recurrent pattern of use despite negative consequences. So, a single episode of problematic use is not, clinically speaking, indicative of an abuse disorder, any more than a single instance of overeating would necessarily indicate an eating disorder. Any one really bad lapse could be a sign of trouble to come, certainly, but alone is not enough to make a diagnosis.

To reiterate: even if use is intemperate or otherwise ill-advised, it does not necessarily meet the diagnostic and statistical criteria (DSM-IV) used by clinicians to indicate clinical abuse. If you gorge on a buffet, and then make yourself sick later, one could certainly argue that it was a bad idea, and that you behaved in an unhealthy manner, but one would not diagnose a clinical abuse disorder based on the one instance alone. All diagnostic abuse criteria (see below) involve recurrent use despite negative consequences.

So what about heroin? Or crack cocaine? There are certain drugs that are considered to be at an extremely high risk of being abused. So high, in fact, that these substances are considered to have no medicinal value whatsoever, despite the fact that they certainly have a pharmacologic effect. They are classified as Schedule I controlled substances and include such things as heroin, cocaine and marijuana (although topical cocaine has some surgical applications and the use of medical marijuana is currently a hotly debated topic). In almost every instance, even one-time recreational use of heroin or crack would be considered abusive by most people, but again, for purposes of diagnosing someone as having a substance abuse disorder, there must be recurrent, continued use that meets the following additional abuse criteria:

Abuse. Abuse is not merely indicated by the fact that bad things arise from using. Abuse is indicated by continued use in the face of those negative outcomes. Many, if not most, people have misused a substance at some point in their lifetime. Overuse of alcohol is extremely common on college campuses. But not every young person who has ever intentionally drank too much alcohol for recreational purposes merits a diagnosis of alcohol abuse, even if that person was very, very sick afterwards and really regretted it. It is only those persons who continue to drink too much, time after time, despite getting sick and despite regretting it every time, that we say have alcohol abuse disorder. I say "have" because, under the medical model, alcohol abuse is a disease. A choice is made, certainly, but any pattern of self-destructive, maladaptive behavior, no matter how indulgent, is properly considered a condition of the brain (this becomes more intuitive in cases that progress to full-blown dependency: see below).

The formal DSM-IV criteria state that abuse involves "continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the substance." This includes the failure to fulfill major role obligations at work, home or school and legal problems. Abuse is also defined as using in physically hazardous situations, such as drinking alcohol while driving or operating heavy machinery--but again, in order to be diagnostic it must be recurrent use in physically hazardous situations: one DWI is bad enough, and it may be a sign of alcohol abuse disorder, but two or more is diagnostic of the disorder of abuse, if not of outright alcohol dependency.

Dependence. When a person becomes dependent on a substance (or a behavior, like gambling or binge-eating or engaging in anonymous sex, etc.) the qualifying difference is that now the person has begun to lose control. As with abuse, the addicted person continues to use "despite knowledge of adverse consequences," such as failure to fulfill work role obligations or in physically hazardous situations, etc., but in addition to, say, risking losing one's job with continued use, in dependency other elements are present as well (at least three, according to the DSM-IV): they include giving up or reducing other important social, occupational or recreational activities; devoting an inordinate amount of time obtaining, using or recovering from using; taking larger amounts of a substance and for a longer period of time than intended (or again, gambling and losing more money than originally planned, etc.); a persistent desire or repeated unsuccessful attempts to quit; or, if a person is physically addicted as well, tolerance and/or withdrawal effects. A person may not be consciously aware of it at any given time, but nothing characterizes dependence better than the relative inability to stop.

Tolerance. Tolerance is a marked decrease in effect at a given dose, resulting in a marked increase in the amount of drug taken in order to achieve the same high. The development of rapid tolerance has a special name: tachyphylaxis. For many people, tolerance and/or withdrawal symptoms are the hallmark of "addiction," but the development of some tolerance is a normal finding with many habit-forming medications (such as sleeping pills) that does not, in itself, indicate addiction per se. Furthermore, because not everything is necessarily physically addictive (i.e., allowing for psychological addictions), evidence of tolerance and/or withdrawal is not necessary for a diagnosis of dependency.

Also, consider that people who become dependent upon non-physically-addictive pursuits can also experience this subjective need for "more" to achieve the same thrill, such as when a pathological gambler raises the stakes or when a sex addict takes greater and greater risks in order to reach the same level of prior excitement.

Withdrawal. Withdrawal, on the other hand, is a purely physical consequence. Symptoms are characteristic of the abused substance and range from tremors, sweating, diarrhea, to insomnia, depression, hallucinations--even death. This criterion is met when a person takes the substance to relieve or avoid withdrawal. Some withdrawal can be brief and indeed life-threatening (e.g., alcohol and other sedatives), while other withdrawal syndromes last weeks and only make you wish you were dead (e.g., opiates and related narcotics)! The presence of withdrawal indicates that a significant degree of tolerance has been developed, but the development of physical tolerance does not always result in withdrawal.

Ask yourself. There are various screening tools used by psychologists which consist of self-inventories that patients complete and which are then scored to give an idea as to the likelihood that there is a substance abuse problem. The simplest are the four "CAGE" questions:

Have you tried to (C) cut down?
Do you get (A) annoyed by others' comments about your use?
Do you ever feel (G) guilty about your use?
Do you ever take an (E) eye opener in the morning to get going?

A better survey is the more comprehensive 28-item Drug Abuse Screening Test (DAST) developed in 1982 and based on the Michigan Alcoholism Screening Test (MAST). Questions include: "Are you always able to stop using drugs when you want to?", "Have you ever neglected your family or missed work because of your use of drugs?" and "Have you ever been arrested for driving while under the influence of drugs?" among others.

Remember that these simple, straightforward yes/no questions are designed to assist clinicians in screening for abuse and dependency disorders; unless you are in serious denial, a few moments of quiet introspection will probably tell you most of what you need to know. Given the propensity for denial in most addicts, if you even suspect that you may not be in complete control of your extracurricular activities, that should be a red flag to you. Most people who use drugs "for fun" don't start thinking in terms of addiction until the problems have started piling up, so if you are already wondering about it, chances are you may be on your way to even more serious trouble ahead. Be smart; turn back!

So, to summarize: if you are using a substance (or engaging in some other risky, thrill-seeking behavior) despite the ongoing problems it is causing, you are technically abusing, and if you get so wrapped up in it that you then begin withdrawing from the non-users in your life and begin spending more and more time using or trying to use, or dealing with the fallout of having used, or you spend a lot more time, money and effort than you initially planned on spending (yet again), or you've thought about stopping but somehow haven't been able to… then you have officially become dependent on your new pastime; i.e., you are "addicted."

Why do some people progress from abuse to dependency, and others do not? Most alcoholics will tell you that, looking back, it is obvious to them that their alcohol dependency began with their very first drink, even if their problems didn't start until years or even decades later; most also have strong family histories of alcoholism. Other individuals who used and abused alcohol recreationally for years, say, during college, were able to put it aside after graduation with little or no trouble. It is obvious that for these individuals alcohol dependency was never a real threat. It is not that one group is better or stronger or has more "willpower" than the other: it is simply that one group has the illness and the other group doesn't. Both were exposed to the necessary precipitating factor (alcohol), but only the vulnerable population got sick. This is the medical model of addiction, the same model we apply, for example, to juvenile onset diabetes: genetic vulnerability (biological predisposition) + exposure = illness.

So, what to do if you are affected? Do what I did: get help.

Because it is an illness (no one chooses self-destruction), one thing is certain: you will need help. Not necessarily professional help, but it's always a good start. Doing it alone, on the other hand, is never advisable. Fortunately, you won't have to go it alone, no matter how isolated you may find yourself, because there are millions of people out there suffering the same as you and there are many helping hands. Much more on the topic of addiction, where and how to get help, to come.

Alcoholics Anonymous
Narcotics Anonymous

Why Your Antidepressant May Not Be Working

2009-08-06T09:35:00.003-05:00

Modern antidepressant medication trials are highly effective across the board, but many patients, particularly treatment-naïve individuals who are new to taking psychotropic medications, often report that their medication isn't working as well or as quickly as they had anticipated. This article covers the most common mistakes and misconceptions patients make when first taking prescription psychotropic medication for purposes of improving their mood. Once these common problems and pitfalls have been fixed or ruled out, there are indeed various options you can explore with your prescribing physician to alter the prescribed treatment regimen and get a better response.

The medicine has not been taken for a long enough period of time. This is probably the most common reason a medication doesn't seem to be working after starting taking it, and it is simply a matter of expectation: early on, it simply hasn't had enough time to work. Although in a minority of cases a person will begin feeling better within a few days (I've seen this with the dual-acting agent Effexor a number of times, especially in individuals with moderate-to-severe symptoms that are largely due to endogenous, or physical, depression), it is more standard for a person to appreciate only mild side effects initially, for as long as two or three weeks, before gradual improvements begin to be noticed. In fact, many times just as most of the side effects are beginning to disappear, the therapeutic effect begins kicking in. It is definitely worth sticking it out until this occurs!

Even in those individuals who begin to feel better right away, the full effect of an antidepressant medication can easily take 2-4 weeks or longer to manifest. Considering that many times a starting dose will have to be optimized by increasing it a few times, depending in part on how the person is tolerating and adapting to the side effects, it could be 6-12 weeks or longer before just the right dose has been taken for long enough for a medication's full benefit to become apparent. So patience is key. That said, in the vast majority of cases, you should begin to see noticeable improvement in your symptoms well within the first month.

What can you do in the meantime? One thing your doctor can do is to prescribe other, short-term medications designed to address certain target symptoms while you are waiting to feel better. For example, if insomnia is a prominent symptom of your depression, your doctor can prescribe a short course of a sleeping medication that will treat that symptom immediately and let you get some rest while you both wait for your mood to improve. Once your depression is better, your insomnia should self-correct and you can hold the sleeping pill. Or, for example, if you are taking an "antidepressant" SSRI medication (such as Prozac, Zoloft or Lexapro) that is actually being prescribed to you to treat the symptoms of panic disorder, rather than allowing you to continue to experience panic attacks while you wait for the SSRI to take effect, panic can be very effectively blocked in the short term with what we used to call "minor tranquilizers" (such as Valium or Klonopin) while you wait the several weeks for the SSRI to begin working.

It is important, however, not to get too attached to these temporary quick fixes, because in the long run you will be much better off with the standard daily dose of the non-addictive medication that is best indicated for your condition, rather than taking pills on an as-needed basis, pills that work quickly, but typically not for long, and which are usually habit-forming. In fact, sometimes the early quick fixes actually sabotage the treatment plan (especially in individuals who are prone to substance abuse), so be sure to have an open and frank discussion with your physician if you begin to lose faith in the actual recommended treatment with its early side effects and modest, gradual gains, in favor of the sedatives and tranquilizers, and especially if you feel you are at risk of becoming addicted to those early band-aids. Overreliance on them may leave you quite disenchanted with the gold standard treatment, which works by a completely different (and ultimately, superior) mechanism and which can't compete with the "feel-good drugs."

The medication is not being taken properly and/or consistently. That is, doses are being missed. This is easy enough to do, especially if your regimen requires you to dose more than once a day, or with complicated regimens that require starting at a low dose and then titrating (adjusting) the dosage on your own, before you see the doctor again. If you are not used to taking medication you can simply forget to take it, or if the titration schedule is complicated you can become confused as to how and when to increase your dosage.

As far as effectiveness, it really doesn't matter what time of the day you take your antidepressant, and you don't even have to take it at the same time every day, but you do need to take the full dose every day. Sporadic use will diminish the benefits or even prevent any benefit, and with some medications and with regard to certain symptoms (such as anxiety and irritability), erratic dosing can actually lead to rebound symptoms in which you do worse.

Get a MedMinder or other medication dispenser; you can find them at any pharmacy and most grocery stores. They are basically medication trays consisting of a row of boxes labeled with the days of the week and sometimes with the corresponding times of the day, so that if you can't remember whether or not you've taken your medication for that day all you have to do is look.

With regard to medication regimens that change over time and that you need to ramp up or down between doctor's visits, make sure you ask your doctor to write down the dose-adjusting schedule in complete detail, especially if you are given free samples. When in doubt, call the prescriber's office and ask for clarification. Too much medication can lead to terrible side effects and too little wastes time.

The dosage is too low. For a variety of reasons, sometimes a patient will languish at a dose that is subtherapeutic, and whether it is the doctor's fault for not increasing the dosage when necessary or whether the patient doesn't return for his or her follow-up appointments in a timely manner, many people derive little or no benefit despite compliance with their treatment regimen because they are simply not taking enough. Sometimes an individual will do very well on a starting dose and months later, when s/he is feeling symptomatic again, not realize that the medication has stopped helping and that a dose adjustment is even possible. Be mindful of medication "poop-out." This is seen with Prozac and other SSRIs. A simple and modest dosage adjustment is typically sufficient to regain a positive response, and this doesn't mean that the medication will have to be increased in this manner indefinitely.

You are taking the wrong medication. When a medication stops working, sometimes a dosage change is sufficient, but other times a complete medication switch is in order. For reasons that are not understood, some medications just don't work as well for some people as they do for others; the choice of medication is often one of trial and error at the beginning.

To minimize the number of adverse trials, in choosing a medication for you your doctor will take into consideration the specific symptoms that are causing you problems, the potential for a given medication to cause unwanted side effects (certain patients may tolerate one potential side effect better than another), and your own prior medical history and family history. Family history is often helpful in determining how likely you are to benefit from treatment with a particular medication or class of medications in that, if you have a first-degree relative, such as a parent, sibling or child, who responded well to a certain medication, then starting with that medication may be a better approach than starting arbitrarily.

Your prescribing doctor can also consider augmentation strategies (combination treatments), and if you are still not responding, your primary care doctor may refer you to a psychiatrist for advanced psychopharmacologic intervention.

Untreated substance abuse is interfering with treatment. Abuse of alcohol and other recreational drugs will certainly sabotage treatment. Often patients are not completely honest with their healthcare provider, especially if they are new. Perhaps they feel embarrassed or ashamed, or maybe they are in denial or are not yet ready to give up their substance use. If you truly do not have a drinking problem, then removing alcohol from your diet should be no problem; you can always resume "social drinking" later, when your mood is all better. On the other hand, if you find it a challenge to forego drinking even for a few months, then you should seriously ask whether you are being completely honest with yourself.

Even if you do not believe that you suffer from chemical dependency, if you are having mood problems and the physical problems that go along with it (sleep disturbance, appetite and energy problems, difficulty concentrating, etc.) then taking a break from any and all other mood-altering substances before embarking upon a psychotropic medication trial almost goes without saying. In some cases just laying off the recreational drugs for a few days or a couple of weeks resolves the depressive symptoms (substance-induced mood disorders).

Even moderate use of alcohol can confound your new medication trial. Besides, if you are tired all the time and not sleeping well and you are irritable and your mind is full of negative and depressing thoughts, alcohol is contraindicated whether or not you choose to submit to a medication trial. And if you think that, "Alcohol is the only thing that makes me feel better!" then you really have something to discuss with your physician.

Psychological factors are overruling biological factors. Sometimes medications don't "work" because the problem is not primarily a physical one, even though you may be experiencing plenty of physical symptoms (e.g., because you are not sleeping well or eating right or stress is giving you headaches or indigestion, etc.). If your central nervous system is functioning within normal limits and your unhappiness has more to do with your environment, medications may not make much of a difference if you do not also address the specific stressors in your life. That includes personal relationships and work or school responsibilities.

That said, the SSRIs (Prozac, Zoloft, Lexapro, etc.) and other modern antidepressants can go a long way to block stress reactions, such as crying spells, feeling overwhelmed, angry outbursts, obsessing about your problems, dwelling on the past, worrying about the future, etc., and so even in situations which have more to do with difficult life circumstances than with unhealthy brain chemistry, a brief trial of medication can help--especially since severe stress induces psychosomatic changes, including in the nervous system, that can lead to self-sustaining illness, until the line between what is externally caused and what is internally caused becomes blurred and irrelevant.

If you do choose to see a psychiatrist the aim is for medication to reduce specific symptoms--target symptoms--enough to help you better cope with the situation in the short term and make necessary changes in the long term, but make sure you and your doctor have clearly set out what those target symptoms are and don't forget to involve your support system and consider counseling and other professional services, as appropriate. This way you will only leave the target symptoms to the medication and you will not neglect to address everything else that needs to be addressed, non-medicinally, to come out of your depression and anxiety. Some target symptoms will be completely addressed by medication, while others will improve with medication, allowing you to continue working on them with cognitive and behavioral strategies, including lifestyle choices and psychotherapy.

If dissatisfaction is significant enough, medication by itself obviously won't solve the problems at hand, and by adopting this holistic approach you will be less likely to be disappointed that the medication isn't helping if psychological factors outweigh physiological factors.

Other medications or medical conditions are interfering. Finally, very infrequently, there may be other physical reasons why you are not responding to antidepressant treatment the way you should be, but these reasons tend to be limited to certain physical aspects of your condition: sleep patterns, pain thresholds, energy level, appetite, for example, and not necessarily to more mental, global processes such as overall outlook, ability to cope, etc. And rarely if ever will a condition such as anemia, which will certainly make you feel tired, completely block any noticeable benefit from a medication designed to improve your mood. One notable, and not uncommon, exception would be hypothyroidism. Endocrine (hormonal) problems in general can have profound mood-altering effects and should be ruled out in patients in whom they are suspected. Check with your doctor.

Understanding PTSD (Post-Traumatic Stress Disorder)

2009-08-05T09:02:00.003-05:00

The term "PTSD" (Post-Traumatic Stress Disorder) has entered the popular vernacular, such that it is a term that is bandied about fairly commonly, and often incorrectly. Many times what people mean when they say "PTSD" is actually what psychiatrists classify as an Acute Stress Disorder (308.3), or an Adjustment Disorder with Anxiety (309.24), according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), the publication that mental health scientists use to operationally define psychiatric syndromes for the purposes of carrying out research.

In psychiatry there are no diagnostic blood tests or definitive biopsy samples; instead, diagnoses are arrived at by considering the presentation, history, and serial mental status examinations and by ruling out other medical conditions for which more objective laboratory tests and diagnostic procedures are available. Because mental health diagnosis is therefore inherently more subjective, in order to ensure that researchers were talking about the same clinical phenomenon it became necessary to devise a convenient method of classifying the various psychiatric disorders according to certain diagnostic criteria. This article briefly outlines the DSM-IV-TR diagnostic criteria for PTSD, so you can understand what doctors mean when they use the term and to improve communication between you and your healthcare provider, if you feel that you may be suffering from this disorder.

Before enumerating the established diagnostic criteria, it's worth emphasizing again that all DSM criteria were developed, by consensus, among panel members of the American Psychiatric Association for the purpose of improving communication among researchers and ensuring the cross-validity of their studies. The DSM is chiefly followed to make sure that one group of researchers studying "PTSD" is actually studying the same disorder as another group studying "PTSD," so that meaningful conclusions can be drawn and comparisons can be made.

Clinicians--practitioners seeing patients in a treatment, as opposed to a research, setting--are generally encouraged to follow the same guidelines, but the difference is that in the clinic we are less concerned with statistics and more concerned with patient outcome. Accordingly, if the DSM indicates that "4 out of 5 of the following criteria must be met for a diagnosis" of this or that disorder to be made, an experienced clinician is more than justified in substituting his or her own experience and judgment in making a diagnosis and proceeding with treatment if, for example, in any given case, only 3 criteria are clearly met, etc. In a clinical setting, it is more important to consider the entire presentation, including a patient's prior medical history and family history, than it is to be a stickler about the number of criteria that must be satisfied; the latter only becomes important in the context of conducting meaningful and valid comparative research.

That said, for any given psychiatric syndrome there are certain core criteria which, if absent, more or less preclude the diagnosis. With PTSD, the principal criterion is that the condition follows a traumatic event (hence "post-traumatic"). Without the presence of an obvious precipitating trauma, a diagnosis of PTSD cannot be justified. Likewise, the essential features of PTSD include the fact that the 1) trauma is followed by 2) re-experiencing, 3) avoidance, and 4) agitation.

Trauma. The person was exposed to ("experienced, witnessed, or was confronted with") a traumatic eventthat involved actual or threatened death orserious injury to the self or to others. Earlier versions of the DSM specified that the trauma had to have been of a universal character; i.e., an event or experience that anyone in similar circumstances would have found traumatic, and of a severity so as to be life-threatening. Updated criteria are less stringent, allowing for the mere fear of loss of life or limb in order for a person to have been sufficiently psychologically scarred so as to develop the symptoms of PTSD.

This more subjective interpretation of "traumatic" includes witnessing threatening or deadly events happening to others, in the absence of any perceived danger to the self, as well as merely hearing about violence or death done to others ("confronted with," although in this writer's opinion, this last form of trauma seems a bit broad, and at least to me suggests the presence of another, pre-existing anxiety disorder, and/or a personality disorder, or some other form of impairment in coping skills in such a vulnerable individual). PTSD can also develop in children who have experienced sexual molestation, even if it was not violent or life-threatening.

The second component to having experienced or witnessed a qualifying trauma is likewise largely subjective: "the person’s response involved intense fear,helplessness,or horror." Thus, even if the trauma was not life-threatening per se, so long as it was perceived as such and the person reacted with intense fear or horror, this criterion is considered met. The point is that the trauma is beyond ordinary. Classic examples are kidnappings, rape, and events of war. Working for a mean boss does not usually qualify, unless s/he literally torments you.

Once trauma has been endured, the PTSD syndrome itself consists of three major problems: mentally re-experiencing the trauma over and over again, engaging in avoidant behaviors to minimize traumatic recollections of the event(s), and persistent symptoms of increased physiological arousal.

Re-living the trauma. The traumatic event is persistently re-experienced in one or more of the following ways: recurrent and intrusive distressing recollections; nightmares of the event(s); flashbacks; and "intense psychological distress" and/or "physiological reactivity" at exposure to internal orexternalcues that symbolize or resemble the traumaticevent. Physiological reactions might include an elevated heart rate, sweating, chest pain, difficulty breathing, other symptoms of a panic attack, light-headedness, fainting, etc.

Flashbacks consist of sudden, discrete episodes during which a person acts or feels as if the traumaticevent were actually recurring. This can involve actual perceptual disturbances such as experiencing illusions and/or hallucinations, including those that occurupon falling into or awakening from sleep (hypnagogic or hypnapompic hallucinations, respectively) or while under the influence of an intoxicating substance. In other words, if a person only flashes back when drunk or half-asleep, it still counts.

Persistent avoidance. According to the DSM-IV-TR, three or more of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; the inability to recall an important aspect of the trauma (psychogenic amnesia); markedly diminished interest or participation in formerly significant activities; feelings of detachment or estrangement from others; restricted range of affect ("a numbing of general responsiveness"); and/or the sense of a foreshortened future (not expecting to live out a normal life span, failing to make distant future plans).

Persistent symptoms of increased arousal. Two or more of the following: difficulty falling or staying asleep; irritability or angry outbursts; difficulty concentrating; hypervigilance (paranoia); and/or an exaggerated startle response. Hypervigilance is treading with trepidation, metaphorically speaking, constantly looking over one's shoulder, half-expecting to re-encounter the trauma. It is especially common in attack victims and is often closely associated with being easily startled.

Duration requirement. The DSM also requires that, for any given psychiatric syndrome, symptoms endure for a minimum period of time in order to justify making a diagnosis. If symptoms last only a few hours or days and then disappear forever, we do not diagnose mental illness. For PTSD in particular, symptoms are expected to persist for more than one month before a person is considered affected.

Finally, the DSM requires that any mental health disturbance cause "clinically significantdistress or impairment in social, occupational, or other importantareas of functioning," a criterion that attaches to all disorders by definition, although here the requirement seems a bit redundant: it is unlikely that such would not be the case if all other criteria of PTSD are met.

Understanding "Adult" Attention-Deficit Disorder (ADD)

2009-08-04T12:14:00.006-05:00

Attention-Deficit Disorder (ADD, or ADHD--the H stands for hyperactivity, which may or may not be present) is a fad diagnosis in the U.S. By this I mean that, while ADD/ADHD is certainly a valid condition suffered by some individuals who require treatment for it in order to be able to function to their fullest capacity, there is also what I call an epidemic of public awareness regarding the condition that has led more people than ever before to wonder if they suffer from it, and after a little lay research, into thinking that they do, in fact, "have it."

These individuals then present to mental healthcare professionals reporting symptoms that are certainly consistent with ADD--mainly difficulty concentrating and getting things done--and more often than not, unfortunately, they end up diagnosed by well-meaning clinicians with a condition for which in many cases they do not, in actuality, need treatment. Bipolar disorder is another condition that is exceedingly over-diagnosed these days; the difference is that few individuals seek out a doctor to confirm a diagnosis of bipolar disorder, whereas many more people hear or read about ADD and convince themselves, and ultimately a prescribing practitioner, that they need treatment with stimulant medications.

This article is based on my personal experience evaluating and treating individuals who have presented complaining of inattention, specifically "Adult ADD."

Adult ADD vs. ADHD. One thing worth noting: there is no actual separate condition for adults as opposed to children; the term "Adult ADD" was coined to refer to adults who suffer from ADD because the disorder is one of childhood. That is, it presents very early in life as hyperactivity, inattention and/or impulsivity and tends to improve as a child matures (especially the hyperactive component, if it is present to begin with).

It is so principally a pediatric condition, in fact, that in the past, few individuals with bona fide ADHD who had been diagnosed in grade school or earlier and who had benefitted from treatment remained on medication into adulthood. For one thing, the hyperactive, "bouncing off the walls" component is just not seen in adults, who are better able and more inclined to control their physical behavior; moreover, even inattention often improves enough with age that in the past, most of these individuals were not treated into adulthood, but nowadays--in part because of the trendiness of the diagnosis, in part because problems concentrating do not necessarily improve on their own--more and more adults are being treated for ADD, hence the term "adult ADD."

What is truly disconcerting about this new trend is the number of adults being treated for "ADD" for the first time, as adults, after unremarkable childhood academic and behavioral histories, sometimes because their own children are diagnosed with "ADD." It is my firm impression that the vast majority of these latter-day diagnoses are false and that otherwise normally or even high- functioning adults are being labeled and treated for a condition they do not, in fact, have.

Because of the popularity of the diagnosis and the pitfalls of treatment with a stimulant medication (see below), I always approach every case of suspected "Adult ADD" with a certain amount of skepticism. Not only must other conditions be ruled out, but ADD itself must be ruled in, something I do not see happening much. Because of the highly subjective nature of the symptoms, I personally am very reluctant to assume that a person has ADD in the absence of more compelling evidence to that effect: i.e., objective, practical difficulties at work or school. Interpersonal problems are also common with ADD, but if there are only relationship problems and not also occupational (work and/or school) problems, I look for other, more likely explanations.

Here are some red flags that suggest that an individual who complains of ADD-type symptoms does not, in fact, have ADD:

No history of academic or behavior problems as a child. As stated, ADD/ADHD, with or without the hyperactive component, is a disorder that is present from birth (or at least the potential is there). It may not become evident or clinically relevant until the toddler is old enough to move around and grab things, when hyperactivity becomes a problem, or perhaps later in pre-school/kindergarten or during grade school, when inattention causes problems in the classroom, but whatever else, the disorder does not wait until adulthood to show up for the first time to cause problems. If a person was not singled-out by a parent or a teacher as an unusually impulsive, hyperactive and/or poorly attentive child early on and, moreover, if a person did reasonably well academically, it is extremely unlikely that any ADD traits that may be present were ever significant enough to warrant treatment, then or now.

The retrospective approach. The problem with trying to rule out ADD with a negative prior history is that most people who are presenting for the first time as adults with the complaint of poor concentration and the notion that they are suffering from ADD will in all sincerity adopt a retrospective approach: "Looking back…" they say, "I had problems all along--I just didn't know it!" And while it's certainly one thing to have had problems all along and not to have known what they were caused by, or that anything could have been done about them, it's quite another to have been oblivious to the problem itself, which is usually the case when people look back to try to find justification for a latter-day diagnosis of ADD. In that case, it wasn't a problem at all if no one (parents and teachers especially) was aware of it at the time. That doesn't mean that there isn't a problem now; it only means that the history is not consistent with a diagnosis of ADD. Other things need to be considered and ruled out.

In my practice I've even had adults with advanced degrees--relatively highly functioning Master's and Ph.D.s who were never identified as children and who were never treated throughout their long academic careers--tell me they are more-or-less convinced that they have ADD! When I've pointed out their many accomplishments having required no treatment at all, the standard response is that, yes, that may be true, but "It was really hard for me," and "I had to study extra hard to get by." That may also be true, but if a person is able to buckle down and put forth a little (or a lot) of extra effort and thereby overcome his or her problems with attention and concentration, then obviously s/he is not suffering from an organic brain syndrome that requires treatment with powerful stimulant medications in order to make it by, occupationally and socially. Because that is what ADD is, whether an adult or a child: an organic brain syndrome the symptoms of which require powerful medications in order to be alleviated. Individuals with bona fide untreated ADD suffer the absolute inability, due to a brain problem, to focus on any one thing for more than very brief periods of time, with obvious practical repercussions such as poor grades or loss of employment. They do not excel simply by trying harder.

Other, more common problems have not been ruled out. "ADD" may seem common because the diagnosis is so popular, but given the vast number of inaccurate and invalid diagnoses out there, it is not nearly as widespread as it appears to be. Consider the fact that in some countries ADD isn't even recognized as a disorder. While this is an extreme viewpoint with which I disagree, in those countries the official prevalence of ADD is zero: nobody has it! My point is simply that it cannot be a plague in the United States and non-existent elsewhere; somebody is getting the incidence wrong. Either way, mood disorders, for example, are much more common and are more easily, and therefore more reliably, diagnosed. The first thing I do when evaluating the symptom of difficulty concentrating is to rule out depression. Other possible causes of ADD-type cognitive deficits should always be explored and discussed during an evaluation. If you and your doctor never talk about anything else but ADD, the chances that you will discover another reason for your cognitive symptoms are not very high.

One general rule is that, throughout early and middle adulthood at any rate, untreated ADD symptoms will be more-or-less constant throughout, so that if cognitive symptoms are relatively new or tend to come and go, other etiologies are probably to blame.

The idea that one must have ADD because medication used to treat ADD works amazingly well. Another scenario: a person with trouble focusing takes someone else's Adderall and it works like a miracle to improve the "symptom" of inattention. [I place the word "symptom" in quotation marks because a finding is only symptomatic in the strictest sense if it is indicative of a larger problem. You may have legitimate difficulty concentrating after a poor night's sleep, or when you are under a lot of stress, or simply because of a noisy environment. In these instances the problem concentrating is still a problem that may need to be dealt with in the short term, but it's not a "symptom" in the sense that it indicates some underlying pathological process of some sort, of which the inattention itself is merely one manifestation.]

Part of the reason people believe that they had ADD all along and just didn't know it, and so were just working harder at doing well, is that people who have tried ADD medication notice a remarkable improvement in their ability to concentrate, such that with medication they don't have to try at all. This is because ADD medications are performance-enhancing drugs, and so this leads to the mistaken impression that one has ADD simply because one got an impressive response from medication.

The take-home message here is that any level of inattention, including that which is not symptomatic per se, will be rapidly and unequivocally alleviated by prescription medications for ADD. These medicines work to improve concentration, regardless of whether or not you have ADD, just like narcotic pain medications will numb you to physical discomfort, even if you are not experiencing clinically-significant pain, or prescription-strength sleeping pills put you to sleep, even if you are not suffering from insomnia. Stimulants are powerful in the same way: they help you pay attention, whether you need the help or not. And so, just because the medication helps with concentration does not mean you suffer from the disease of inattention.

Does treatment with stimulants make it easier for individuals who nevertheless do not have ADD to focus? Certainly it does; but that is true for everybody. Meanwhile, the potential liability of these medications is serious. They should never be prescribed lightly, and in particular, if a person is no longer in school or is in no danger of being demoted at work or losing clients or customers because of mistakes made due to inattention, treatment with pharmaceutical-grade speed (many ADD medications are actually amphetamines) is simply not warranted.

If you can buck up and plough through, then you should just do that, because 1) there is almost certainly nothing wrong with your brain function and 2) the physical and mental side effects of treatment with stimulant medications are not worth it, even if you are fortunate enough not to be prone to chemical addiction.

The fact that these medications--many of which are chemically related to the "speed" that is purchased on the black market for recreational abuse--also increase energy and motivation and elevate mood, at least initially, make them very popular among those who take these medications, contributing to a widespread tendency to overuse them, even by people who have no intention of doing so.

Like father, like son. "My son has ADD and I think it must run in the family." In today's climate in which children are routinely over-diagnosed with ADD/ADHD even more so than adults, another very common scenario I've run into time and again is when a parent, with an unremarkable history as above, is referred for an evaluation for ADD because his or her child was recently diagnosed, and the parent identifies with the notion of problems concentrating and getting things done.

This is, after all, one of the reasons ADD is such a popular diagnosis, because so many people agree that, at times, they experience significant problems keeping on task. But while most of us experience disorganization and the inability to multi-task from time to time for a variety of reasons (being tired, for example), we are not all suffering from severe organic brain dysfunction, no more than being forgetful and absent-minded means we are all developing Alzheimer's Disease.

It's true we all grow increasingly forgetful as we age, yet thankfully most of us do not go on to develop dementia. Likewise, many of us experience sometimes dramatic mood swings, but we don't immediately think we may have undiagnosed bipolar disorder. Similarly, we all become unfocused and unorganized at times, yet most of us do not suffer from ADD. And yet, debriefing individuals from the notion that they have ADD remains a challenge, because unlike with bipolar disorder and Alzheimer's, people don't seem to mind believing they might have ADD, especially if there is an easy and impressive way to treat it.

When a family member is diagnosed with any unwanted medical condition we don't immediately and excitedly think, "I have it too! Treat me!" But for some reason the core symptom of ADD, inattention, seems universal enough, and the easy, highly effective and well-advertised available treatments for it are very tempting to otherwise healthy individuals.

Finally, when a person is prescribed stimulant medication, it is no surprise that it works remarkably well at improving concentration. But stimulants actually do much more: they temporarily increase energy and motivation, and they elevate mood, so you are not only focused, you are alert and focused, and boredom (which itself can lead to distraction) simply evaporates on these medications, which lends a sense of purpose and accomplishment to even the most mundane of tasks. In fact, one potential side effect of stimulant medications is becoming hyper-focused, where you spend too much time on a task, sometimes embroiled in irrelevant details, and it can actually become counter-productive because your work becomes over-inclusive and inefficient.

Becoming hyper-focused is the least problematic of the common stimulant side effects. Stimulants cause insomnia, anorexia and various physical effects: headaches, dry mouth, queasiness, jaw clenching, intestinal cramps. Psychologically, they are notorious for increasing irritability and often lead to markedly increased argumentativeness and in some cases overt hostility, even violent behavior. In susceptible individuals, stimulants induce manic episodes and psychotic symptoms (paranoia and hallucinations are quite common). And then of course there is the "crash," when the effects of medication wear off and you get the opposite of everything: lethargy, hypersomnolence, rebound distractibility, even clinical depression in some cases.

Another very important thing to keep in mind if you are being treated with a stimulant for ADD: starting and slightly higher doses will always help significantly with inattention (the therapeutic effect), whether you have the disease or not, but you will rapidly develop tolerance to the euphoria that the medications induce. This euphoria (a supratherapeutic effect) comes in the form of increased energy, motivation, and enthusiasm for the task at hand, studying, etc. If the dose is too strong you will actually feel "high" and you may find yourself talking more and sleeping less and having a lot of fun! The higher you go, of course, the worse the crash later.

The thing to avoid is increasing the dose when you begin to develop tolerance to the supratherapeutic, euphoric effect. Many patients make the mistake of thinking that the medication "is no longer working" because it feels different. Suddenly they are no longer as interested in working all night, or they aren't as motivated as they were when they first starting taking the medication. This is normal and does not mean that a dosage increase is indicated. The first time you take a stimulant medication, no matter how modest the dose, you will likely experience some degree of euphoria. But even if you truly have ADD, when this stimulated effect wanes, you will still be able to focus on the task at hand because of the medication. Remember the goal is not to be distractable; it is not to be super-focused and super-motivated. The dose may very well need to be adjusted initially to best suit your needs, but ideally it should be working in the background, helping you without your being aware of it, or "feeling" anything. You are aiming for a reduction in symptoms, not the induction of a stimulated state of awareness (which, again, is more-or-less unavoidable the first time you begin taking these types of medications, so you may very well confuse that stimulated state with the actual intended therapeutic effect). Beware the false notion that the medication has stopped working because you can't feel it anymore and resist the temptation to ask your doctor to keep adjusting (i.e., increasing) the dosage over time as you develop tolerance to the stimulating effect, unless you are truly re-experiencing symptoms.

People do the same with anxiety medication. They may start taking Valium for panic attacks, and the first time they take it they feel a wave of relief in the form of mild sedation and muscle relaxation. Not only are they not panicking, but they are actually "mellow." Over time, with continued dosing, the brain quickly adapts to the sedating effect, and a person will not feel anything after taking a dose. If s/he has confused the initial, supratherapeutic effect with the intended effect, that person might then complain that the medication isn't working anymore: "I don't feel anything," forgetting that the whole point was not to feel anything: not to feel panic! Valium will continue to block panic attacks long after it stops making you feel like you are under the influence. Stimulants work in the same way on the opposite end: they will cease abruptly and noticeably elevating your mood even as they continue to allow you to remain alert and focused on whatever it is you are trying to focus on.

And don't forget the valuable effort you put into everything you do: surely if you are trying to stay focused, you will much better be able to do so with the help of medication, no matter how little you have taken, no matter how long you have been taking it. Most people who choose to be conservative with their regimen do very well, indefinitely, on very modest doses compared to other individuals who, abetted by their doctor, end up on doses that are triple and quadruple what they started out on, and even higher. It is these patients who suffer the worst of the pitfalls of being on these types of medications in the first place.

There is no reason a pill should do everything for you, especially when it comes to your mind. Remember that the more control a pill has over your mind, the less control you have. If instead of helping you stay focused the medicine is forcing you to pay attention, you will become hyper-focused. If the medicine is inducing you to overreact, you will hurt someone you love. And if you are already prone to substance abuse, you may very well lose control and possibly wreck your life.

How To Treat Premature Ejaculation (Medical Model)

2009-08-02T12:25:00.001-05:00

When I was a medical student in the early nineties, they were still teaching us the coitus interruptus technique of addressing premature ejaculation ("withdraw and apply pressure"), despite the availability at that time of selective serotonin reuptake inhibitors (SSRIs, for the treatment of anxiety and depression). While there are certainly various psychological and physical techniques that do not involve the administration of a prescription medication, the most effective, full-proof method of stopping premature ejaculation (PE) can be found under the medical model. The drawbacks include the potential for side effects (see below), cost, and the fact that the treatment can only be prescribed by a doctor, but the benefit is that it works, every time.

The administration of a very low dose of an SSRI such as Prozac, Paxil, Zoloft, Lexapro, Celexa, Luvox or another medication with SSRI properties such as Effexor or Cymbalta works well (older, tricyclic antidepressants are not recommended for this indication because of the greater potential for side effects).

Delaying a person's orgasm (women who take SSRIs are equally affected, by the way) is actually itself considered a "side effect" in the context of treating depression and anxiety. What is considered medication-induced "sexual dysfunction" is actually the desired effect in the context of treating PE. In this context, the dysfunction is PE and the medication-induced delay is a benefit.

Because such a small dose is needed, side effects are minimal. Most commonly they include headaches, queasiness, and diarrhea or constipation, but if they occur, they will be mild and short-lived. The body will quickly develop tolerance to these common side effects, whereas delayed orgasm (which is itself considered a side effect of these medications in the context of treating depression and anxiety), tends to persist.

Also because the recommended dose is so small (10mg or less of Prozac and Paxil, for example; 25-50mg of Zoloft, depending on body weight), there will likely not be a significant change in your mood over the long term, but you might notice decreased irritability even at the very low doses, especially at first. Any mood effects will tend to be beneficial: a higher threshold for tears, a lower propensity to worry, or become upset, etc.

If you are not clinically depressed or there is nothing seriously wrong with your mood, no harm will come from taking an SSRI for the indication of premature ejaculation, and there will be no long-term consequences when/if you decide to discontinue using the medication. Always confer with the prescribing physician, however, whenever you are contemplating making any changes, including and especially discontinuing taking the medication. If you have been taking a higher dosage for a significant amount of time, there can be very brief, rebound irritability or anxiety if you stop this type of medication abruptly, so your doctor may recommend lowering the dosage gradually over time before stopping it; it all depends on the exact medication and the dosage you end up on. Perhaps more importantly, how your mood will react on and off the medication will depend on the presence of any underlying mood problems, diagnosed or undiagnosed, which may be related to a family history of depression or other mood problems. A family doctor is well-qualified to prescribe SSRIs for the treatment of both premature ejaculation as well as uncomplicated clinical depression, so you won't necessarily need to see a psychiatrist.

Another potential side effect to watch for on these medications is weight gain, especially with Paxil and Lexapro. Even at low doses sometimes there is a significant change in weight. The change will occur over time, however, so being mindful and stopping the medication early if it is causing weight gain is enough to prevent any long-term weight change. Waking up in the middle of the night is another common side effect that might last several weeks on these types of medications. Check with your prescribing doctor about what else to expect, but most people on nominal doses for PE do well exploiting the sexual side effect of this medication, without reporting any noticeable changes in their mood (certainly no negative changes) or other physical effects.

The medication is usually recommended once a day, every day, at any convenient time of the day, but most of these medications will also work on an as-needed basis (for PE), if you take them a couple of hours before anticipated sexual activity.

You may actually experience complete anorgasmia (the inability to climax at all); this is completely reversible and will improve spontaneously over time by holding the medication, but if this happens, simply halve your dosage and try again. Paxil is the most potent serotonin reuptake inhibitor, so it is associated with the most potent delay.

Finally, another aspect of the "sexual dysfunction" SSRIs cause involves decreased libido, or sexual arousal (which infrequently leads to erectile dysfunction in some men who may already be vulnerable to that effect).

Obviously, if this were a significant effect it would obviate the usefulness of using SSRIs to treat PE. The thing to know is that, for the vast majority of men, including older men who may already be experiencing some degree of erectile dysfunction (ED), sex drive is strong enough that any amount it is decreased on SSRIs is usually not a problem, if it is even noticeable. Even older men who complain of ED do not complain of problems with desire; it is the relative inability to physically respond to that desire that is the problem. Similarly, an otherwise healthy male can experience significantly delayed orgasm with no practical effects on the strength of his erection, and no problems with sex drive per se. (Women, in particular older, postmenopausal women, tend to report more problems with the complete loss of desire on these types of medications).

Exceptions do occur, of course; discuss any noticeable changes with your prescriber, but rest assured that all of these sexual side effects are completely and rapidly reversible by lowering the dosage or stopping the medication entirely.

How To Know If You Need Prescription Medication for Depression

2009-08-02T12:18:00.003-05:00

We've all experienced depression that comes and goes: mild, spontaneously low moods that get better all on their own and more moderate depressive episodes that are the result of traumatic life events (physical illness, loss of a job, the death of a loved one, divorce, etc.), but sometimes depressive symptoms like feeling tired and loss of appetite do not merely accompany physical illness, but represent physical illness itself. We call this clinical depression, to distinguish it from the doldrums that are otherwise commonly experienced, "the blues" that otherwise do not require formal treatment because they get better on their own.

If you are depressed and you think you might need to see a doctor about it, chances are already pretty good that you may be clinically depressed, meaning that your mood problem is more than situational, or a response to everyday stress, but has become something physical. This article will help you sort through some preliminary questions to help you determine if what you may be suffering is due to (for lack of a better term) a "chemical imbalance."

Many people suffer unnecessarily--sometimes for years--with clinical depression and don't even know it. They may think that the way they feel is just part of life, or they may have been depressed for so long that they have actually grown insensitive to their symptoms and not even realize that, for example, their energy level is much lower than normal and their ability to enjoy life is seriously compromised. I've interviewed patients who were obviously depressed, individuals who were overtly suffering from major depression that could almost be diagnosed on sight, who nonetheless denied ever experiencing depression when asked! But if you know you are depressed and just aren't sure whether you have crossed the line into a medical condition, consider the following:

When in doubt, consult with a professional. In other words: see a doctor. See a doctor, see a doctor, see a doctor, because only a qualified physician can diagnose, and ultimately treat, major depression. If you already see a therapist or counselor or have access to a nurse, social worker or some other type of mental health professional, you may want to start there.

Symptom severity. How severe are your symptoms? This is the most important consideration, because regardless of the cause of your condition--whether purely physical versus largely situational--the decision to treat with medication will ultimately be based upon 1) your degree of impairment and 2) the likelihood that your symptoms will improve on their own in a reasonable amount of time. Are your symptoms interfering with your ability to function at work or school, or are they negatively impacting your relationships? One criterion professionals use in diagnosing clinical depression and recommending medical treatment is the fact that mood symptoms are interfering with "normal social and occupational functioning."

Suicidal Ideations. This symptom is, by definition, severe. While most of us have, at one time or another in our lives, experienced fleeting, passive thoughts along these lines, it is never "normal" to seriously contemplate suicide. Serious thoughts involve formulating a plan, even if it's only imagining what you would do, or obsessing on thoughts of harming yourself. In the event of so-called active suicidal ideations, seek help immediately.

Many people admit to suicidal thoughts when depressed but believe that they would never act on them (called "passive suicidal ideations"). While this may be somewhat reassuring, remember that suicide attempts are often impulsive acts. Serious, ongoing thoughts of death that are part of a depressive episode always indicate the need for professional treatment, if not actual medical management.

Length of illness. How long have you felt depressed? Major depressive episodes typically last 6-9 months, but can last a few weeks to many years. The longer you have been waiting to "feel like yourself again," the more likely it is that there is something biologically awry. And while untreated major depressive episodes typically resolve on their own--eventually--they do tend to recur, and without treatment, successive episodes tend to be longer and more severe.

When other remedies aren't working. When symptoms are moderate to severe and things like exercise, stress reduction, talk therapy, and even over-the-counter homeopathic remedies (like St. John's Wort) have failed, a medical consultation may be in order. If you are aware that your mood is suboptimal and you are bothered enough by it that you have tried specific things to improve it with no luck, there's a good chance that something is not quite biologically right with you at the moment. If things are really getting bad, you may find that you can't even bring yourself to do certain things that might make it better, like keeping up with your exercise routine; you just don't have the energy.

Family history. Another indication that what you are experiencing is largely physical, as opposed to situational, is a positive family history. If you have a relative that has been diagnosed with clinical depression, you have a significantly higher probability of being affected sometime in your lifetime yourself, particularly in the case of a first-degree relative (parent, sibling, or child).

If you are having serious symptoms and you have any family history at all, you should be evaluated, and especially if you have a family member who was successfully treated you should definitely consider being treated yourself. Moreover, there is evidence to suggest that if a family member did well on a particular medication, you are more likely to do well on the same medication, so keep that in mind when discussing treatment options with your physician.

Any family history of suicides, completed or attempted, in relatives who may or may not have been diagnosed or treated is also very important to discuss with your doctor. Of course, family history is not always present, even in cases of unequivocal major depression, so you can never rule it out based on a negative family history.

No reason for feeling down. When depressive symptoms are moderate to severe and they persist, but there is no obvious cause, or stressor, a physical condition may be suggested. If you feel negative and you are having crying spells "for no reason," the reason may be biological. Many women are familiar with this phenomenon as part of premenstrual dysphoria (PMS, PMDD), when hormonal changes result in increased anxiety, irritability and tearfulness when nothing in the environment is specifically provoking those heightened emotional reactions. In this case we say the mood problem is endogenous, because it is caused by factors within the body.

Not all endogenous mood episodes require treatment with psychotropic medications, of course; many such episodes are mild or transient or both, and so do not require medical treatment, but some episodes are moderate to severe and protracted and so medical treatment is at least worth considering, if not vital. Hormonal shifts are one common cause, but other forms of clinical depression are thought to originate in the central nervous system itself and are to-date poorly understood. Both men and women who are predisposed can experience these endogenous changes in mood, which, unlike premenstrual symptoms which typically last only a few days, can last weeks, months, and even years.

While spontaneous, endogenous mood episodes indicate a potential need for medical intervention, the thing to keep in mind here is that even situation-specific despair can sometimes require treatment, if the symptoms are severe and do not improve on their own over time. Many major depressive episodes have been precipitated by grief, for example, where losing a loved one to death or divorce triggers a depressive reaction that starts exogenously, but that essentially becomes maintained and exacerbated by endogenous processes. However it starts, when depression becomes progressively devastating to the person who is suffering, medical intervention is warranted.

Neurovegetative signs. Besides the severity of the symptoms, the nature of the symptoms themselves can be important clues. An abundance of so-called "neurovegetative symptoms" strongly suggests physical disease. These are symptoms of the body, as opposed to the mind. Things like psychomotor retardation, which is being slowed down, consisting of any one or more of the following: low energy, difficulty concentrating, finding that it takes great effort to get out of bed, to stay active, even to talk and think, at the more extreme end (if this is the case, medical treatment is definitely necessary!). Other neurovegetative signs of depression include loss of appetite with significant weight change, loss of sexual appetite, and trouble sleeping, or sleeping too much. On the flip side, weight gain is sometimes seen in depression.

The more physical manifestations there are in general, the more physical the problem, obviously. So if there are crying jags that don't stop and fairly rapid, unintentional weight changes in either direction, with disturbed sleep, low energy and difficulty concentrating, a physical examination is in order, at the very least. There are a number of medical conditions (apart from major depression itself) that can present in this way, including endocrine problems, that can easily be ruled out with simple lab tests.

Early Morning Awakening. Perhaps the most common physical manifestation of depression is insomnia. It is so common, however, both in the context of depression and in persons who are not depressed, that by itself insomnia is hardly indicative of a need for the medical treatment of one's mood. However, while there are various kinds of sleep disturbances in depression, one special kind of insomnia that is classically seen and which strongly suggests physical depression is early morning awakening. This involves routinely waking up, completely and spontaneously, several hours before the alarm clock (3 a.m. or 4 a.m., usually), and being unable to get back to sleep. This is a "textbook symptom" that isn't always present, but when it is, it strongly suggests physical depression over situational depression, which is more commonly associated with difficulty falling asleep at the beginning of the night (for example, due to excessive stress and worrying).

Depression worse in the morning. Another hallmark of endogenous depression is that it is much worse after sleep. Turning the brain off for prolonged periods during sleep exacerbates endogenous depression, such that people with physical depression usually feel their worst first thing in the morning (or after a long sleep), and then, as the day goes on, the brain revs up, energy increases and they feel a little better. Whereas depression that is primarily due to an unhappy life situation (a stressful job, a bad marriage, etc.) usually adopts the opposite pattern: mood becomes progressively more negative and agitated as the day, and the day's problems, wear on.

Pregnancy. Depressive symptoms following a pregnancy due to sudden hormonal shifts at delivery are quite common and do not always represent full-blown postpartum depression; the "postpartum blues" are typically brief and mild and spontaneously improve over a few days, but any such depression is by its nature physical, should be closely monitored, and if moderately severe or persistent, treated. A woman who has just given birth should have a very low threshold for discussing her mood symptoms and the potential need for treatment with her obstetrician.

Similarly, significant, persistent changes in your mood following surgery or some other major medical procedure or medical event, including the initiation of a new prescription medication, strongly suggests the onset of a physical depression that may or may not require treatment with a psychotropic agent. In some cases it's as simple as stopping a new medication that's causing depression; in others it's a matter of addressing some other complication of treatment.

Anhedonia. Other cardinal symptoms that are not themselves strictly physical but that are clearly associated with neurological and biochemical deficits and that therefore suggest clinical, or physical, depression, include a loss of the ability to experience pleasure (called anhedonia), feelings of excessive guilt, excessive regret, hopelessness, helplessness and feelings of worthlessness. Whenever any of these are present, especially when they are excessive, even irrational, major depression is suggested, and no amount of talk therapy will make them better.

Whatever your concerns or suspicions, if it's getting worse, consult with a professional. And if you have experienced prior episodes--even if they eventually got better on their own (as most do)--get a consult, because untreated major depressive episodes become more frequent and more severe over time.

There is an adage that says that if you show a carpenter a nail, he'll hammer it, because a) he has the hammer already in hand and b) that's what carpenters do. This truism extends to all professions. If you consult with a psychiatrist, the chances are very high that you will be offered prescription treatment for your symptoms. In part this is due to an honest selection bias: if you have taken the time and trouble to make an appointment with a mental health specialist with prescriptive authority, chances are your symptoms are severe enough that you require some form of specialized treatment, and if you have been referred there by your primary care physician, chances are that other options have been explored and exhausted. But some people end up talking to a physician who routinely prescribes psychotropic medications who don't necessarily need psychotropic medication, so be sure that your doctor engages you in a comprehensive discussion about your situation before jumping to mental health treatment options that require a prescription pad.

Side Effects A-Z: Minimizing Sexual Dysfunction (Anorgasmia)

2009-08-02T12:14:00.002-05:00

The selective serotonin reuptake inhibitors (SSRIs, such as Prozac and Zoloft) are the safest and most widely prescribed antidepressant and anti-anxiety medications available and a real boon to millions of patients worldwide. They are highly effective, non-addictive, and they save lives. Unfortunately, among the most common of side effects induced by these medications are those that typically prove to be among the most recalcitrant: sexual dysfunction, in the form of 1) a relative inability to climax (delayed orgasm or complete anorgasmia) and/or 2) decreased sexual arousal, including in a minority of males, erectile dysfunction.

While other side effects caused by these medications, such as queasiness, headaches and diarrhea, resolve rapidly and, for all intents and purposes, completely with continued use, sexual dysfunction is one of those side effects that can persist for many months, or even indefinitely, with little or no improvement (like weight gain, temperature dysregulation and disruptions in the sleep-wake cycle--see my other articles).

Sexual dysfunction as a side effect is one of the leading reasons people who are otherwise benefitting from treatment with psychotropic medications seek to discontinue them. For others, who recognize that they need treatment with psychotropic medications to function, sexual dysfunction is something they "learn to live with." This article addresses how to avoid or at least minimize sexual dysfunction, when treatment with these types of medications is deemed valuable and necessary.

Don't take an SSRI. If you require treatment with psychotropic medication, one obvious strategy is avoiding those antidepressants that are known to cause sexual dysfunction. The problem is that most of them cause it. While it is true that Wellbutrin, for example, does not cause sexual side effects, Wellbutrin is not an SSRI; Wellbutrin does not act on the serotonin system. It is by increasing the neurotransmission of serotonin that sexual dysfunction is induced. However, it is also by increasing the availability of serotonin that we get effects such as protecting a person from crying spells, decreasing irritability and blocking panic attacks. So, while Wellbutrin is a good antidepressant for some individuals who are not particularly anxious or irritable, it doesn't do much for these symptoms in others, and can actually make anxiety and irritability worse in some cases. So, while avoiding manipulating serotonin levels is one certain way to avoid sexual dysfunction, there are relatively few available medications that work this way, and the ones that do often are not indicated.

Wait for it to get better. This is obviously the easiest thing to do, and sometimes it even works! Almost all side effects do improve over time, most fairly rapidly and significantly, if not completely. Unfortunately, sexual dysfunction tends to persist, often indefinitely. It does get somewhat better for most people given enough time, however, so a conservative "wait and see" strategy is not entirely unreasonable, especially for those patients who are suffering fairly serious mood problems for whom sexual health can wait. For those individuals who are severely depressed, sexual arousal actually often improves with treatment of their depression; anorgasmia (the inability to climax) is usually the complaint among most patients who are experiencing sexual dysfunction due to medications. The good news is that all sexual dysfunction side effects are reversible with discontinuation of the offending medication, no matter how severe they are and no matter how long they have been going on. Even after months or years of sexual dysfunction due to treatment with medication, a person will revert to his or her baseline upon discontinuation. Always, always confer with your prescribing physician, however, BEFORE you adjust your psychotropic medication, especially discontinuing it.

Lower the dose. All side effects are more-or-less dose-dependent. That is, they are first noticeable when medication levels reach a certain threshold, and then they intensify with increasing doses beyond that. In general, the greater the dosage, the greater the potential for the side effect, and the more intense the side effect is likely to be when it occurs. For example, in a person taking it for the first time, a very low dose of Prozac may not cause any unpleasant GI effects; a higher dosage may lead to queasiness; a much higher dosage will induce vomiting. One way to avoid vomiting is to begin at a low dose and increase gradually over time. If they continue taking it regularly, eventually most people become more or less immune to the nauseating effect of this drug.

Similarly, we can expect sexual dysfunction to get worse with escalating doses. The difference is that sexual dysfunction often becomes "complete" at fairly low doses: an individual can lose her sex drive altogether or an individual becomes completely anorgasmic sometimes with the very first dose. Lowering the dosage isn't an option, and since the side effect may not improve appreciably over time, the "start low, go slow" strategy that works so well with other side effects, such as queasiness and diarrhea, just doesn't apply.

Try a different SSRI. If you're on the lowest effective dose and you've waited long enough and your doctor doesn't feel that you can or should avoid an SSRI altogether, know that different SSRIs will tend to cause varying levels of sexual dysfunction among different people, so if one medication is causing severe problems for you in this area, discuss switching to a different medication with your doctor. Among SSRIs, paroxetine (Paxil) is the most potent inhibitor of serotonin reuptake in vitro, which, milligram-per-milligram, translates into some of the most impressive, and problematic, sexual dysfunction clinically. In my experience, it's the worst one; I avoid prescribing it when sexual dysfunction is a key concern. On the other end of the spectrum, citalopram and escitalopram (Celexa and Lexapro) seem to be among the least problematic in this area, which is not to say that they don't generate complaints as well.

The choice of antidepressant is a complex one. There are many factors that need to be considered, including target symptoms, personal and family history and the potential for other side effects, so you should always confer with your treating physician in choosing the medication trial that is right for you, but know that not all of these medications are created equal when it comes to inducing sexual dysfunction.

Timing. The SSRIs are taken daily, sometimes in divided doses and, when suitable blood levels are reached and a person has been taking the medication for long enough for certain physiological changes to take place in the brain, the beneficial effects of these medications on a person's mood last all day. Like the effect on a person's mood, sexual dysfunction will also tend to occur at a more or less constant level while a person is taking the medication. However, with regard to difficulty achieving an orgasm--which, again, is by far the most common complaint among patients taking these medications--timing can actually make a difference.

Although it may always be more challenging to achieve an orgasm while taking an SSRI, there are times when it will be virtually impossible, and one of those times is immediately after dosing with the medication, when the level of the medication in the bloodstream is essentially peaking. If you take 200mg of Zoloft, for example, and then attempt to climax half an hour or an hour or two later, you will experience monumental difficulty doing so, and will probably quit trying, very frustrated. If, on the other hand, you attempt to climax as far removed in time from your last dose, you will have a significantly improved chance of succeeding (there is no guarantee that you will succeed, of course, but your chances will be much greater).

Because of the dose-dependent aspect, one strategy for the person who otherwise needs 200mg of Zoloft a day is to divide the dosage into 100mg twice a day. In general, it will be much easier to climax after 100mg than after 200mg. On the other hand, someone else may find it best to take their 200mg in the morning as usual and attempt to climax either first thing in the morning (before that dose) or at the very end of the day. Check with your doctor, adjust your dosing schedule and do what works best for you. Obviously, having to schedule times for sexual activity may not be convenient or feasible for a lot of people, but at least knowing that there are zones of time during which you are more or less likely to be able to climax can save you a lot of frustration and also help you to be more patient while you wait the weeks or months it can take to see some spontaneous improvement of this bothersome side effect.

Antidotes. There are various other prescription medications that can be added to your SSRI by your doctor for the specific purpose of reversing sexual dysfunction. Wellbutrin is one medication that can be added for this purpose, Buspar is another, and there are others. This is a hit-or-miss strategy; the addition of these adjunct medications can significantly improve sexual dysfunction in some individuals while making no difference at all for others. The downside is that it involves taking yet another medication, with all of the cost and inconvenience and potentially new side effects taking a prescription medication can entail, but when it works to reverse the dysfunction, most people feel that it's worth it.

A note on erectile dysfunction (ED). Men who experience ED as a result of treatment with these types of antidepressants and anti-anxiety agents are almost always men who have either previously experienced ED or who are otherwise at risk for it: older gentlemen with histories of high blood pressure, high cholesterol and/or diabetes, for example. Because SSRIs can diminish the libido (sex drive), lowered arousal can contribute to some degree of ED, but the fact is that most males will not experience a complete loss of their sex drives (that effect is more common in females, especially older, postmenopausal women). Even older men with established ED will rarely complain that SSRIs have completely deprived them of their interest in sex or that, as a result, their ED is noticeably worse; rather, these men are likely to complain about what almost all individuals experiencing medication-induced sexual side effects complain about: the decreased ability or relative inability to climax.

Of course, for those few individuals for whom ED does seem to be a consequence of treatment with an SSRI, any of the above strategies apply, but if there are no other medical contraindications, using medications approved for the treatment of ED is certainly worth considering, and the success rate is likely to be greater than using adjunctive medications in an attempt to reverse anorgasmia.

How to Avoid Medication Side Effects ("Start Low, Go Slow")

2009-07-22T11:41:00.001-05:00

The frequency and intensity of side effects are directly proportional to the amount of medication taken (dosage, especially relative to an individual's body weight) and the rapidity with which it is absorbed. The more milligrams you take at one time and the faster you absorb them, the greater the potential for side effects.

So, to minimize side effects in general:

Take the lowest effective dose, and always start out with the lowest recommended dose and build up from there as tolerated and as recommended by your doctor, until you get the symptom relief you are seeking. It may be a good idea at the very start to halve the recommended dosage and take a few "test doses" that may not get the job done, but that will gradually introduce your body to the new substance. Once you are used to a medication, you develop a tolerance to many of the most unpleasant side effects, such as nausea, diarrhea and headaches. Generally speaking, the more unpleasant the side effect, the faster it improves, if it's going to improve at all.

Even at the target dose, divide the dosage into two or more separate administrations if your doctor says you can. Taking 100mg of anything in a single dose is always going to cause more stomach upset (or whatever the side effect may be) than taking 50mg twice a day, or 25mg four times a day. Dividing the dose is less convenient and can cause you to forget doses, which is countertherapeutic, but if you can remember and be disciplined and consistent, many side effects can virtually be eliminated by splitting doses.

Along the same lines, if you are taking more than one medication and it's not too inconvenient, try to avoid taking multiple medications at the same time. Side effects from one compound can be additive and even synergistic with those from another. Even waiting as little as ten or twenty minutes between one medication and the next can save you unpleasant physical sensations that otherwise come with the territory.

If it doesn't interfere with absorption in a negative way, take medication with food or milk (be sure that minerals in the food don't block absorption of the medicine!), and not just "with food," but after a substantial meal; i.e., on a full stomach. For example, taking ibuprofen on an empty stomach can cause painful acid indigestion, which can lead to peptic ulcer disease in some people, but taking Advil on a full stomach protects the stomach lining. For other medications that don't necessarily irritate the GI tract directly, food and/or milk coat the lining of the small intestine, simply slowing absorption, which slows the onset of side effects like nausea and headaches. Of course, the onset of efficacy is also slowed; something to consider if you are taking pain medication.

If you discontinue a medication for awhile and then resume taking it, treat it as though you were taking it for the first time and "start low, go slow." The longer you have been off of a medication, the more your body has lost whatever tolerance it had built up against the side effects.

Children and the elderly are often more sensitive to medications than others, and often require much lower doses than otherwise healthy adults. This has to do with factors as varied as body weight and liver function; your doctor will know the best dose for you, but keep this principle in mind with over-the-counter products.

Many side effects are subtle enough that they can be slept through! If not otherwise contraindicated, take your pill at bedtime and snooze through what you might otherwise have been awake to notice (we're talking generally mild, immediate effects here). Some side effects are aggravated by a lot of physical activity; you may not feel tired and dizzy on a medication unless you are standing up and sitting down and otherwise physically active after taking it. Narcotic pain medications are known to cause nausea, but the nausea is almost entirely dependent on moving around; if you lie still, the queasiness disappears. Taking medication at night or near bedtime can obviate the problem. If a medication makes you tired, why not take it when you're supposed to be relaxing anyway?

How to Maintain Good Sleep Hygiene

2009-07-22T11:31:00.006-05:00

By S. Silva M.D.

Insomnia is a common complaint in any doctor's office and by far one of the most common complaints in psychiatry. While there are various medical conditions to be ruled out (such as obstructive sleep apnea), the vast majority of cases are either mood- or stress-related, or else have no obvious cause. Many cases are chronic. Likewise, while there are many medications available to treat this condition, medications are not without their side effects and, for chronic sufferers, even the most effective sleeping pills lose their efficacy over time.

Regardless of whether or not you choose to submit to pharmacological or other medical treatments for insomnia, a good starting point is what health care providers call good "sleep hygiene." These are important tips that should be followed by everyone, whether you suffer from clinical insomnia or just the occasional fitful night of sleep (or the lack thereof). Sleep hygiene refers to one's habits concerning sleep.

Avoid caffeine and other stimulating substances before bedtime. Not only will caffeine keep you alert, but it is a diuretic. Diuretics promote the excretion of water by the kidneys, making middle-of-the-night trips to the bathroom more necessary. This is already a problem for many older adults.

Avoid excessive use of alcohol. Alcohol of course is itself sedating (it's one of the principal ingredients in NyQuil), but taken during the day or early evening, alcohol can actually lead to a rebound state of wakefulness at bedtime or in the middle of the night, greatly exacerbating insomnia. It's also a potent diuretic.

Avoid going to bed on a full stomach immediately after eating a heavy meal. If you suffer from acid indigestion, remember that lying down tends to aggravate reflux; bedtime is one of the best times to take an antacid.

Avoid a heavy workout before bed. Adrenaline and other stress hormones that are released during vigorous exercise will keep you wide awake. Schedule your workouts for the early afternoon, or better yet, start your day off right and exercise first thing in the morning; it will set a great mood and energy level for the whole day!

Ensure the right sleeping environment: for most people, a dark, quiet, cool room. If you sleep better with a little "white noise," try an oscillating fan (which works nicely to keep you cool as well), or invest in a sound machine. The TV's sleep function works as well, but turn the volume down low and pick something you have no interest in. For children, a night light can make all the difference (for some adults, too!). An aquarium provides a little light and a nice, soothing water effect as well. If you work the night shift and sleep during the day, draw the blinds or consider a night mask.

Adjust the temperature of the room to your comfort; most people have trouble sleeping when it's too warm. On the other end of the spectrum, body temperature drops when you sleep, so light sheets are always a good idea and sometimes a blanket. In the winter, sleeping by a fire can be wonderfully cozy (but please, attend to fire safety measures, always!).

A soft but firm mattress and a comfortable pillow or two go without saying. (I sleep with two pillows, one of which is a long body pillow with which I travel whenever I can.)

Many people report that having an orgasm leads the body quickly into sleep, other physical parameters permitting.

A lot of people also recommend reserving the bedroom for sleep (and sex), so that the bedroom environment becomes associated with sleep in the mind. I'm not sure this behavioral principle (conditioning) is as relevant as it's cracked up to be. Watching a little television or reading in bed is okay for most people and can even be part of the process of winding down from the day.

Conversely (as far as operant conditioning is concerned), I do think it's useful to develop a little ritual before bed each night. Make it your own: wash your face, brush your teeth, pet your cat…whatever suits you. This starts the winding down process and begins to alert and mind and body that sleepytime is approaching. One of the most impossible things to do is to come directly home from work or some other stressful situation with the weight of the day's worries still on your mind and thoughts about everything you still have to do tomorrow and jump in bed and close your eyes and try to immediately fall asleep with no in-between downtime. It's not practical and it's not healthy.

Another behavioral/environmental principle suggests that if you don't fall asleep within the first half hour or so, don't lie in bed fretting and watching the clock. Instead--if it's practical--get up for a little while, maybe have that proverbial glass of warm milk* or fix a light snack, perhaps do a little tidying up or a quick chore you had left undone before going to bed, or read a little or watch a little television until you begin to feel like you can try again.

Again, this "if you can't beat 'em, join 'em" approach is not always practical; you may live with someone who is sleeping just fine whom you don't want to wake, or it may be very late at night and you have to be up early the next morning, but one of the worst things you can do is toss and turn. It ratchets up your stress level and decreases the likelihood that you will get any rest. And if you have to get up early anyway, sometimes it's simply best, if there's only an hour or two to go, to just go ahead and get up for the day. It avoids wallowing in misery until the bitter end when the alarm goes off and you haven't slept a wink anyway and hopefully you will be that much more prepared for sleep the following night.

This is not about giving up; it's about finding some peace of mind through acceptance.

This is another way of saying: DON'T WATCH THE CLOCK. If it's the middle of the night and getting out of bed is not a reasonable option, it's better to lie there quietly with your eyes closed and your mind relaxed than it is to fight being awake. You won't sleep if you are fighting anything anyway, and so acceptance of not being asleep will at least make it less arduous. This technique of being okay with being awake removes at least one barrier to deeper relaxation: frustration and anxiety. Oftentimes boredom will set in, and if you can avoid becoming irritated by THAT, and remain still and quiet, the body's natural response will actually be…to slip into a light sleep! So don't fret, and just be awake if that's what you have to be, but don't be surprised if letting go doesn't just give you what you've been struggling to achieve all along.

This actually works. It depends on stopping yourself from thinking, "I'm still awake…When am I going to fall asleep?...What time is it?...I have to work in the morning…I'm still awake…What time is it now?" At first you may have to remind yourself to stop reminding yourself that you're not asleep yet, which is obviously a bit counterproductive in itself, but eventually you'll get the hang of it.

Counting sheep (metaphorically speaking, of course). This is a bad idea. By this I mean thinking about anything, no matter how mundane. Reviewing the day and planning for tomorrow should be part of the winding down process, not part of the falling into sleep process. It's just another form of watching the clock, really.

The brain goes to sleep when it has nothing better to do. In other words, the mind can only fall asleep when it goes blank; so long as you are thinking about something--anything--you won't fall asleep, you'll go on thinking. Concentrating on anything (sheep included) is counterproductive.

You might think that you fell asleep last night thinking about this or that, but in actuality, you fell off to sleep in that moment when your mind wandered away from whatever it was you were thinking about, and for a few seconds your mind forgot to contemplate anything, allowing it to slip into the first stage of light sleep. Even thinking about how tired you are will keep you awake, as most of us have experienced, to our utter consternation. It's not until you allow yourself to simply feel tired, with no thoughts or commentary of any kind attached, that you will slip away.

Practicing mind-clearing meditation during the day helps a lot of people repeat the practice at night; when you are lying down and your mind goes completely blank, you WILL fall asleep. That's why yogis and yoginis don't meditate lying down: it quickly leads to unconsciousness!

The trick is clearing your mind of all thoughts. When it is awake and rested, clearing itself of thoughts is the last thing the mind wants to do; it is not the mind's function. Its function is to distract us with perceptions and ideations. Mindfulness is antagonistic to slumber.

If you have a bed partner, you will want to negotiate with that person regarding your individual sleeping habits and problems that may arise (such as snoring, hogging the sheets and tossing and turning).

Be mindful of your circadian rhythm; naps are usually healthy parts of a person's day if they are well-timed, but excessive sleeping during the day has obvious deleterious effects on one's ability to find sleep at night.

Other considerations such as jet lag can come into play. With regard to jet lag, some people report modest success taking melatonin at bedtime, a homeopathic, over-the-counter hormone remedy that helps adjust the sleep-wake cycle. On the stronger pharmacological side, the medication Provigil is an excellent means of resetting one's circadian rhythm by extending wakefulness until it's time to sleep, without interfering with sleep when the time for that comes (but that's another topic that is outside of the scope of simple, non-medicinal sleep hygiene).

*Does a glass of warm milk really induce sleep? This folk remedy has been explained by some who point out that milk contains tryptophan, an essential amino acid that is metabolized into serotonin and melatonin, all of which affect sleep, but in actuality the amount of tryptophan in a glass of milk is physiologically negligible. It's not an unpleasant way to achieve a placebo effect, though, and lowfat milk is a great source of calcium and vitamins A and D!

How to Make Your Sleeping Pill Keep Working

2009-07-22T11:19:00.005-05:00

By S. Silva M.D.

Prescription sleep aides are among the most commonly administered of medications, and they can be a Godsend for many patients. Although once only approved by the FDA for brief trials, recently the FDA approved Ambien for long-term use. In actuality, any prescription sleeping pill can be used safely and reliably on a chronic (i.e., nightly) basis, with favorable results. The problem over time, however, is that a person develops tolerance to the sedative effect of these medications and requires ever-increasing dosages to reap the same benefit as when s/he first began taking them, which in many cases leads to drug dependence, withdrawal effects, and even in some cases addiction and/or overdose. This article addresses how to avoid the problem of escalating the dosage of a sleep aide, while maintaining considerable benefit from the prescribed medication.

When you have chronic insomnia that requires nightly dosing with a medication that cannot be increased indefinitely without risking serious side effects (to say nothing of the fact that, sooner rather than later, the higher dose itself will fail to work as expected), here's what you may be doing wrong, along with some secrets to preserving the efficacy of any sleeping preparation:

• Begin with the lowest effective dose of the medication and do not increase it unless or until absolutely necessary. This will conserve those higher doses for when you really need them. The sooner and faster you up the dosage, the more rapidly you will develop tolerance to the sedative effect of the drug, and the sooner you will become frustrated by the fact that the medication is apparently no longer working for you.

Once you have increased the dosage once or twice, feel free to back down on those subsequent nights when you already feel especially tired, or think that you might not have particular difficulty getting to sleep; better yet, skip the medication entirely whenever you can. This will preserve efficacy over time, because tolerance is always reversible.

• Take the full dose of the medication on an empty stomach, with plenty of water. This will speed the rate of absorption, which will maximize the medication's potency. With a sleeping pill, you want to absorb it rapidly and completely, so that you get to sleep in the same manner: quickly and fully. If you take the medication on a full stomach, this will result in its being absorbed more gradually over time, as it dissolves into the food present in your stomach; the food itself presents a physical barrier to absorption. This in turn results in a gradual relaxation that, if too gradual, may not tip you over into desired sleep. For example, 10mg of Ambien will have a much more impressive effect if you absorb it over a period of, say, 15-20 minutes than that same dosage will have if it takes an hour and a half to enter the bloodstream, and thus, reach the brain. This is true regardless of your body weight, liver function, or level of tolerance.

Along the same lines, take the full dose all at once. If you know you will need more than 5mg of Ambien to get to sleep, don't take 5mg an hour before bedtime and then wait to take another 5mg when you actually get in bed; you may find with this strategy that you are tempted to take yet another 5mg at 3 a.m., and still not get to sleep. This wastes the potency of the dosage you are needing. Take all 10mg or 15mg at once, preferably on an empty stomach, 10-20 minutes before lights out.

This is not to say that taking another 5 or 10mg later, if absolutely necessary (and okayed by your doctor), won't work: often extra doses do help, but it's a bad habit to get into, splitting the dosage of a sleeping pill. Take what you need when you need it and be done with it. Taking extra doses of a sleeping medication while under the influence of that medication is particularly unadvisable because this can lead to unintentionally taking more of the medication than is needed or safe, and exceeding your doctor's recommendation. This is because you will begin experiencing cognitive dysfunction after the first dose; even if you don't feel sleepy, you WILL be impaired, and that includes memory and judgment. You don’t want to be titrating your dose of sleeping medication once you become confused and forgetful. People have accidentally overdosed because they take extra doses of medication after they've taken doses they've forgotten they've taken!

• Take "drug holidays" when feasible. As previously stated, if you are already tired and feel like sleeping without it, or if it's the weekend and it's not absolutely necessary to be asleep before midnight, skip the medication entirely that night. This will delay and even reverse the tolerance you have built up for the drug up to that point, likewise preserving the efficacy of the medication over the long-term.

The more regularly you take a sleeping pill, the more surely you will develop some immunity to its sleep-inducing effect, but the more nights in a row that you go without the medication each time you take a "holiday" from the drug, the more you reverse any tolerance you have acquired up to that point. Frequent drug holidays can prevent the development of tolerance in the first place, which is ideal.

One way to take more drug holidays is to make sure you have good "sleep hygiene." Just follow the rules for maintaining good sleep that are well-known (see my article on How To Maintain Good Sleep Hygiene).

• Avoid consuming alcohol, because you will develop cross-tolerance to many prescription sleep aides if you regularly drink (especially the benzodiazepine class of medications, whose names end in "-pam," such as Valium, ****, Klonopin, Ativan and others, as well as Ambien, Sonata, Lunesta and most other, newer and commonly prescribed agents). While drinking alcohol and then taking sleeping pills can lead to a synergistic effect (which can actually be quite dangerous and is responsible for the majority of deaths due to accidental overdose), drinking alcohol in the early evening several hours before bedtime can lead to a direct state of rebound wakefulness as the effects of the alcohol diminish. This can lead to insomnia all on its own. In the context of treatment with a sleep aide, there is no longer an additive effect when a person takes the sleeping pill, but because of cross-tolerance due to alcohol consumption, the brain resists the sleepy effect of the medication. Cross-tolerance of sleeping pills with alcohol is more of a long-term effect, but drinking alcohol in the early evening can diminish the effects of a sleeping pill that night by this mechanism.

People who drink regularly and/or heavily often notice that they have a "built-in" resistance to sleeping medications from the start; that is, at the starting doses that are prescribed by doctors. This existing tolerance can be reversed, however, by laying off the alcohol in much the same way that any level of drug tolerance can be reversed by weaning off of the habit-forming substance and avoiding it as much as possible in the future.

People who take certain anti-anxiety medications during the day (for panic attacks, for example) will encounter the same phenomenon of not being as sensitive to the sedative effects of a given dosage of sleeping medication, if that medication is also a benzodiazepine or a medication like Ambien that is cross-tolerant with benzos.

• If you have chronic insomnia that requires nightly dosing with a medication that cannot be increased in dosage indefinitely (that would be all of them!), here's what you should realize:

When you first take a medication for sleep, the medication works powerfully to shut down your brain, assuming that your body hasn't already built up some immunity to it due to cross-tolerance with alcohol or other sedating substances. In that case, after you first take the medication and begin absorbing it, the drowsiness that comes upon you basically forces you to sleep. If you are already tucked in, that makes it easy to drift into unconsciousness. If you are still up and about, you will stop whatever it is you are doing and find your bed, because it's that, or fall on the floor.

However, once you have developed a tolerance to the medication, it will no longer "force" you unconscious; it will no longer compel you to find your bed whatever you may be doing. It will still help considerably in gently encouraging you--allowing you, as it were--to fall asleep…if you are comfortably in bed, in the right position, with the lights out, trying to relax and clear your mind. The medication that once put you to sleep now merely assists you in drifting off, and while this effect can also wane over time with tolerance, it rarely disappears completely. That is to say, you will definitely develop tolerance to being "knocked out" by a given dosage of a sleep medication, but that dosage or perhaps a slightly higher one will always significantly relax your mind and your muscles and it will always promote sleepiness to some degree. But in order to take advantage of that sleep assistance, you have to be sure that your mind and body are not working against you.

What happens is that, depending on how quickly and fully you absorb the medication, there will be a window of time during which your blood concentration of the medication will be peaking. It is during this window of opportunity that you should be in bed, ready to drift off. If you miss it--if you're emptying the trash or brushing your teeth or talking on the phone or yelling at the kids--when you do finally get in bed and turn the lights out, your blood levels may already be dropping and you may have missed your chance to take full advantage of the medication's soporific effect.

• This is a very common mistake people make: they take their pill before they are ready to commit to sleepytime, and while they are "waiting for it to kick in," they're paying bills, surfing the internet, reading, or seeing what's on TV.

This is a huge mistake. Take your medication and then GO TO BED. Don't take it and do other nighttime stuff, waiting to pass out. I once had a patient who admitted to me that she took her sleeping pill, then drove to the convenience store for a carton of milk! Besides being dangerous, she was obviously not ready for sleep. It's no wonder the medication didn't help her find sleep: she wasn't looking for it. And thank goodness she didn't find it on the way--or rather, that it didn't find her! (Even had she walked to the store it would not have been a good idea.)

• The thing to understand here is that, very soon after regularly taking a sleeping medication, it induces sleep more gently than it did the first few times, because your brain develops natural immunity to the sedative effect. The medication has to work harder to put your adapted brain to sleep, which means you either have to take more milligrams or you have to make it easier on your body to succumb to the medication's attenuated effect. Since it is neither feasible nor safe to continue escalating the dose of a sedating medication (or any medication, for that matter), if you want your sleeping pill to keep working you have to do everything you can to let it work, which means don't fight it with an alert mind and an active body. Take the medicine, lie down, close your eyes, clear your mind and relax into it.

• The other thing to remember is that, if you take a drug holiday, and you wait long enough, the medication will work like new the next time you take it. You should still follow the rules outlined in this article, but you will find that the medication works better--and at a significantly lower dosage--than it had been before you took the break.

How to Know If You Have Been Misdiagnosed With Bipolar Disorder

2009-07-22T09:35:00.007-05:00

While only a qualified mental health professional can diagnose bipolar disorder, it is by far the most over-diagnosed mental illness today (along with ADHD). This article will help you sort through some of the basics, to better prepare yourself for that talk with a psychiatrist or therapist, if you think you may be suffering from this disease.

The key is understanding mania. We all get depression, and we all understand that there are different levels of depression; most of us, thankfully, have never experienced true endogenous major depression. Mania, however, is widely misunderstood. The lay public and even many (if not most) mental health professionals mislabel various types of agitated moods as "manic episodes." There are different levels of mania as well, but even the simplest, lowest grade of mania--hypomania--is a step or two above and beyond any of the familiar forms of agitation all of us feel from time to time.

Do not confuse "mania" with other forms of emotional turmoil. Manic episodes can be characterized by elation, irritability or anxiety, for example, but they are not just euphoria, not simply aggravation. Mania is not even just extreme instances of these; mania is a sustained (usually weeks to months) state of psychomotor agitation, along with other neurovegetative signs (physical findings, like a decreased need for sleep, markedly increased libido and/or sped-up mental processes which manifest as super-fast thinking and pressured speech). In a nutshell, mania is like being on a stimulant drug, without the drug. There is sleeplessness and other forms of physical agitation, increased goal-directed activity, and increased risk-taking behavior. See below for disclaimers on each of these common, but commonly misunderstood, symptoms.

One major distinguishing characteristic is that manic episodes do not last minutes or hours, unless they are induced by stimulant drugs whose effects wear off. In that case, the diagnosis would be a substance-induced manic episode, which is not endogenous bipolar disorder. Bipolar disorder, or manic depression, occurs spontaneously, is often inherited, and usually starts fairly early in life (early adulthood or, less commonly, adolescence--rarely in childhood). It consists of alternating episodes of major depression (which usually comes first) and mania; untreated episodes of either of which last months, even years. Not minutes, or even hours! If you think you were "manic" last night (and you weren't high on drugs), but today you feel normal or even a little down, you were almost certainly not clinically manic last night. Whatever the agitation was, it was not due to bipolar disorder; untreated mania lasts 6-9 months, on average. Even "rapid-cycling" bipolar doesn't cycle from morning to night, no matter what even some health care providers might be saying.

Racing Thoughts. Patients report "racing thoughts" because enough mental healthcare providers have asked enough patients point-blank, "Do you have racing thoughts?" that the term has entered the popular vernacular. This is unfortunate, because what people usually mean when they spontaneously endorse "racing thoughts" is worries, even obsessive thinking. Not being able to shut the mind off at bedtime, for example. This is not what psychiatrists meant when they coined the term, referring to mania. For one thing, a manic individual doesn't need to sleep, doesn't want to sleep, doesn't lie in bed trying to turn the thoughts off; a manic individual runs with his or her thoughts and impulses (usually to his or her detriment). So those sleepless nights when you're tossing and turning and can't stop thinking about all your problems--common enough, but nothing to do with "racing thoughts."

It's a poor question to ask, clinically, "Do you ever have racing thoughts?" because the presence of racing thoughts will be evident to the examiner without having to ask: speech will be pressured, that is, rapid and difficult to interrupt, and may not make a lot of sense. The connections between individual thoughts are often loose, and it can really be impressive to hear.

Sure, sometimes individuals experiencing mania will have a subjective sense that their thoughts are racing. They might feel that they cannot speak fast enough to get the words out, that ideas are tumbling over themselves in their mind, but, alternately, a manic individual may be so sped up that s/he isn't aware that thinking and speech are abnormally rapid and over-inclusive.

If you are drowning in ideas and can't talk fast enough to get your point across and your mind is darting from one brilliant insight to the next, you may be having "racing thoughts," but at that point you have a formal thought disorder and the thoughts themselves are likely the least of your problems. Otherwise, thinking too hard and too much (almost always worried thinking) or obsessing or ruminating on a particular topic that's unwelcome to you and that you wish you could get out of your mind has nothing to do with mania.

Sleeplessness is another hallmark of mania, but again, it's not insomnia in the sense that you want to sleep but can't. When you experience mania, you don't feel the need for sleep, bedtime becomes an inconvenience and the fact that the rest of the hemisphere has called it a day is too bad for them! A manic person may know s/he is supposed to be sleeping and should be trying to, because everybody else is, but that person doesn't feel the need for sleep, or very much of it, at any rate, for days on end. Again, it's like being on speed, without having taken any drugs. Even as little as two or three hours a night is often more than enough sleep to satisfy the manic individual. Of course, as with the guy on drugs, a crash is inevitable. The difference is that, for the manic depressive, the crash might not come for many weeks or many months, by which point lots of havoc has been wrought in that person's life by ill-advised, impulsive behavior. It's not the wakefulness itself that's the problem, especially not to the person experiencing it, beyond the inconvenience of it; it's what the person does while not sleeping.

Impulsivity manifests as increased pleasure-seeking, and the risk-taking that goes along with that. As I've said, there are different levels of mania, so there are different levels of outrageous behavior that manic individuals accomplish, but the key is that the behaviors are way out of the norm: way, way, more heedless and hedonistic than is typical for the person at baseline, and for most of us that means pretty scandalous behavior. Things like extreme promiscuity, spending hundreds or thousands of dollars on things one doesn't need and can ill-afford, even criminal activity. Again like the gal on drugs, getting arrested is something that happens to acutely manic individuals all the time. Being high gets you in trouble, whatever the cause.

Spending sprees. We've all been on little spending sprees. The manic spree is beyond the pale. It's infused with overt grandiosity, a careless sense of "must-have" entitlement and it usually involves hundreds or even thousands of dollars spent on items of little or no practical value. In the middle of a manic episode, there is no hesitation or buyer's remorse, no guilty feeling that nags, "I shouldn't be spending so much," etc.

Instead, there's a sense of urgency that pervades everything during a manic episode: an acute need to spend, to acquire, to invest in material things. Often the spree is an expression of big plans to come, of a false sense of personal capability, even greatness. "I'm worth it."

Thoughts of, "Can I really afford this?" are entirely alien. Even if it's all being charged, the notion that the spender isn't clever and resourceful enough to raise the funds to pay for it all anyway is unthinkable. Manic individuals are often sure they are about to become very rich, and very famous, very soon, so why put off the purchases? Once on the spree, impulsivity takes over and truly bizarre items make the shopping cart, items that are often pretty or fancy or exotic, but items the utility of which is sometimes difficult to explain when things have calmed down. Have you ever asked yourself about a purchase, "What was I thinking?" If you have, it was probably limited to some article of clothing you later had second thoughts about. Multiply that feeling many times over and imagine asking yourself why you thought you needed an antique jewel-encrusted scimitar and you begin to imagine the types of purchases a truly manic spree can result in.

Most people have never experienced a manic spending spree, because most people are not bipolar.

Expansiveness. Ever feel like going up to a complete stranger and bonding, becoming best friends instantly, or better yet, proposing you run off together to find adventure? Probably not. Manic individuals take "outgoing" to new, sometimes dangerous, heights. Social barriers become non-existent, and reasonable interpersonal boundaries often get trampled. This can be very unsettling to the person accosted by the manic individual (provided that person is not hyper-expansive herself).

When expansiveness meets hyper-religiosity, the person finds a street corner and starts preaching to the world; literally any passer-by could be the next repository of the manic individuals' endless, newfound sense of cosmic understanding.

Hyper-spirituality. If there is a gold-standard manic symptom, this is it. A manic person can become suddenly in touch with God (as s/he understands God). This is not merely a religious epiphany; it's paranoia in its grandiose form (not all paranoia is persecutory). When mania is strong enough, it is not at all uncommon for the person to feel a special connection with God, even to hold himself or herself forward as a prophet. History is replete with examples of individuals for whom this experience became an actual self-fulfilling prophecy (no pun intended): billions and billions of followers have been engendered by the greatness that pure spirituality endows.

These are some of the highlights of actual mania, albeit moderate-to-severe; several of the examples above qualify for mania with psychosis, that is, losing touch with reality, although most manic episodes do not result in psychosis. Of course there are milder, subtler forms, which is why so many practitioners confuse lesser forms of agitation for hypomania and diagnose "bipolar type II," which consists of major depression and minor episodes of mania. But true mania is still true mania, no matter how mild, and the fact remains that most of these "hypomanic" diagnoses are just plain wrong. Anxiety and irritability and sleeplessness and impulsivity, even when pronounced and protracted, are usually not signs of an actual manic episode. Actual mania is much rarer than garden-variety agitation.

The distinction between actual mania and other forms of agitation is a critical one, because the mood stabilizers used to treat mania can be quite toxic, much more so than the standard antidepressants that are on the market. The latter are safe and well-tolerated and even help those episodes of agitation that are mistakenly labeled as "manic episodes," whereas mood stabilizers per se (such as lithium and Depakote) are heavy-duty medications with heavy-duty side effects and should not be used carelessly.

Not only that, but if you are mistakenly diagnosed as bipolar a prescribing doctor may hold back on so-called mood elevators (like Prozac) because s/he thinks that they will make your "mania" worse, when your "mania" is actually extreme irritability and anxiety that's causing mood swings and what you need most is a medication like Prozac! Prozac and Zoloft and Celexa and other SSRIs will stabilize most (non-bipolar) moods, and are often underutilized in individuals because of a false bipolar label. Even in actual patients with bipolar disorder, these medications can be extremely beneficial, when properly paired with an antimanic agent.

Once a person has been diagnosed with bipolar disorder, the diagnosis tends to stick, regardless of its accuracy, as the individual goes from one mental healthcare provider to the next, because often the diagnosis is simply accepted by the new practitioner, who fails to take a comprehensive history and perform adequate serial mental status examinations himself or herself, to verify the diagnosis over time. I have treated literally scores of individuals who had been treated for years by numerous physicians for "bipolar disorder" who turned out not to be bipolar, so be skeptical, ask questions and make your treating physician prove to you why your symptoms are those of actual manic depression and how s/he ruled out other, more common syndromes like unipolar depression, adjustment disorders, substance abuse and personality disorders.

No one is equipped to diagnose himself or herself; see a qualified mental health professional, but it never hurts to research what you are being told. Good luck.

Read this: An Unquiet Mind