Monday, October 14, 2013

The Patient's Responsibility Part II

Once in awhile, a patient will preface what they are going to say by saying "I hope this isn't TMI [too much information]." There is no such thing as TMI for your therapist.

It used to be common knowledge that patients in therapy were supposed to discuss all of their thoughts, feelings and experiences. Dreams and sexual fantasies were common topics in therapy sessions. Of course, most people are not comfortable immediately discussing their most personal thoughts, which is fine. Most people begin by talking about what is going wrong in their life. It's important for the therapist to know more than the superficial details, however. Patients who hide details of what they consider embarrassing material may be leaving out important information.

Sometimes people hide information out of fear. A drug addict who doesn't really want to give up drug use may hide the extent of his/her use in order to avoid confrontation and a referral to an inpatient facility. It's important to trust that the advice a therapist gives is based on clinicial evaluation, not judgment.

I've had some patients who apologized for cursing in sessions.  If you feel like cursing to express yourself, go ahead (if you feel like cursing at me, however, I suggest we discuss what is making you angry instead).

The basic rules of social interaction mostly don't apply in therapy sessions, the exceptions being that you are supposed to be on time, pay any bill that you owe, and participate. Cursing, talking about sexual behaviors or fantasies and admitting to drug and alcohol use fall into the realm of expression. Without your honest expressions, therapy cannot be effective.

Monday, October 7, 2013

My Thoughts on Psychiatric Medications

Usually about 20-50 percent of my patients are taking psychiatric medication. Psychiatric medication can be extremely useful, even crucial; however, it is often misprescribed.

About one out of every five times I see a new patient who is already on psychiatric medication, the person has been prescribed the wrong medication. Someone might ask how I know, as I am not a medical doctor. First of all, if a medication isn't working, then someone should not be taking it. Secondly, my consulting work in psychiatric facilities involves reading the entire medical records of  patients. I've read the records of severely ill patients who are taking three, four, or even five medications. I spend time discussing clinical care with the prescribers in the hospitals (along with a multidisciplinary team including our team psychiatrist). What this means is that I've become extremely familiar with both the intended effects, side effects and possible adverse reactions of most psychiatric medications.

Some common errors I have seen are: Prescribing dangerous anti-psychotic medications instead of anti-depressants to depressed patients, failing to properly diagnose conditions such as Attention Deficit Hyperactivity Disorder in adults, failing to prescribe mood stabilizers when warranted, prescribing anti-anxiety medications for what is actually depression, failing to consider the consequences of prescribing addictive medications to persons who already have addictions, and more.

Several years ago I had two patients who were being prescribed Zyprexa, an anti-psychotic with potentially serious side effects. I knew this was not the right medication for these two depressed patients. In one case, I called the patient's psychiatrist and suggested changing the medication to something else. The doctor decided to try something different and the patient improved markedly. In the second case, the doctor (a different doctor) ignored my suggestion and the patient tried to kill herself. Fortunately, she did not die, and I made sure she was admitted to a hospital where her medication regimen was changed.

In other cases I have just spoken directly with the patient and suggested they talk to their prescriber about their medication. Sometimes this is effective. In one case, the patient had been taking a medication for panic disorder even though she did not have panic disorder. She had been dutifully taking this medication every day (a highly addictive medication) and had begun to wonder if it was making her sleepy. Her doctor agreed she could reduce the medication and she quickly became less sleepy without developing any more anxiety.

I have often thought in recent years that the practice of medicine in this country leaves much to be desired. The explanation of one of my colleagues is "today doctors treat symptoms instead of illnesses." He's probably right. Without figuring out what the underlying illness is, the medication can be wrong and even dangerously wrong.

If you need psychiatric medication, or a new prescriber, I can refer you to someone whom I believe to be competent.

Saturday, June 29, 2013

Can Vitamin D Help Your Mood?

  This article in The New York Times focuses on the increased rate of suicide in springtime, but it's more interesting for what it says about a possible link between depression and inflammation:
suicide patterns

"Dr. Kaplin studies depression in patients with multiple sclerosis, an autoimmune inflammatory disease. In M.S., he says, depression and inflammation feed each other: Even after accounting for the psychological effects of any serious illness, M.S. heightens depression risk..."

"Inflammatory cytokines play crucial roles in fighting infection, but they can also cause problems. When people with hepatitis C are given the cytokine interferon to help fight the infection, for instance, up to 40 percent become depressed and one in 50 attempt suicide. Other studies suggest that inflammatory cytokine activity reduces levels of the neurotransmitter serotonin and halts the growth of new brain cells — two hallmarks of depression."

As for the link with springtime, the article notes "One possibility is that many people enter spring sensitized to inflammation by late-winter battles with seasonal infections like colds and flu.
A second possibility involves tree pollen....Yet another possibility involves vitamin D. The low levels caused by lack of sunlight in the winter are thought to lead to inflammation; one recent study tentatively suggested a link to suicide."

In addition to private practice, I also do consulting work in psychiatric hospitals, and I've noted in the past several years that most hospitals are now testing their patients' vitamin D levels. Many patients'  tests show vitamin D deficiency (which is easily resolved with supplements in most cases).

 I've also noticed that some psychiatrists are prescribing fish oil for their patients--fish oil has a slight anti-inflammatory effect and some believe it reduces depression.

Nutrition and overall health are very important for combatting and preventing emotional illness. I always recommend that my patients receive complete physical exams that test for problems such as vitamin D deficiency, thyroid problems and other common problems that could be implicated in their symptoms.

Wednesday, June 19, 2013


Anxiety disorders appear to be on the increase. This may be due to many factors. There are many simple techniques that can be used to reduce anxiety:

1. Progressive Muscle Relaxation: Tense and release muscles in one part of your body at a time. Start either from your feet or your head, working in one direction. This can help insomnia when done at bedtime.

2. When worrying about an upcoming event, ask yourself "What's the worst that could happen?" You may then realize that whatever the worst is, it won't be catastrophic and you can probably handle it.

3. Evaluate your fears--are they logical? How likely is it that the bad outcomes you imagine will happen?

4. Drink less coffee and evaluate medications you are taking, such as Sudafed, that can increase anxiety. Some sleep medications may cause rebound anxiety the following day.

There can also be complex reasons for excessive anxiety, such as an underlying lack of self confidence or fear of being alone and/or independent.