Ask a Jaded Mental Health Professional
 

I'm a psychiatrist, and I've worked in the mental healthcare industry in a variety of capacities for over 15 years. I have expertise in psychological test batteries, diagnosis, insight-oriented and dynamic psychotherapy, psychopharmacology, and research. If I haven't seen and treated (or attempted to treat) a particular mental affliction, it hasn't been discovered yet.

If anyone has any questions about issues pertaining to mental health issues, I would be happy to offer whatever insight my training and experience may offer. Fire away. . . I am your humble servant.

DISCLAIMER:
Any responses I provide on this board SHOULD NOT be considered by any means to be a substitute to consultation with your own physician. It is not possible to accurately diagnose and make sound treatment recommendations based on interactions on a message board. I am simply providing my personal opinion, based on my training and background, in an effort to help whoever is interested become a more informed consumer when they seek appropriate medical care. Thanks!

madp

Hi.

I've a question about Lexapro. Is it possible to build a resistance to it where it seems to no longer be as effective as it once was?

Do beta blockers like Atenelol effect depression as well as short term memory? My doc won't give me a straight answer.

Resistance is not really the correct word (it is more relevant to drugs such as opiates where the body literally requires greater and greater quantities to achieve the same result), but Lexapro can become less effective over time, or the patient can go through cycles in which the drug may variable seem less or more effective.

When it comes to depression, there are many factors that can influence how the patient feels beyond the agent and dose the patient is currently on. Common problems that can cause depressive symptoms to return include the use of certain substances, problems with thyroid functioning, an increase in stress, and relationship difficulties. As for drug use, cocaine and exctasy will ALWAYS result in depression hangovers, and extasy in particular burns out the receptors in your brain that allow the body to regulate depressive moods over time. Excessive alcohol use also causes depressed mood.

As for your particular case, you should reflect on any changes in your day-to-day living that might be related to the increased depressed mood. If you are not abusing substances, and you have not had an increase in stressors or relationship difficulties, then you might begin to consider whether or not the Lexapro is losing its effectiveness for you.

Lexapro is generally the drug of choice in the US for *mild* depression, because it works very well with minimal side effects. It is not considered the MOST effective agent, but it is very effective for most patients (as most do not have entrenched major depression), and it has fewer side effects than the "stronger" agents. For that reason, your doctor might suggest a dose adjustment rather than a different agent if you are not feeling better on your current dose.

Finally, a few questions come to mind:

How long have you been on Lexapro?

How long have you felt depressed? Has it been for most of your life, or a briefer period of time? Has it been due to a particular event (or events) that occurred in your life, or does it seem completetly unrelated to what is going on in your daily life?

I hope that is at least minimally helpful!

The straight answer is "yes," but it occurs in a small percentage of patients who take the drug. In their clinical trials, 12% of atenolol patients experienced depression, compared to 9% in the placebo group. "Tiredness" was the most common neuropsychiatric event (26%) in the clinical trials, but it is likely to dissapate over time.

The way that short-term memory problems and depression are described in the prescibing information for altenolol suggests that these are by and large rare events (especially short-term memory problems), but when they do occur they can have a significant impact on a patient's functioning.

If you notice some real changes in your funtioning in these areas, then you may want to inquire with your doc as to what other options exist for you. It is possible that another beta-blocker will not cause these problems, or at may at least cause them with less frequency or severity. However, as all beta-blockers have the same mechanism of action, the potential is there for all agents within the class to cause a similar range of side effects.

When it comes to drugs like beta-blockers that may literally allow you to live longer and to stave off progressive life-threatening illnesses, you often have to take the good with the bad.

I'm curious: are you under the care of a cardiologist, or a primary care doctor?

Hope that helps!

I strongly believe that depression is 80% mental (conscious and controllable) and 20% physical (chemical) in 99% of individuals. I've seen a lot of evidence to corroborate that position, but very little for the opposite.

If you had to place a percentage, as I have above, on how much depression is physical vs mental, how would you place them?

And do you have any recent information (preferably scholarly journals, preferably online) that provide evidence for a direct physical causation?

Thanks for doing this.

This is a serious question, so please understand that I am not on the attack. I wish other physicians would do what you are doing:

I was led to believe that there is a code of ethics or a fee schedule or some kind of club rule that said physicians should not give medical advice over the internet...

I heard that the only advice that could be given was "Eat healthy, exercise, get plenty of rest, get regular check-ups." Other pointed questions often get the form answer "Go and talk to your doctor, I can't give advice like that without a history and physical."

So, here are my questions:
How do we change the physician culture such that advice can be sought and given using this media?
What caused you to offer advice?
What instruction has your professional regulatory body given you in regards to internet advice?
Can you tell us how you chose the path of psychiatry, in contrast to another specialty?
Is there a case you were involved in that really stands out in your mind? Why?

Again, thanks for being part of the TFP. :thumbsup:

"Can you tell us how you chose the path of psychiatry, in contrast to another specialty?"
Similar question to Ben's, I am just about to get my BA in Psychology, besides personal interests what do you recommend? Or recommend to stay away from? (talking about any fields that have to do with psychology: psychiatry, neuro, physio, cognitive, developmental, etc.) Like any fields about to become more important in the future? Or would clinical really make ya (most people) jaded? Any advice at all would be appreciated, thanks.

It is not possible for me to provide reliable medical advice over the internet. Consider my responses to be no more than "informed opinions." I would never profer specific treatment recommendations in this forum. It would be irresponsible for me to attempt to do so.

I'm like your next door neighbor who also happens to be a doctor, simply sharing some personal opinions over dinner.


I don't know the answer to the first question. I am not politically connected. Physicians typically don't like their cache of knowledge being dispensed informally because it's often irresponsible and difficult to enforce accountability, and because it's bad for business.

I am not offering any advice, medical or otherwise. I am simply offering whatever knowledge I may possess that will allow readers to pursue traditional treatment from their physicians with a little more sophistication and savy.

I chose psychiatry because the disease states interested me.

There are many cases I've seen over the years that were poignant for one reason or another, but I am hesitant to provide "case studies" in this forum for a variety of reasons.

Thanks for your encouragement!

There is a variety of thought out there on this subject, which the scholars refer to as "depressive subtypes." I think that most psychiatrists would agree that many people with depression are depressed at least partially because they have learned maladaptive ways with which to interact with the world around them. Maladaptive behaviors rarely produced the desired results, and often produce undesirable results, and thus the individual finds themselves living in a world of their own making which is unable to meet their emotional needs.

There are also many cases of depression which seem so entrenched that no matter what the individual does to restructure his/her life, attitudes, outlooks, etc, they cannot break out of it for an extended period of time. There are many psych's more scholarly than I who might argue that this might be a more biologically-based depression.

Scientologists would say that it's all due to "body thetans," disembodied spirits who were "killed" by an alien emperor long ago, and who latch onto us and cause a broad range of "illnesses" from homosexuality to bad eyesight. (sorry, I had to throw my Scientology dig in somewhere).

In the end, I don't think we have the sophistication or data to say with any degree of certainty whether or not these theories are fact, nor to nail it down to a particular ratio or percentage. Physicians were interested in these theories insofar as they might potentially predict which depressed patients would respons to which types of treatment(s), but subtyping depression has not offered any reliable treatment-response guidance according to my understanding of the literature.

As for literature, Stephen Stahl's "Essential Psychopharmacology" is my Bible for approaching pharmacological treatment.

I am jaded. I was very idealistic and intellectually curious about psych and neuro topics when I was a younger, but now it is just part of who I am. The mystery and romanticism are all gone. It's simply a body of knowledge that I have learned, no different than computer programming or rebuilding an engine.

I don't mean to be a smartass, but this is really not something I can advise a stranger on. If money is important to you (and believe me, it gets more important the older you get), avoid Ph.D. programs unless you are a bonified genius who wants to spend your entire underpaid life in an academic wonderland. Don't go to grad school because you can't figure out what you want to do. . . only go if you know exactly what you want to do, and grad school is the path to get there.

Thanks, I think I needed to hear that (only time will tell). Ironically after speaking with so many different people (friends to professors) no one has said that. They all seem to want to push me into grad school.

I'm under the care of one of the best cardiologists in the world *beams with pride*. I have, or rather had, high blood pressure from a heart condition - both a coarctation of the aorta repair, and endocarditus - that usualyl left me around 135 while sitting down. Atenelol was perscribed and I used it for something like 2 or 3 years. After a time, I was allowed to do real exercise again, and as my general physical condition improved, so also did my circulatory problem. I discontinued my Atenolol several years ago and now enjoy perfect blood pressure. The reason I am concerned about the possible side effects of the drug is the possibility of symptoms of a problem arising later in life. If I take Atenelol when I'm 17, could there me physical or mental reprecussions later in life? I've done a bit of research, and it seems that many drug tests are rushed, and thus cannot always account for the full effects of a drug, espically over a very long period of time. While I am emotionally balanced and have a decent memory now (I think), what about 10, 20, 30 or even 50 years down the road? I don't want to be getting depression, or any other negative symptom of the Atenelol, just as I hit my 30s, midlife crisis, retirement, etc.

Ah, yes, the jaded mental health professional. I, too, my friend.

After 4.5 years doing therapy with kids in a school-based/home-based program, drug rehab, and shelter setting, I applaud a 15 year committment. I switched to Pediatric Hospice and Palliative care two years ago due to a severe case of compassion fatigue. I cannot say that I will be working in the field in another ten years, but I hope I can cut it. Applause, madp, you deserve it.

Will, I'm glad you're under the care of a great doc. . . they can be hard to find these days, as most have to work twice as many hours to make the same pay they made 15 years ago. It sounds like you are the rarest of patients: one who actually follows your doctors recommendations!

Because beta blockers are not part of my regular medical arsenal, I can't speak with the same authority on the subject as I can on psychiatric meds. However, my experience with drugs which adversely affect the central nervous system is that their effects are temporary, and not something to worry about after the drug has been discontinued. There are a number of drugs out there that can make you stupid when you're taking them, but the effects go away as soon as you D/C them. I wouldn't waste a moment worrying about long term effects from altenolol if I were you.

Shucks, fred. . .you're on the front lines. Your faith in the basic goodness of mankind takes a beating out there. I stopped doing psychotherapy because I either became too wrapped up in the patient's issue in some cases, and just couldn't muster up any genuine empathy in others.

When the best "therapeutic" response I can come up with is "what the f@ck are you doing to yourself?!". . .it's time to stop pretending that I'm actually being helpful.
:lol:

I went to grad school for a Ph.D. in clinical psych before I went to med school. After 3 years and $30,000 of debt, I realized I wanted to be a psychiatrist rather than a psychologist. It was wasted time and money, and it's impact on my finances was significant for a long time. That's why I caution you on grad school: the debt builds up very fast (grad schools are in business to make money), and most of them actually graduate a relatively small percentage of the students whose money they take.

I do my best. Frankly, I don't know as much about medicine as my doctors. I have had a string of really exceptional doctors (except my current GP) that have proven themselves again and again, beginning with my first cardiologist, Doctor Thomas Carl. I count myslef as being extreemly lucky/blessed. To this day I'm friends with several pediatricians, a psychologist (we bacme friends long after I changed theripists, so don't worry), and a cardiologist.
I realize that you are a psychiatrist and probably don't perscribe beta blockers very often, but you seem to know exactly what you're talking about. I appreciate the information very much.

I believe mine was, "Please, please don't tell me that you're saying that you want to kill yourself because Mommy won't get you a cell phone??!!"

And absorbing the pain and stories of abuse on a daily basis. I ended up on meds myself and I'm okay with that. By the way, I'm still learning about Wellbutrin XL and no one will give me a straight answer about this part... could it really decrease the violent headaches I've had for over two years? The first headache lasted sixteen months without a pain free day. About six months after I started taking it, I got more frequent breaks in between headaches, when I did get a day or two. I take a really long time to adjust to medications that are designed to affect mood. But I've been on it for a year and a half and now the headaches seem to come once or twice a week rather than every single day. I'm just curious. For the headaches, they (GPs) gave me Depakote and after four doses I thought I was having a psychotic break. With Neurontin, my ADHD went through the roof to the point that I was a dangerous driver. When a neurologist handed me a Topamax rx, I laughed, tossed it in the trash and walked out. Nooooo more of those, please. *shudder*

Oh, and it didn't help me quit smoking. :lol:

Personal opinion question...

What do you find most appealing: Pathological Psychology, Sociology, Social Psychology, Child Psychology, Neuropsychology or good ol' counseling.

Please explain why!

Hmm, you need a bigger group of friends and professors... or at least get some who are more jaded. :D I'm not terribly jaded, but I'm pretty realistic... and after 3 years pursuing a PhD (about halfway through), I'll tell you to listen to madp. You'd better know what you're doing when you apply to grad school, no hemming and hawing or hoping it will be the end-all of your existential crises. :)

Grad school can be a WONDERFUL time of growth... but if that's the only reason you are going, you're not going to last. Go because there's nothing else that would help you fulfill your life goals, AND go if someone will pay you for it (esp. in your field). I still haven't paid a dime of my own money for my work so far... and I intend for that to continue till the end!

-----

As for the OP!! What a wonderful thing to do... thank you for offering your knowledge and experience to the TFP world. :thumbsup: I actually have a rather banal question, but one I am curious about personally...

I have not been on any kind of meds, but have had depressive tendencies for a good set of years and have been going to counseling for 2+ years. That's helped, but I think what's really helped is that in the last 9-10 months I've been hitting the gym regularly (at least twice a week, up to five times a week). I am noticeably less negative and less prone to depressive bouts, particularly in the last half of those months.

I've heard that regular exercise can have the same effect on a person's depressive state as some medicines... but that it takes longer to see those effects (rather than just taking instant-acting drugs, you have to go to the gym for some 6 weeks or so?). Is this true? And if so, why don't more doctors prescribe regular exercise instead of drugs? Is it the instantaneous gratification thing, or does it really just not work as well?

Hey Hal. . . being jaded, much of what I do lost it's shine many years ago. Having said that, I am interested in personality theory (related to both psychopathology and couseling/psychotherapy). Even though I don't provide formal psychotherapy services any more, it was the most gratifying skill that I learned. I think a big part of "why" is that in reading the most influential theory books, I realized that they were the works of truly great minds, intellectual giants who also understood how to communicate, and just being able to grasp the concepts and apply them in my work made me feel like I had accomplished something significant.

My favorite patient populations to work with are inpatients (although the ones who are only interested in "3 hots and a cot" until their disability check comes in and they can go blow it all on alcohol or drugs lose my interest pretty fast). Inpatients who really just want to get back to the humble lives they have made for themselves make my job feel meaningful. Plus, their stories and experiences are always interesting. Being a sophisticated city slicker, it is enjoyable to me to be in the presence of such unpretentious honesty on a regular basis.

Neuropsych is the wave of the future, and it is the area where I spend most of my reading and continuing education time. The more we understand the relationship of gentics, and of neurotransmission, with mental illness, the more exciting the drug development programs become. The most promising research paradigms are all based in neuropsych imho.

Social psych, sociology, and child psych are not really interests of mine. I was not blessed with the patience to work well with children, and we are already bombarded with so much "sociological" data from the media and market researchers that it has become associated with sloppy research design and meaningless results in my mind.

My other interests include fast cars, fine women, gourmet food, and speckled puppies, not necessarily in that order. :)

I recall seeing data showing that regular excercise has a benefit on depressed mood, and I would not necessarily doubt that it may have similar efficacy to psychtropic meds in individuals with mild depression/dysthymia (which sounds like the mood disturbance you experienced).

A good psych will recommend healthy life habits- including excercise, healthy diet, and regular social activities- as part of the treatment plan for a depressed patient. However, one of the symptoms of depression is that a patient loses motivation and energy, and just can't drag themselves to the gym, to a social event, etc.

As I mentioned in an earlier response, most psych's realize that the way someone lives their life, and the attitude or preconceived notions with which they live their life, contribute to depressive episodes. If fundamental changes are not made in the way they live their lives, they are likely to experience episodes of depression over and over (or will reside in a constant state of low-grade depression/dysthymia). We are social beings, and we need healthy social relationships to enable us to view ourselves in a healthy, positive light.

Going to the gym regularly is helpful in a variety of ways: it provides structure to our daily lives, relieves stress, provides regular social interaction, makes our bodies aesthetically pleasing, boosts our immune systems, and seems to have a positive impact on the balance of neurotransmittors in our brains. However, it is not a "cure all." I've known plenty of people who worked out regularly yet struggled with depression pretty regularly.

Unfortunately, there is no panacea for depression. As such, it would be irresponsible for a physician to withhold a reliably effective treatment (i.e., anti-depressants) from our patients in the hope that maybe going to the gym, yoga, tango lessons, or bingo night at the local Catholic Church might do the trick.

Fred, I haven't used Wellbutrin for migraine prophylaxis. From my experience, my reading of the literature, and consultation with headache specialists, the consensus seems to be this:

Topomax is the first line agent, as it will result in about a 50% reduction in headache frequency for 50% of the patients who take it (and it can also cause you to lose weight, but can adversely affect your short-term memory);

Zonogran is a very similar agent to Topomax in terms of side effect profile, but perceived to be slightly less effective;

Depakote might be the most effective agent, but it can cause weight gain and most migraineurs are women;

Amitriptyline (brand name Elavil) is an old tricyclic antidepressant which also has good efficacy in migraine prophylaxis, but is pretty sedating.

If I were you, I'd use whatever works for me. If the Wellbutrin doesn't work in the long term, I wouldn't be shy at all about trying Topomax, Zonegran, etc. Also, as for your reaction to Depakote, I wonder if the primary care physician dosed it properly. Migraine doses of Depakote are pretty small to have caused such a dramatic reaction. Also, I would go to a headache specialist rather than a primary care doc if my headaches were so frequent and so debilitating.

Thanks for a thorough and informative reply, madp. You answered my question very well. I certainly don't mean to imply that exercise is a panacea for depression; you are right, I have known many exceptionally athletic people who still suffer from depression. It is part of a greater suite of treatments that could be applied, in different combinations, to each individual.

I have certainly gone through times when I simply lacked all desire/motivation to go to the gym on a regular basis, and I often lack motivation to attend social events (even now)... though this doesn't usually make me depressed, since I am an introvert and tend to be happier with fewer people around me.

I guess what shocked me, and where my question came from, was seeing the improvement in my own mental health in conjunction with increased exercise. If I had known it would have helped *that* much, I would have started this regimen earlier! :lol: But if I was still struggling with depression, even after a number of lifestyle changes, I certainly wouldn't hesitate to inquire about certain medicines that would help me with that... because then it would obviously be something biochemical.

I think what has been bothering me about *some* people's use of anti-depressants is that they don't go through with lifestyle changes in addition to the meds. My mother has been on Xanax, then Paxil, for a good 10-12 years... she has never really exercised, is overweight, and continue to have very low self-esteem, controlling behaviors, panic attacks, and all manner of other issues. She is usually resistant to counseling, though says that her meds are what "keep her sane." I guess I wish the doctor would prescribe something in addition to the meds... like a gym trainer who would, in effect, force my mother to get to the gym and try to work out on a regular basis.

Anyway, sorry for my ramble, but thanks for your answer again. I understand the complexity of treating mental health issues... but you have illuminated a new aspect for me. :)

It's the same story with many different meds. Take, for example, the class of cholesterol-lowering drugs known as statins (Zocor, Lipitor, Crestor, etc). Many people, despite repeated warnings and admonitions from their doc to excercise and change their diet in order to reduce their dangerous cholesterol levels, fail to make the recommended changes. The end result is that many people who could control their cholesterol with a healthier lifestyle instead depend on a drug, and a very expensive drug at that. Then, they bitch and moan about the cost of prescription medication, and want the government to force pharma companies to lower their prices!!???!!!

Hey Grandpa! Put the bacon-cheeseburger down, walk up and down your block a couple of times a day, and you won't have to spend so much money on prescription drugs! Capice?!!!

That actually worked with one of my borderline clients. :D

Thanks for the great information,
Uber jaded, ex-psych

Lol, one of the reasons I decided not to go into counseling. I had a feeling I would want to say that all the fucking time. :)

Leading the horse to water is the easy part. . . getting them to drink is another story!

Hello madp!
I'm wondering what are the best ways to support a friend going through depression? You previously mentioned that they tend to lack the energy to do things (like exersize) or go places...would it be best to strongly encourage them (i.e., drag em out)? Encourage and then leave them alone? Let them know consistently that you are there for them? Be a source of positivity?

Like many people, I have friends going through very tough times. This one in particular is aready receiving counseling and I believe is taking a prescription for meds. They're doing their part, as far as I can see.

I don't want to get *over-involved*, but I do want to be as effective a support as I could possibly be.

Hubby had a siezure as a result of a head injury. About 11 mo later he was struggling with some depression (partly because of his injury) and his physician prescribed Zoloft to help deal with it. When Hubby finally reached the full dosage (he was started on a lower dose and then worked up to the one the Dr prescribed) that same day he suffered a second siezure. This second siezure occured about one year after after his first. What I discovered after reading up on Zoloft online at WedMD and Pfiser's websites was that Zoloft was contra-indicated for individuals who had had any siezures. When I confronted the physician with this information he denied it and said there hadn't been any risk and this was just a fluke. This particular physician has also done other things with members of my family that cause me to question his reliability. What I'm asking is, 'Is the physician telling me stories? Should he have at least warned us that this was a possibility? Are there any other medications that would have been more appropriate for hubby's particular situation?' Unless there was a severe malpractice problem I would not pursue anything but I am asking for my own peace of mind. I'm unsure that I should trust any of my family (parents and grandparents included) to this particular physician.

I think it depends on the severity of the depression, but I think it's always good to maintain the consistency of your friendship (e.g., frequency of phone calls, invitations to socialize, etc) even if they individual is unresponsive to them for a period of time. Obviously, having a steady, reliable friend is a great asset for someone who is going through emotional difficulties. The irony is that people often alienate their friends when they are going through difficulties.


Reanna, there is a range of competencies among physicians. Some are brilliant, thoughtful, and thorough, others are completely incompetent and out of the mainstream in the way they practice medicine. Some do a great job with certain types of patients, yet are challenged by treating other types. I am curious as to whether to doctor treating your husband for depression is a psychiatrist or a general practicioner. This can influence how much he/she knows about risks associated with certain drugs.

We have known for some time that certain anti-depressants, while they don't cause seizures, can lower the seizure threshold for patients that are vulnerable to seizures. Wellbutrin is the one most associated with this risk, but Zoloft is not typically considered to be highly associated with this risk. However, the "coincidence" of the seizure occuring immediately after increasing the dose is suspicious in my opinion (meaning, it's something to mull over, but not necessarily proof that the Zoloft is responsible). Also, they specifically excluded individuals with a history of seizures from their clinical trials, possibly demonstrating that there is something about this class of drugs that makes the FDA nervous about using them in seizure-prone patients. This is information that I would definitely share with a patient who has a history of seizures. Some docs are so afraid of malpractice suits that they don't always "come clean" about remote risks associated with drugs when the rare occasion occurs that these risks come to fruition.

Before I can really tell you what I might do if I were in your husbands shoes, I would need more information. First, what types of seizures does your husband have? Second, what medication and dose is your husband on to treat the seizures, and has he tried other medications for the seizures? Third, what other medications besides Zoloft has he tried for depression?

With this information, I can tell you what my thought process would be. From your brief description, I don't believe that anything that could be considered "malpractice" has occurred. However, I agree with your suspicions that your current physician might not be the man for the job considering your husband's unique clinical presentation.

The Dr was a General Practitioner.

Hubby was not on any antiseizure medications at the time that he began taking Zoloft. This was because the seizure that he did have previously was directly related to his head injury. After 6 months they tested him and took him off the Dilantin.
His primary seizure was a grand mal. I suspect that hubby had numerous petite mal seizures not long after his injury because I would be talking with him and he would stare and blank out for 30 seconds at a time and miss what I'd said or done. I thought it was a result of the Dilantin he was taking at the time because he would slow down a lot after taking each dose and then perk up shortly before the next dose was needed. I thought he was just slowing done. It wasn't until his second seizure that I began to think back and wonder if he wasn't having minor seizures.

Hubby has not taken any more medications for depression. After his second seizure he was put on Lamictal (for seizures) and has been on it ever since. He's managed to get more active and get out more and I believe it helped his minor depression that had come on after his injury. The lamictal does not have NEAR the negative side effects as dilantin did for him and he's fairly content with it. His mood is even and relatively positive, so that he doesn't feel a need to take any antidepressants at this time.

Head injuries cause what is known as "partial" seizures, and they can grow into what is called a "secondarily generalized" seizure (partial = petit mal; generalized = grand mal). However, if you control the partial seizure, you prevent the secondarily generalized seizure from occuring. I would bet the farm that the "episodes" you witnessed with your husband were types of partial seizures.

If I were in your husbands shoes, Lamictal would be my first choice for treating the depression. Lamictal was introduced as a treatment for partial seizures, and has recently been recognized as an effective treatment for bipolar depression. While it doesn't have an FDA indication for unipolar depression, there is alot of anecdotal evidence that it is effective in these cases as well. Thus, the drug can kill two birds with one stone: help prevent seizures, and help treat the depression. For me, it would be a no-brainer.

A few of caviats:

First, seizure doses of Lamictal tend to be larger than depression doses (e.g., 400mg/day vs. 200mg/day), so there is no guarantee that a depression-sized dose will effectively control seizures. Dilantin (phenytoin) would be the last drug I would be on for seizure control over the long term because, while very effective, it potentially causes too many complications. There are at least 6 drugs I would want to try *before* settling for Dilantin, but neurologists have been using it for so many years that they are quite comfortable with and competent at managing Dilantin patients.

Second, due to the risk of a very serious rash known as Stevens-Johnson syndrome, Lamictal has to be started very slowly. However, all psychs and neurologists are aware of the risk, and will titrate the drug very slowly (which *greatly* reduces the risk). Stevens-Johnson occurs *very* rarely when the drug is used properly, and the rare cases I have seen have been caused by a general practicioner who was not adequately experienced with the drug.

Third, if a patient starts Lamictal and it either doesn't work for them, or they have side effects that they can't tolerate, it must be discontinued very slowly (i.e., reducing the dose a little at a time) due to the risk of inducing a seizure if it is discontinued abruptly.

Finally, I would not allow a general practicioner to treat my depression given the history of seizures. I would seek out a competent psychiatrist, and I would lay out all my concerns on the table. I would also lay out my expectations that he share his thought process with me, and be completely up front about risks associated with my treatment given the experience I had with my general practicioner.

Again, I am not giving you or your husband specific treatment recommendations. I am just sharing with you what I would do if I were the patient. Take it for what it's worth!

*EDIT:* I missed the part of your post where you said your husband is now on Lamictal. I think that most neuro's and psych's would agree that this would be the first med they would try in your husband's case, so it sounds like the problem is taken care of!

I have a some question's.

My mother has Paranoid schizophrenia. I know a lot about it.
So what is the % that it could be passed on? I am afraid of that, because I do want to have kids someday.

I have a doctor but she's the type you go to if your sick.
I want to know what type of doctor do I need to go to, to talk about my Mental Health to?

I think I have some sort of Mood Disorder. I have some in mind. I hope it's not what my mom has.
I think it's one of these: *Bipolar disorder
*Attention-deficit/hyperactivity disorder (ADHD)
*Borderline personality disorder
I am always Irritable. I Have a lot of Mood swings.
I have a Inability to deal with stress, I kinda get frantic about stress.
I have a Difficulty controlling emotions.
#1 Anger, sometimes escalating into physical confrontations(I hit or feel like wanting to hurt someone or something)
The list goes on and on.

So, I was thinking about writing down a list of mood problems that I have and I was going to have some family members of mine, my husband and a friend help me list things I do. Then wanted to give it to my Doctor, she is just a normal doctor though.
What do you think I should do?

Thankyou much for clarifying things for me.

Hubby did have a "secondarily generalized" seizure that resulted in a grand mal siezure. I recall watching as the right side of his face began to seize and then it spread from there through his whole body.

His is under the care of neurologist for his Lamictal doses and sees him yearly. He has not had any further seizures for the past 3 years so the dosage seems sufficient.

I wrote the following things a while back, and I no longer feel as bad as I did, but I'd still like to hear what you have to say about it.

I feel really bad all the time and I just wanted to see if anybody has any ideas of what I should do. I've been depressed for almost three years, and have been on celexa, prozac, and effexor all for at least six months each. None of those medications have seemed to do anything. Recently, my emotional state seems to be getting a lot worse. I wake up feeling terrible, an odd kind of bad feeling, like something you would feel in a dream. I feel like I am not in the same world that I have been living in. I feel like I'm part of some nightmare where everything just feels bad. I feel nothing for people I used to love. I will talk to these people and they will just give me all kinds of weird feelings that make them seem like strangers, and this just makes me feel worse. It hurts me just to talk to my mom or dad or girlfriend, so I don't. They will say things and immediately I will just hate them for it, or think they are stupid, but I don't want to be thinking these things. They just pop into my head. I just want to sleep all the time because I can feel good in my dreams. Have you ever been so scared of something real. For instance, you found out your dad has cancer, and the fear or some other bad feeling worse than fear, dread maybe, just takes over your life. Every moment of the day feels like that. Like dread is what is happening. That is how I feel but for no reason it seems, and these facts just make me feel worse, and then that results in other effects that make me feel even worse. My life has no plot except that it is bad. I hear people tell me they love me and it doesn't feel like anything to me. I can't feel anything good at all. I'm also in school, and I can't go to class because it makes me so nervous. I'm not worried people are thinking bad things about me or that I might say something stupid; I'm just worried. I just keep wishing I could go back in time. People take for granted that good things will make them feel good and bad things will make them feel bad, but I feel like nothing can make me feel good, and everything makes me feel bad, like my brain is just some program that produces bad feeling no matter what the input is. I know I need help, but I can't help but doubt that there is any help. I hear that antidepressants make you feel numb and I dont want that, even though I am numb right now. I can't help but think that the meds made me this way. Do you think I should go back on medication? I can't help but feel paranoid about it making me "numb". I mean I feel numb now, but I don't want to be satisfied being numb. Really, I just want to be able love the people that I love. How can something so special be lost so easily. It makes life seem like a joke. All I feel is negativity for the people I once loved and I can't help it. It seems like their importance just faded away like the funniness of a joke you hear more than once, and it shouldn't be that way. Things that are important shouldn't be like joke. I think maybe I just don't like my girlfriend, but then I think about the way I used to feel about her, and I need to get it back. I don't know how to like people. I just get used to them and wear them out, but I don't want to be that way. It seems like all I control is my body, and thoughts and feelings are just coming from nowhere.
Is it possible to change who you are. Everytime someone says something, some negative criticism just pops into my head. How do I stop valuing the things I value?

Thanks for reading.

This may be slightly off topic, but I'm an aspiring neuroscientist toying with the idea of medical school. I'm not sure what specific field I want to go into, but possibly behavioral neuroscience or neuropsychology. Any suggestions? How was your medical school experience? Why did you go into psychiatry and not another similar field?

More on topic: what negative behavioral effects (depression, lethargy, stoicism) might be triggered by birth control?

With so many issues and questions, my best advice to you would be to seek a reputable therapist (either a Clinical Social Worker or a Clinical Psychologist). You need to sort through these issues in your life and figure out what you can do about them. That's really the only insight I can give you based on your post, and I hope you find it helpful.

Stoicism is a negative behaviorial effect?

Stoicism can be triggered by birth control?

Huh.

The feelings and experiences you described sound like a genuine "Major Depressive Episode." Most people who ask for help with depression only experience mild- to moderate-severity depression. Few people understand what true Major Depression is all about. It sounds like you do, and I'm glad that you're feeling better.

There are a couple of meds that are relatively new that have shown promising efficacy in depression: Lamictal (a GABA-ergic agent), and Seroquel (an atypical antipsychotic). Many docs are learning to use these adjunctively with SSRI's in an effort to get better efficacy with true Major Depression.

Having said that, understand that you are at continued risk for another Major Depressive episode. While you are feeling better, you have the opportunity to give structure to your life and to revamp your mental approach to life in such a way that you are better equipped to stave off future episodes. I'm not going to preach to you about how to change your attitude or outlook, but suffice it to say that one's attitude shapes and frames emotioinal experiences. It takes work, inner strength, and support, but learning how to minimize the impact of the world around us on how we feel, and taking personal responsibility for creating a life that will make us happy, are crucial skills to acquire. I hate to use a cliche', but there is nothing outside of us that will make us happy with ourselves. If we look for external sources of happiness and satisfaction, we will always be disappointed.

You have been through one hell of an illness, and I salute you for your resilience.

Unless you are passionately compelled to pursue more esoteric, narrow, and academic career paths, forget about behavioral neuroscience and neuropsychology. There are limited career opportunities with graduate degrees in these disciplines, and there is vicious competition for the opportunities that do exist. I tried out the academic life, and I found it stifling, homogenized, and somewhat divorced from reality, so I am biased on this subject.

Medical school is a decent career path. It's hard work and long hours and crippling to your social life, but it is rewarding in many ways as well.

As for the question about birth control. . . any medication that alters hormones has the potential to affect mood.

Stoicism is DEFINITELY a negative behavioral effect when triggered by a bad date, but I've never tried birth control pills before. :lol:

Stoicism as in emotional and mental apathy, not the philosophical movement. Emotional apathy, on a practical level can hinder decision making, and on a social and personal level can harm relationships and immediate-well-being, among other things. I would consider this a symptom of potential behavioral changes (including clinical depression) because of the presence of novel or changed hormonal levels.

I am passionately compelled, that's certain, but I am also impassioned with a love of many things that may limit my choices in various ways. I've got a lot of sorting out to do amongst my academic, occupational and social/personal life. Being twenty-something is more difficult than I would have expected.

I think it's a noble path, for sure. If I didn't pursue something concerning neuroscience and I attended medical school, I'd consider going into ob/gyn or developing health care in third world countries/parts of the US.

Might there be any preventative measures, such as changes in lifestyle or other medications, that could counter those changes? Do you have any specific knowledge on the affects of female birth control? Trends, et cetera.

Tuft, it's not my area of expertise, but I do know that the implants and injectibles (Norplant and Depo-Provera, most notably) have been associated with a higher frequency of mood disturbance. Also, the pills that have a combination of both estrogen and progestin have a documented greater potential for causing depressed mood than those that contain progestin only.

With oral contraceptives, I've never had a patient complain specifically about it's affect on mood, so I haven't really had to impetus to do thorough research and consultation beyond the basics. Your ob-gyn would know more about the specifics than I do. The best I can do is suggest that an oral contraceptive containing ONLY progestin is less likely to cause or exaccerbated mood episodes than other oc's, injectibles, or implants.

Thanks for the reply. It may be a cliche, but hearing it said by a psychiatrist adds some power to it. Thanks.

What are your opinions on Tianeptine as a treatment for depression and anxiety?

Noah, tianeptine is not FDA approved for use in the US, so it is not a medicine that US psychiatrists use except under special circumstances.

In general, it is a tricyclic antidepressant, yet does not appear to cause the same degree of cognitive disturbance, abuse potential, or disturbance in sexual functioning that other tricyclics can cause.

The efficacy data suggest that it is probably as efficacious as most SSRI's and and other tricyclics. However, there is nothing in the data that suggests it has any advantage over other agents currently available in the US. Furthermore, the manufacturer apparently doesn't believe it that it has any advantages that would allow it to make any headway in the VERY lucrative US market, and thus have not been willing to pay for FDA clinical trials.

One caviat: there is a general belief in the concept that someone's genetic coding predisposes them to be "responders" or "non-responders" to various drugs within a class. Thus, any given individual may not respond to a drug that has tremendous efficacy with the majority of patients who take it, and any given individual may respond like gangbusters to an agent that has poor efficacy for most patients who take it. In the end, the only important question is "how does it work for you?" If you are not currently on the drug, the data suggest that there are probably more promising options out there.

As a lady (and this topic comes up OFTEN in the Ladies' Lounge and Sexuality), I have to say that in my experience, the Ring has been pretty good to me in terms of hormonal BC. I have always been a bit moody in general, but I do think that being on the Patch for a year exacerbated the problem, a bit. Once I switched to the Ring, which is supposed to have some of the lowest hormone levels available (due to its placement in the vagina, practically in the bloodstream itself!), I do think my moods calmed down *a bit*.

I have never been on oral contraceptives or anything injectible, btw, but I have heard that the injectibles really do screw up a woman's body more than any other BC. The least-affecting route (other than barrier methods) is most likely the IUD.

But this is all informal experience... probably be best to talk with an expert in the contraceptive field about that stuff.

madp,

I have been on 20 mg of Paxil for about 5 years now due to panic disorder. I have a very hard time losing weight and keeping it off. When I started on Paxil I was around 200 lbs (I'm 6'2"), now I am around 290 lbs. I am now 26 years old and I eat a 2200 calorie diet and exercise 3 times a week. That should be enough to get me down to around 250 at least. Is the lowering of the metabolism due to the Paxil at fault for my weight difficulties? Or is it the fact that I am now 26 and getting older? Also, I would love to get off Paxil, but whenever I consider it, it seems I have a minor panic attack within a week or so of considering and I don't do it. Any insights?

Thanks

Panic Disorder or Heart Problems?
 

My Family Doctor cannot figure out what is wrong with me, can you offer an opinion? Over the last 6 months or so I have been experiencing heart palpitations very often, and usually many in a row. These happen mostly after exersize, after eating, or sometimes when Im doing absolutely nothing. My Dr feels that panic attacks bring on the heart palpitations, but I feel that the palpitations bring on my anxiety, as they are very scary to have. I was put on Zoloft, 50 mg, which has done nothing at all, even after 6 weeks. The only things that seem to help are beta-blockers, which I dont like taking, because I cannot exersize, or even walk fast after taking them. Not to mention drink any alcohol. As a mental health Professional, do you beleive that a person with anxiety should be having so many palpitations (many per day), especially after eating and exersize?
I know you dont specialize in this field, but could a certain birth control pill (or horomone related issues) alter a persons' anxiety level to the point of panic disorder?
Thanks so much!

I am out of town until late next week, and will be unable to respond in a thoughtful manner until I return.

thx,
madp

Not a problem at all. Thanks for taking the time to respond and have a safe trip.

Weight gain is not a common side effect with Paxil, and certainly not the degree to which you're talking about. And, to be completely honest, that's where my expertise ends on this subject. However, if you want to get off of Paxil, psychotherapists with expertise in cognitive-behavioral therapy have great succcess in helping people with panic disorder completely overcome the problem to the extent that they no longer require pharmacotherapy. If you life in a metropolitan area, there should be an expert or two around. However, if the therapist only "dabbles" with cognitive-behavioral therapy, it is likely to be a longer "trial and error" process.

Getting back to the weight gain. . .if you REALLY eat a 2200 calorie diet and exercise 3 times a week. . . .I'm completely baffled. Is this degree of obesity (and let's face it. . . 290 at 6'2" is dangerously obese) common in your family? Are you on any other medications? I'm afraid I don't have any insight, but I would go see an endocrinologist if your diet and exercise routines are as you describe them. That just doesn't make any sense to me, and quite frankly it doesn't sound normal.

Panic disorder can definitely cause heart palpitations, and most people who go to the ER thinking they are having a heart attack are actually suffering from a panic attack.

Having said that, there are way too many things that could be causing your palpitations for me to even give you an educated guess. I often ask people if they take any decongestants (i.e., claritan D, Allegra D, Pseudophed, etc), or drink excessive amounts of strong coffee, because all of the above cause heart palpitations like an MF. But again, there are just far too many possibilities for me to give you any kind of meaningful or reliable response. Sorry. Go to a cardiologist and get a stress test if you aren't happy with the answers you're getting from your primary care doc.

Also. . . a brief afterthought. . . Paxil is generally considered to be the SSRI of choice for people suffering from panic disorder.

tamiks8 - I will also re-emphasize that you should talk to a GOOD cardiologist. My mom has had a very similar-sounding history - wild heart rate jumps for seemingly no reason, as well as when trying to navigate stairs or just walk. She's older than you, I'm sure (63), but... I thought for sure it was panic attacks. But nope. She has a fantastic cardiologist who is getting to the bottom of things. A big part of her problem was that she's hypertensive (HBP), and has a weakened valve (I think the AV valve, but I'd have to confirm). Also, she has anemia - the type where she has too many RBC's, so her blood is thicker and harder to pump.

There are a lot of factors that go into these things, and you should talk to a doctor that will look at the WHOLE picture, and not just the part they're good at.

For people with aspergers like my self, I've found that I have immense problems starting out relationships of any kind. What are some books or groups that can help alleaviate the problems of dealing with society that makes my life so stressful?

Roadkill, Aspergers support groups can be found in most cities. Also, for social activities, go for things that provide structure to the interactions (e.g., volleyball/basketball leagues, continuing education classes, yoga, church groups, etc.). When the social situation has some degree of structure and mutually agreed upon purpose, most people find it much more comfortable to interact.

Beyond those common exceptions, a therapist who has experience with Aspergers syndrome would probably be able to help you put together an individualized strategy for coping and bringing the stress level down.

Thank you for your help.

Also, albuterol (the most common form of inhaler for asthma) can cause heart palpitations.

Dr.,

Thanks for all your previous responses.

Do SSRIs, specifically Lexapro, have any effect on testosterone levels, muscle building, or strength gaining, or anything else related to that kind of stuff?

Also, every time I am taking an SSRI I get worried that the medication os going to "burn out" some part of my brain, or make it so that I need the medication to stimulate a certain part of my brain. Is there any reason for me to think something like this could happen?

Thanks.

Hey Jaded Mental Health Professional,
My ex-fiance left me about 6 months ago. We have had a relatively stable 4 year relationship. She took a one month trip and called me at the end of the month to tell me she had met the most wonderful person in the world. The conversation continued with her saying that she wouldnt be coming back home. Ever. She hasnt returned. She remains in contact with her family, but that is all. She even left her teenage kids with her exhusband, even though she had full custody. She has a history of Borderline Personality Disorder, and all that it implies. I know I should have run from her in the very beginning, but it was an intense relationship that I dont regret. How common is this behavior with BPD? What do you think is going to occur to her long term? Thanks.

Hi madp,

I have a question for you so here goes.

I grew up in an alcoholic/drug addicted family. Both my parents, there second, and third marriages, and numerous boyfriends and girlfriends all were raging drunks/addicts. Three of my five brothers also struggle with these same problems, and so do various aunts, uncles, and cousines.
I rarely drink, maybe twice a year, but even then it's still only light social drinking. Bieng around alcohol or even just the thought of it gives me severe anxiety. I am really actually jealous of people who can drink and have fun, because I feel I have been cheated.
Now here is the problem, every man I meet turns out to be an alcoholic. It's almost like a sick joke. And no, I am not picking them up in clubs or bars. I really try to screen them, but it seems its always hidden at first. There must be be something subconscious I am doing/looking for. I know I have a co-dependant personality, but I swear I make a conscious effort to avoid these situations.
Of course I wonder if it could just be that my image of alcohol is severly distorted?
I dont know if you can give me any advice, but I thought I would put it out there. Thanks.

man, when i go to sleep i dont dream.

i cant remeber the last time that ive had a dream. its something thats been bothering me for a while.

Thanks for doing this!

I suspect that my wife is mildly depressed - in that she seems to have more bad days than good, and that sometimes she gets in a 'funk' where nothing can cheer her up...and they seem (to my unexpert opinion) to be more serious and frequent than the normal 'blehs' that everyone gets. I should mention that both my mother and my brother suffer from depression - both of them exhibit symptoms much more severe than my wife...but I think I see the same kind (thought not at anywhere near the same level of severity) symptoms in my wife. My question is, what, if anything should I do?

A few years ago, I finally convinced my wife to see a psychologist, and, honestly, I don't think she did anything useful...she proscribed some meds (I don't remember which one at this point), and said essentially "see you in six months"....my wife said the meds didn't help, and didn't go back.

So, it continues...again, it seems to be very mild as far as the symptoms go - no suicidal tendincies, or anything like that, but...just too many 'bad days' for no good reason. I've tried of couple of times since the last Dr. that maybe she could try someone else, but she hasn't yet. I feel like if she talked to someone who actually cared and worked with her, maybe she could get some help...maybe with medication, maybe not, I don't know.

So, what do you recommend? Should I keep 'pushing' her to make an appointment, or should I back off and wait until she's ready to do it on her own? It's very frustrating to me, because *if* she does suffer from depression, it is very mild...much of the time she's just fine.

problems with husbands mental depression
 

Ok my husband has a lot of problems, I dont even think his psychiatrist understands him. His depression has lead him to cutting and trying to overdose a few times. He has a lot of anger issues, has been through anger management, and it didn't help.

His medicines include Wellbutrin 300 mg/day- for his depression, Trileptal-2400 mg/day for anger, Cymbalta- 60 mg/day for chronic knee pain and for premature ejaculation, Thoriazine - 50 mg as needed for anxiety, Risperdal - 4 mg at night for sleep, Fentanyl patch 50 mcg/hr- chronic knee pain. None of his medicines are really helping his depression, nor his anger, even though his fentanyl does help his knee pain (he was shot in the knee and has serious tissue damage).

He goes through a lot of mood swings and his nerves are really messed up. He shakes uncontrollably when he gets anxious, and starts to throw fits so to say. He has anxiety attacks 2-3 times weekly. His psychiatrist changes his medicines once every month or so, because nothing seems to work.

He has been on Lexapro, Seroquil, Trazadone, Paxil, Effexor, Abilify, Remeron, Neurontin, Haldol, Klonapin, Ativan, Visteril, and god knows what else. Hes immune to everything he takes, and when he does start to feel better, a month later, things get worse. I dont know if his psychiatrist is putting him on way too many meds, and something isnt working right, or if he is just going to be stuck with his problems forever. He can't work due to his problems, and has been waiting on disability for 17 months now, so we're kinda poor.

I don't know what to do. There is only one psychiatrist in the area, and everything outside of town doesnt accept our insurance. I'm kind of giving up, because I feel as if there is nothing left except to dope him up on thoriazine. Any suggestions?

i posted this before but the thread was cleared before i could read the responce.

i dont dream. i cant remember the last time i had a dream. it makes me think sometimes...any ideas on why?

where'd ya go Doc ?
 

just when i was going to take advantage of the free advice, you go on sabatical :rolleyes:

just kidding, hope everthing is ok.

what you are doing is "fantastic", and from reading the responses, helping lots of people ... kuddo's! :thumbsup:

here's my question: is there a real difference between ADHD & ADD? & do you think you can grow out of ADHD & have it become ADD?

What is the name of the condition where a person believes they're invulnerable? Even in situations that pose immediate, obvious physical harm the person doesn't think they will be harmed. I heard the name of this some time ago, but forgot. Hopefully I've given enough information.

edit: I thought of something else. I know hallucinations of feeling bugs/insects crawling on oneself are common for people with psychosis, and I think psychopathy too. Are there other conditions or situations that could cause a person to feel this?