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  • Can Adderall and an antidepressant be used at the same time?
  • What are ‘Bath Salts’?

 Other questions answered below:

    • A reader asks about taking both Adderall and an antidepressant. 
    • A reader asks about AA (Alcoholics Anonymous)  and the treatment of depression.
    • A friend asked how she might know if someone she cared about would accept help for what seemed like severe depression and perhaps PTSD?
    • A reader, J, asks about hypnosis as a treatment for alcoholism
    • A friend asked how she might know if someone she cared about would accept help for what seemed like severe depression and perhaps PTSD?
    • A university colleague from New York State asks about anti-depressants and weight gain
    • A reader asks about depression, anxiety and fibromyalgia
    • GL asks about Obsessive Compulsive Disorder and hoarding
    • A reader asks about her sister, wondering about what is causing her problems and how she can help her get the care she has so far been reluctant to pursue.
    • KC asks how she can know if her treatment is working? 
    • JS asks: what can I do with my 24 year old daughter in the midst of an acute bipolar illness with drug abuse?
    • A reader asks: How can I get off my medications?
    • Many have asked, is there a relationship between mental illness and violence?
    • Why do people with a mental illness or addiction seem to smoke so much and what can they do to quit?
    • A daughter asks how to recognize when psychiatric medications are causing problems in elderly people?
    • A reader asks what is the connection between stress and illness?
    • A clinical colleague asked: what do we know about the risk of relapse from cocaine?
    • What do you do in the Emergency Department when there is a life threatening mental health problem?
    • A mother asks about her adult daughter and whether certain drugs can damage the brain? 
    • How do antidepressants work? 
    • A daughter asks how to recognize when psychiatric medications are causing problems in elderly people?
    • A colleagues asks how can managers help improve workplace mental health during this stressful economy?

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A reader asked: Can a young adult take both Adderal and an antidepressant?

drlloyd: If a person has a lifelong (beginning in elementary school) history of ADHD and benefits from stimulants and also has a moderate to severe depression and wishes to be treated with medication for that condition as well, then both a stimulant and antidepressant can be used. There tends to be more of the use of SSRI’s (prozac and lexapro which also have indications in people under 18) – but not exclusively. This is an important decision to be made between patient, doctor – and at times, family.

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What are ‘Bath Salts’?

‘Bath Salts’ Aren’t What They Used To Be….

Remember when bath salts were what you put in hot water before you lowered yourself into a bath so you could have a wonderful soak? Well I suppose you can still get these but sales of another form of ‘bath salts’ are reaching new records – and bringing grave health hazards. While news of their popularity (and risk) has circulated for some time, there is very disturbing information just out.

The Centers for Disease Control and Prevention (The CDC) has released the first report on thirty five (35) patients who appeared in Michigan Emergency Departments (EDs) from mid-November 2010 until the end of March 2011. One of the people who ingested the ‘bath salts’ was already dead upon arrival at the ED. The others suffered from severe agitation, rapid heart rate, high blood pressure, paranoia and other psychotic symptoms including hallucinations and delusions (ideas contrary to reality and not responsive to efforts to correct them with reality). Some of these patients were violent. Half of those who came to the EDs required hospitalization, half of those were admitted to the intensive care unit. Sixteen of the cases had pre-existing mental health or substance abuse problems.

‘Bath Salts’ are stimulants, cooked up in underground labs. They are sold on the internet, at head shops, convenience stores and even some gas stations. The packages typically contain methylenedioxypyrovalerone (MPDV), mephedrone and pyrovalerone, all amphetamine-like in their action. The drugs are taken by mouth and sometimes inhaled or even injected. Needless to say, the last two routes of administration are associated with the worst reactions. While stimulants are controlled drugs, the labs often produce variations of existing drugs to avoid regulation.

Bags of ‘bath salt’ sometimes have written on them “Not Intended for Human Consumption.”  New York State’s Health Commissioner, Dr. Nirav Shah, banned their distribution (http://www.health.state.ny.us/press/releases/2011/2011-05-23_bath_salts.html). Several states have proposed legislation, as has happened federally, to prohibit these substances, but the law is a slow tool in a rapidly moving market. These substances are also marketed as ‘plant food’ and ‘pond water cleaner’, and in many other ways to elude detection and control. In other words, it will be the same word of mouth that has driven their consumption that is needed to control it.

Speak to your friends. Talk to your children. Doctors, mental health and addiction counselors warn your patients. Let them know: The bath you take with ‘bath salts’ is dangerous and at the deep end of the toxic pool.

Originally published on May 26, 2011 in the AOL/Huffington Post – Healthy Living Section

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What is Acupressure?

You can think of acupressure as “acupuncture without needles.” It is a branch of the practice of traditional Chinese Medicine that aims to promote the proper flow of energy, the fundamental life energy in all of us, using the hands, or herbs, or acupuncture needles.

Perhaps you have heard the term “Qi (or Chi)”, or Ki, or Gi, Chinese or Japanese or Korean terms for the energy inherent in our bodies. Eastern ‘medicine’ for millennia has held that when the flow of Qi is obstructed or hindered all varieties of malaise and illness befall us. Problems with Qi flow can manifest in troubles as diverse as musculoskeletal pain and stiffness, headaches, digestive and sleep disorders, not to mention emotional stress and distress. The task of the Eastern practitioner, thus, is to relieve the Qi blockage, hence helping the patient heal and feel energetically revived.

The branch devoted to the use of pressure points to restore energy flow is called the practice of acupressure. In Japan, it is called Shiatsu, in Korea, Sugi. Sugi literally means hand and energy. Acupressure is different in two principal ways from the many bodywork techniques available today: First, it does not use oils and lotions that bodywork typically employs to aide gliding and kneading strokes on bare skin and the underlying musculature; instead the practitioner applies finger pressure on specific sites of the body. Second, and more importantly, acupressure is directed by a carefully studied and intricate system of some 360 points and 12 meridians on the human body, the same orientations used in acupuncture and considered functional (and externally available) extensions of our internal organs.

I recall the first time I had Shiatsu in a small, spa town in Japan many years ago. A middle aged, dowdy looking Japanese woman with a purse from another era over her arm came to my room. After about a ½ hour I had to stop, and it took me a couple of days to recover from the pain. I attribute that pain to the fact that I was not prepared to let myself relax and let the pressure do its work. Once in Thailand another pressure practitioner began to walk on my back, all 110 pounds of her. It was an experience I wanted to repeat – with someone who I knew had studied and practiced the art.

As a practitioner of Western medicine, I have seen the marvels that science has brought to remedying disease. But we all have seen, as well, how the limits of Western medicine have prompted the growth, in many countries outside of Asia, of what is called alternative and complementary medicine. That’s because we seek more than what western medicine has to offer.

If I have an infection, I want an antibiotic – give me a western approach to my disease. But when I have stress, a pill is not what I want. And even when I am taking a pill or other western treatment for many a condition I want to give my body the resilience and strength it needs to recover. Wellness is truly complementary to treating illness. One does not exclude the other. What so many people now seek are techniques that release the body’s energy to help clear the mind, relieve the body’s ails and knots, and improve our mood. Practitioners are more likely available in cities but not only there. A website that nicely explains Sugi Acupressure is www.sugiacupressure.co

Rousseau was said to have exhorted “bring me medicine, not the doctor.” But that was before the east began to join the west, before western medicine could be combined with complementary eastern techniques. Now we don’t have to choose just one.

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A reader, J, asks about hypnosis as a treatment for alcoholism

Dear Dr. Lloyd,

We have a relative in her 40′s, Native American, adopted at birth that has an alcohol problem. She was raised in your classic white middle class family that seems to have done a good job. She has great values and finished University. Over the past decade, she has been to rehab and at times stopped drinking but falls back into the need for alcohol. She has been in and out of therapy, and we have her back into therapy today. She has tremendous amount of anxiety and fear with heavy nightmares, it seems almost childlike, irrational, but true to her. In her 30′s, she met her biological mother. They are friends today at a distance, it seems the big hug needed never came. It turns out, her birth father was a second generation alcoholic until his death. They corresponded a few times and that went really badly, he had great anger and hostility burst. She has a bit of that as well.

We seen her at her best and worst, therapy and rehab are a short bridge but we doubt a long term solution. She doesn’t have medical insurance and it causes stress, now that she has additional health issues.

We learned that her first experience with alcohol was at the age of 13, and it really never stopped. It seems she is programmed to wake up in the middle of the night to drink as no one interferes or judges. Is there a Hypnosis therapy that can assist in reducing the pre-programmed process?

Thank you, J

 Drlloyd responds

Early onset alcoholism, as you describe, has a genetic component. Even in a non-alcoholic family environment a person with this genetic disposition can develop the disease.

To my knowledge, there is no scientific, evidence base that has established hypnosis as an effective treatment for alcoholism. Hypnosis in general, regardless of the change someone seeks to make, is more successful when a person is ready to make a specific change in his or her behavior (called readiness to change) and can be shown to be receptive to trance-like states and suggestion.  

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A reader asks about AA (Alcoholics Anonymous) and the treatment of depression.

Dear Dr. Lloyd:
At times in my life, I have abused alcohol.  I have not had a drink for over ten years.  There are many people in Alcoholics Anonymous who speak out against antidepressants or other psychotropics.  Some base it on their own experience, some on their own opinion.
I am 1000% (thousand :) percent positive that my sobriety is more a result of the antidepressants than A.A., although meetings were very useful in the first few years. I am so angered and troubled by the issue and having to be “in the closet” about medications that I would just as soon not go to meetings.  I also did not know I had Celiac disease and had severe problems with fatigue, depression, pain, etc. for many years.  This reinforces my firm belief that depression is a medical illness.  Your feedback would be appreciated.
Thankfully Yours, CG

drlloyd responds:

Dear AA member with a medical illness, Depression, major depression with its profound impact on how we feel, think, act and which terribly diminishes our ability to be productive in our lives and puts us at peril to take our lives, IS a medical illness.
The AA proram you describe has got it all wrong — at least the AA group(s) you are attending.
Do they criticize people with diabetes for taking medicine to assist their pancreas and insulin which is not working well enough?
Do they criticize peope with high blood pressure for taking anti-hypertensives, or people in heart failure for taking diuretics?
Not all AA groups are like the one(s) you describe. If AA continues to serve you, as it does so many people, try to find a group that has come to appreciate how depression, a medical illness, frequently occurs in people with alcohol and drug problems. A group that understands that unless the depression is properly diagnosed and effectively treated that staying sober is far less likely to occur.
Thanks for writing, and congratulations on your continued sobriety and for getting effective treatment for depression.
drlloyd

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A friend asked how she might know if someone she cared about would accept help for what seemed like severe depression and perhaps PTSD?

 Drlloyd responds:

She was asking a critical question about a person’s readiness for help. There can be a great difference between a person’s degree of suffering and their willingness (readiness) to seek help. It is readiness that helps someone take the first step.

Here is how I like to go about determining readiness. It involves a few simple questions:

First, ask what do you think is the matter? You may be surprised by the answer, which may be different from what you imagine. For example, you may think it is feeling depressed but you may hear that it is fighting with mom, or losing a friend who is at the end of their rope with all the excuses. It is so important to know the other person’s perspective because that is what concerns and motivates them.

Second, ask what are the ways in which whatever that person says is the matter is causing them trouble or pain?  What you are asking is what will enable someone to do something because unless that person sees the trouble or pain they are experiencing they are really unlikely to do something about it.

Finally, and only if you have been able to get answers to the first two questions, can you then ask what are you willing to do for yourself (or others you care about)? Are you willing to go to see a doctor? Are you willing to see a mental health specialist? To get support from family, friends or faith community?

We all want to help those we love and care about. But succeeding may depend on whether they are ready. If not, don’t give it. Keep trying and asking.

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A university colleague from New York State asks about anti-depressants and weight gain

  Hi Dr. Lloyd – I’m sure you get this question repeatedly.  Are there any anti-depressants other than Wellbutrin that are not known to cause weight gain?

 Thank you for your time

AL

 drlloyd responds:

Indeed, you are correct that Wellbutrin® (buproprion) has an evidence base for not causing weight gain. It also can be helpful in men who experience sexual side-effects from SSRIs.

Speaking about the SSRIs, when they first went on the market there was the suggestion that fluoxetine (then Prozac®) produced weight loss. It appeared it did – but only transiently. After some months there was evidence to suggest that many people gained weight on it.

It is important to stress, nevertheless, that side-effects from a specific drug – like weight gain – affect some people and not others. Weight gain may be common with anti-depressants (except buproprion) but that also means that some people will have the problem and some will not. Which anti-depressant may create that problem in any given person is a question that only a trial on that medicine can determine.

Thanks for asking.

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A reader asks about depression, anxiety and fibromyalgia.

I cannot wait to read more of the testimonials on your website.

I have had clinical depression and acute anxiety, with fibromyalgia.  Now I feel like I am on the right medicine, and most of the time I feel great. I have been on the same medicine that is working pretty good for the last 3 + years. I love being at home instead of going someplace most days – I find that lonely but I am not too interested in making a new move on doing something else. I did give up all my old hobbies and cannot get back into them. I did have one hobby I loved since this happened and can’t get back even into that. I feel paranoid and do not trust anyone… the reason for this was a job situation and I had a no-fault termination. I worked there for 18 years and planned to retire from there. I feel sometimes useless in my life, and don’t know what best direction to go. All our old couple friends have fallen apart, and to meet new people isn’t easy. So what direction can I go?

Drlloyd:

For other readers, fibromyalgia is an all too common illness where a person experiences pain and tenderness in their joints as well as muscles and tendons. Its cause is not known but it often occurs with depression and anxiety, just as you describe. The Food and Drug Administration in recent years has approved several medications, two are antidepressants, for the treatment of this condition.

But it sounds like while your fibromyalgia may restrict you it is your reaction to your job termination that continues to affect how you feel and what you do in the world. That is a sad situation but one that you might be able to do something about.

People who end work (or relationships) in a way that leaves them feeling emotionally injured suffer a form of trauma. They can continue to focus on the injustice, the shame, and the personal doubt this can create. They can come to feel that many situations may result in more emotional pain and humiliation. To protect against more hurt they avoid other people or new situations. But the result is loneliness and often a lack of purpose in life – both of which carry pain of their own.

If this sounds right to you then you might want to speak with a counselor or therapist. Trauma can be worked through and when that happens a person is much more in a position to find new friendships and activities. While new people and hobbies may be hard to initiate they are far more difficult when the barrier of trauma stands in the way.

I wish you well, drlloyd

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GL asks about Obsessive Compulsive Disorder and hoarding.

Dear Dr. Lloyd,

Can you recommend what you feel is the best book or type of therapy to help a person with Obsessive Compulsive Disorder (OCD) overcome hoarding?

Drlloyd:

For other readers, obsessive compulsive disorder is a mental disorder that can cause great suffering and severely limit a person’s ability to function. Some will remember the movie As Good As It Gets with Jack Nicholson and Helen Hunt, though that may not describe how problematic this condition can be.

OCD is a serious anxiety disorder in which a person experience obsessions (repetitive thoughts that a person cannot rid from their mind like Did I turn off the stove (after checking it 25 times)? Will I be exposed to infection if I touch any surface in the classroom? Did I leave the report with my boss and should I call his office again to be sure I did (even though the secretary assured me twice I did)?   and/or compulsions (when a person repeatedly acts in response to an idea despite knowing that it does not make sense like  I will count to four,  forty four times, then I can leave the house safely. I must wash my hands just one more time (after 10 minutes of washing hands red from previous washings) then I can return to work).

For people with OCD who develop hoarding collecting things grows out of control. Clutter becomes a serious problem and can make it hard to live with someone who hoards. Most hoarders save just about everything, but some may more specifically save newspapers, magazines, even trash. Serious hoarding can create health hazards.   

The OCD Foundation website has very good information on hoarding (as well as OCD). They also have a search engine that can provide you with information about mental health providers in your area who may help (http://www.ocfoundation.info/treatment-providers-list.php). You may want to begin answering your question by going to these websites and seeking professional help if the condition is affecting your life or the life of someone dear to you.

drlloyd

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KEM asks about her (new) troubles with other people after a move to a new city – “what’s up with my anger” she asks.

Hi Dr. Lloyd,

My question is regarding something that I see manifesting in my outer life but I don’t know what /why/how I am causing it or am compelled to continue it….

Basically, in the past couple of years, since I moved to a new city with my husband and young daughter (3), I am having a hard time connecting with and establishing/or maintaining  positive relationships with so many of the people in my life (colleagues, friends, some family members  even).

I feel like there is very frequently a level of animosity of others toward me, and somewhat or sometimes me toward them. I can understand this is a part of life sometimes, we can’t like and be liked by everyone but this is showing up so much in my life right now that I feel it has to have something to do with me, but it is not something I am consciously doing  so I can’t seem to correct it.

What troubles me further is that I have never found myself in this situation before so I am perplexed as to whether something has shifted in me for the worse –am I depressed on some level? Or is this just a temporary fluke based on life circumstances and when those change so will this problem?

I know you can’t know the whole specific picture here, so my question basically comes down to: what’s up with the anger? In this case does it sound like it’s related to depression or other mental health issues? Does it possibly warrant meds or medical help? What are some questions I can ask myself so that I may better determine the best course of action?

Thank you so much for your help it will be hugely appreciated,

KEM

Drlloyd: I am sorry that you are having such a tough time in your new city and community. If this is indeed a new experience for you – that in the past you did not have these problems – your recognition about them is the first important step you have already taken.

Is there someone (or a couple of people) you trust and have confidence in that you can ask to speak frankly with you about what is happening? Your perspective about the animosity of others may be correct or it may be the result of how you are feeling or acting yourself. Having others comment on what they perceive may help you begin to sort out what is going on.

Sometime depression can explain what you are experiencing. There is a very good self test for depression called the PHQ-9. It is 9 simple questions you can answer that will give you a score that may suggest you are suffering from a depression. You can Google this test which is free and easy to complete. If your score suggests a depression then you can consult your primary care doctor or a mental he What you are experiencing is distressing and does not appear to be related any longer to the stresses of moving since that was a long time ago. See what you can learn from others and try this test for depression. With these first steps you will be better informed and if you see a mental health professional you will be all the more equipped for that visit.

What you are experiencing is distressing and does not appear to be related any longer to the stresses of moving since that was a long time ago. See what you can learn from others and try this test for depression. With these first steps you will be better informed and if you see a mental health professional you will be all the more equipped for that visit.

I wish you well, drlloyd

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A reader asks about her sister, wondering about what is causing her problems and how she can help her get the care she has so far been reluctant to pursue.

Hello Dr. Lloyd,

 I was so happy to find your website – thank you so much for providing this service!  My 39 year old sister has suffered for most of her life from diagnosed ADD, as well as bouts of substance abuse and depression.  While very intelligent, she is emotionally immature for her age, and has been unable or unwilling to take responsibility for her life, still depending heavily upon my mother for support, both financial, as well as emotional.  She occasionally acts inappropriately in public, and, over the years, has displayed a pattern of impulsiveness with tremendous bursts of irrational anger.  Most of the time, she acts “normally,” but we are always waiting for the other shoe to drop, so to speak.

In research I’ve done over the past year or so, I have developed a theory that she may be suffering from a personality disorder, and I am able to identify in her many (though not all) of the characteristics of someone with Borderline Personality Disorder. 

Thus far, my sister has refused to see a psychiatrist, as she doesn’t feel that she needs one, although recently, she seems to be becoming more open to the idea.  My question for you is how can we find her the best possible professional (a psychiatrist is preferred as opposed to a psychologist) to get her started on a path to recovery?  I have tried researching online, but have not come up with much.  We would like to find someone who is very knowledgeable and experienced with individuals with personality disorders.

We would appreciate your help with this, and any other suggestions you might have would be welcomed.

Again, thank you so much for your help.

A reader

Drlloyd:

Your concern for your sister is very clear. I have seen many family members try very hard to engage their loved one in treatment for a mental health problem. Sometimes they are successful early on and sometimes it takes many years before their loved one is ready to get properly diagnosed and effectively treated. Stick with your efforts.

I find that with people who have reservations about seeing a psychiatrist or any mental health professional that it is important to encourage them to take any step towards better understanding and then working on their problems. If a person won’t see a psychiatrist will they see a social worker or a psychologist? If not, will they discuss their problems with a family doctor or clergy with pastoral counseling experience? Opening up to a professional is a critical first step in recovery from a mental illness.

When you ask your sister what she wants in her life what does she say? It is pretty rare that someone says they want to see a psychiatrist. Instead, people say they want to be able to have better relationships, to do better at work, to have a car or nice apartment or to not be so alone. This is often where the conversation can best start. If indeed a mental illness, including a personality disorder, is getting in the way of these goals then seeing a professional can be offered as a way for that person to achieve what they want if their illness is standing in the way.

If you sister can see that getting help is in her interest then together you and she can talk about what kind of professional to see and what resources are available in your community.

Drlloyd

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A reader, KC, asks:

I am a 35 yr old mother of 4 struggling with intermittent issues of anxiety and depression.  I’ve been on low doses of Paxil and Wellbutrin for over a year now and it mostly seems to help but a couple months ago I had a bad episode for about 3 weeks where I was very depressed.  I decided to try adding therapy and have had 3 weekly visits so far.  My question is this:  how can I tell if therapy is helpful?  Money is tight and therapy is expensive.  My therapist seems to listen and empathize well but I am not sure how to judge whether this is effective in helping me.  

Thank you for your response

KC

Drlloyd responds:

Therapy often complements medication, so your plan to turn to therapy at a time when you were having more symptoms is a good idea. Your question is one of the most important that anyone can and should ask about any treatment- whether it be therapy, medications or any other intervention.

Have you and your therapist talked about what stressors may have caused your symptoms to break through? Have you and your therapist specifically decided what your goals are for treatment so you can tell if your goals are being met? And have you spoken about how long it might take to achieve those goals? Have you and your therapist developed plans for what actions you can take right now to help you improve how you are feeling?

It is critical for a therapist to listen and to empathize. These are what are called the non-specific elements of therapy and they can be helpful. But I would also want my therapist to be actively helping me understand why I am having the problems I am having now and what I can be doing to help myself now. I would want my therapist to ask me what specific goals I have so I know what I want to achieve and have a clear way of knowing if the treatment is helping and I am getting what I came for.

I wish you well, drlloyd

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 A reader, HE,  asked if his son may be autistic:

Hi Dr. Lloyd,

I have a question about getting my son evaluated for any autism disability.

What type of specialist should I bring him to see? I have just brought him to xyxyxyxyxyxyxy (a children’s medical center in upstate NY) to have him evaluated by a behavioral and developmental pediatrician. They say he is not on the spectrum.

He has been using Early Intervention (a Federally mandated state run program for children under three years old with developmental delay or disability) for the past 6 months and he has a speech delay. He has made great progress with Early Intervention. My son is 30 months old now and has about 100-130 words but does combine two words together that often. But I see sometimes certain red flags in my son that are the cause for my concern but don’t know where to turn to.

Do you have any recommend center to bring my son to have him evaluated if he has a problem with autism. I reside in New York City.

I would also like to say that your web site is amazing and very resourceful.

Thank You.

HE

Dr. Lloyd replies:

Dear HE,

Autism is on the rise. In the USA, almost one in one hundred newborns will develop autism. The “spectrum” is an important concept because some of these youth will develop autism and some will be better able to function. People on this most functional part of the spectrum are often referred to as having Asperger’s Syndrome (see my review of a film about Asperger’s in the Review Section of this website). All youth on the spectrum can benefit from good and continuous services.

I am glad your son has seen a developmental pediatrician since they are the most expert in understanding these problems in children. But you have to trust what you see because you are with your son far more often than any doctor and may be picking up changes that still are not apparent, even to experts. One thing you can do is to ask the Early Intervention coordinator about returning for a repeat evaluation by this doctor, who already knows your son and has a baseline to go by. Another thing you can do is to obtain a copy of the report from the pediatrician in upstate New York and bring that if you decide to have a second opinion, perhaps in New York City. Several medical centers with Child Psychiatry Departments in NYC have expertise in Autism, including New York University Medical Center, Columbia Presbyterian Medical Center and Mount Sinai Hospital.

It sounds like your son is benefitting from Early Intervention, which has been a wonderful program for so many youth and their families. But Early Intervention ends at age three, only six months away for your son. So begin planning with the program he is in now about how to maintain the services that are helping so much.

drlloyd

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Question from JS:

Hello Dr. Lloyd,

My daughter (24 years old) is currently in the middle of one of her worst bipolar episodes ever. There isn’t enough space to describe all of the irrational things she has done within the last month or so, including stealing from us, getting in a car accident, and hanging out with low-level drug criminals. She has been under the care of both a psychiatrist and psychologist for the past 4 years and is on medication (when she takes it). We have sought help for her, but have been told she has to voluntarily seek help herself, which she says she doesn’t need.  The illness is quite tricky. She is a very heavy smoker and is taking some sort of illegal drugs.

 We think this most recent episode began when she lost her job. She has a college degree in Communications and Film.

My question to you is what can we do as parents to help stop this before she ends up in jail, or is that the only way out for someone with a mental illness in our society?

Thank you, JS

In Reply:

Dear JS, you painfully describe one of the most difficult moments for families of a loved one who is having an acute psychotic episode, complicated by drug abuse. The acute bipolar illness itself, as you well know, is characterized by an inability for a person to comprehend s/he is ill, often called denial. The abuse of drugs adds to the impaired judgment and drug hunger that drive someone to spend time securing more drugs, typically by joining other addicts such as you describe.

These are extreme moments, and may be dangerous to the ill person. I am sure you and your family did all you could to avert your daughter’s condition from becoming what it has. Early intervention is always preferable to crisis response.

What can you do now? First, as hard as it may be, you need to limit your support to only what you know will be used exclusively in your daughter’s best interests. What this means, for example, is not giving money that she may desperately need and plead for because you know it will be spent on drugs. You can feed and house her (with your safety and reasonable behavior on her part as clear limits you set) but not give her money for “rent”. You can bring her to treatment and, if you can, help pay for it but not support whatever she claims she needs to “get started again” because that is also the black hole of mania and addiction speaking. You can talk to her about the behaviors you see that are self-destructive to her and those who love her when she says she does not need help.

You can- and should – call her psychiatrist and psychologist. They may say they cannot give you information but you can give them information. You can explicitly describe what your daughter is doing so they know the full extent of her current condition, not the version she is apt to provide that minimizes her problems.

And at a certain point when you are persuaded that she is an acute danger to herself as a result of her mental illness you can implore the psychiatrist to seek involuntary hospitalization or you can call a crisis service or the police yourself. Mental health law permits involuntary hospitalization under these circumstances. Hospitals, crisis services and the police are always the most troubling since no one wants to be treated coercively and you do not want to treat your loved one coercively, if that can be at all prevented. That is what you will need to explain to your daughter some time later, in the hospital, when her condition improves. That is when you can try to say it was your love and fear for her safety that had you mobilize to save her life – and that you want this turn with treatment to help prevent that ever happening again.

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A reader asks: How can I get off my medications?

My response is let’s talk about that because I want to help you realize that goal.

Some people will succeed in stopping medications, some will reduce their dose(s), some will use medication on and off, and some will discover they chose to continue (at least for now) because the result of stopping is a price they don’t want to pay. But before we get to planning how to begin, let’s be sure that some really important and too often overlooked principles of good treatment are already in place.

The first is that your treatment should be what good research has shown works. This is called evidence-based practice and is when your doctor and therapist are providing you with care that has been proven to work, and not something that has not been shown to work (for example, a mood stabilizer for bipolar disorder and CBT for depression are evidence based treatments but explorative psychotherapy is not for schizophrenia).

The next two are that treatment should be comprehensive and continuous. Comprehensive generally means that not just medications are used but that medication is combined with supported education or supported work and family education, among other services, for people with a psychotic illness; or that an adolescent is engaged in counseling as well as a serotonin antidepressant for a serious depression. Continuous means that enough time is dedicated to the treatment to give it a chance to work; and that it is with the same caregivers not jumping around from one place to then next. I don’t know of many people who got better after one or two sessions of therapy if their condition was serious to begin with, nor have I seen good results when clinics send people to other places or patients themselves don’t stay in one place long enough to make a difference. I am not talking about years (though for some who have suffered an illness for years or are disabled by it that could be the case, as it is for diabetes or asthma) but certainly more than a few visits.

Another principle is minimally effective dose and duration. This applies to both medications and therapy. It means no more than you need for no longer than you need. Still another is what is called integrated treatment. This applies to people who have both mental illness and alcohol or drug problems, which turns out is very common  – in fact, it often is more the rule than the exception – and it means that both conditions are diagnosed and their treatment provided at the same time in the same place by the same team of clinicians, whenever possible.

I don’t know if the next is a principle or common sense, but to take on a challenge, any challenge, you need safe and reliable housing, decent health (not good to try to stop a psychiatric medication if you have pneumonia or heart failure), not be hungry because you are so poor you cannot afford food, and connection to others who care about you and will support you in your efforts to take the best care of yourself.

If these foundations are in place you also want a relationship with your doctor where the ground rule is what Dr. Pat Deegan calls shared decision-making. Both you and your doctor have responsibilities to be honest, respectful and come to decisions together as two adults working on a problem together. That works a lot better than one person telling the other what to do or each operating in their own world.  Some people like to write up an advance directive (see www.nrc-pad.org) where they write out their treatment preferences and how they want to be treated should an emergency situation arise; it is a way of sharing decisions in a planned and thoughtful way, when you are most able to do so, not when you are acutely ill.

I have spent this much time on prologue because these basics are what determine if treatment will stand a chance of being successful – so let’s be sure that exists in the first place. Anything that deviates from these basics is a sad waste of time and usually brings pain and suffering.

Now, let’s consider how to plan:

-          Are you on more than one medication? If so, talk to your doctor about which one to start with.

-          After you pick which one, go slow. Especially if you have been on a medication for over a year, or years, because your body has become used to it and will appreciate reducing the amount gradually.

-          If you are on a medication known to produce withdrawal, like a benzodiazepam tranquilizer or sedative sleeping pill, then you will need to work very closely with your doctor to manage any withdrawal problems (like anxiety, sleeplessness, irritability or craving).

-          Write down a set of simple and clear things you will want to monitor as you reduce your medication, including how you sleep, your mood, your thoughts, your ability to function at school or work, your relationships with family or friends. You want to monitor for good and bad effects from the change you are making so you can understand when you are succeeding and when you are not – and perhaps learn how far you can go now and resolve to continue later.

-          Identify really trustworthy friends and family who can support you and be honest with you. Ask for their help; you want them to encourage you when that is warranted and give you a dose of reality when you need it.

-          Expect that you are going on a bit of a roller coaster. Your body and mind have become accustomed to a medication so you are apt to have feelings and experiences that could shake you. Knowing this may help you stay the course.

-          Turn to ways you know to help you cope. This can be the support of friends or family, going for a walk or any other form of exercise, listening to music, meditation and yoga. Turn to your faith if you have that. Drink plenty of water and try to eat right, including taking the right vitamins and fish oils.

-          Keep going but don’t keep going when your good judgment (and that of trustworthy friends and family, and even your doctor) says it is time to pause and take credit for where you have come and recognize that it is not (yet) time to take on more.

Managing your medication, including decreasing or stopping it, is part of illness self-management. This applies to every chronic disease, not just mental illness. People with heart disease, diabetes, high blood pressure, lung disease, asthma and countless other conditions do a lot better when they are active, informed and responsible agents of their own health. As Pat Deegan once told me, “I don’t take medications, I use them. You are not the passive recipient of taking a pill, you are a person who is using a medication to achieve certain results. That stance of being in charge of yourself (in this case your medication) is fundamental to a recovery orientation, a conviction that you can have a life with people and contribution – the kind of life we all want.

Finally, and this is one of my favorite quotes: “Never, never, never give up.” Winston Churchill said and his wisdom remains as important today as it was in the darkest days of the last century. Hope is our best companion when we set off on a path of change.

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Many have asked, is there a relationship between mental illness and violence?

From time to time we read in the paper or see on TV that an innocent person or family member is seriously assaulted by a person with a serious mental illness.  Are people with mental illness more violent? While these incidents are infrequent, they are sensational and spread like a virus raising the spectre of dangerous “mental patients” lurking and endangering us all.

People with mental illness are not more dangerous than the general population –unless they are abusing alcohol or drugs and they have untreated serious mental illness. In fact, they are far more likely to be the victims of violence than its perpetrators  - 11 times more likely to be a victim of violence that anyone  in the general population.

When violence bursts onto the public stage and involves a person with a mental illness it seems to evoke a predictable and uninformed response calling for more restrictive treatment of people with mental illness, generally by demanding more and longer psychiatric hospitalizations or greater use of involuntary interventions like outpatient commitment and medication over objection (both court ordered means by which a person must comply with treatment).  But research has taught us something quite different.

Mental illness alone is not a major driver of violent crime. Well done and replicated studies show that the risk of violence is higher among individuals with serious mental illness when they are not receiving adequate mental health treatment – and the risk is considerably greater when these individuals are actively drinking and abusing drugs. The message  is clear: we need to do better at  identifying mental illness early, and engage and retain these individuals in quality treatment (including making sure that care is coordinated and collaborative among all caregivers, for both mental and substance disorders). When we achieve those basic standards of care we will improve the safety of our communities as well as the lives of those with mental illness, and their families.

Individuals with mental illness who are apt to be violent (or become victimized) almost always telegraph their problems for months, if not longer, with worsening symptoms. They appear in emergency rooms and hospitals. They drive their families to distraction – with the families seldom having a responsive place to turn.  When fragmented services, lack of coordination, and limited accountability of caregivers combine the result is to  and deny people with mental illness the services they need to control their illness, and reduce their risk of dangerousness.

Effective psychiatric treatments, the science of psychiatry, are often far from what actually happens in everyday practice: this is the gap between what we know and what we do. But solutions exist to improve the quality of care that will benefit people with mental illness. We can screen and detect in medical and mental health settings the presence of alcohol and drug abuse and provide effective treatments for people with co-occurring mental and substance use disorders. We can identify individuals with serious mental illness and substance abuse and reach out to them when they fail to fill their medication prescriptions or don‘t show for appointments or when they appear in emergency rooms or crisis services. We can do a lot better making families a part of treatment since they are essential allies in care and invaluable supports to their loved ones. We can create quality standards that call for coordination among hospitals, clinics and other mental health care programs in the community, and make these standards a requirement for clinic licensure. We can help train police dispatchers and police officers to recognize when a person is mentally ill and how best to manage a crisis moment.

Sad that we have to wait for tragic events to make the case for quality treatment responsibly delivered. We can do better than that.

A version of this piece appeared in the Huffington Post on October 29, 2009.

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A colleague asks: How can managers help improve workplace mental health during this stressful economy? With employees asked to work longer and harder with less, what can employers/managers do to avoid burnout?

 I recall speaking with a businessman, let’s call him Bill, who had suffered from depression and was at risk for losing his job at a large financial services company. He was despondent, could not focus well, had difficulty meeting deadlines, and was irritable and negative with his colleagues. His depression came on after a corporate downsizing that he thought would affect him but did not.  But it did add to his work demands and anxiety about retention.

His supervisor met with him soon after she noticed the change in him. While she may have suspected Bill was depressed, she never said a word about mental problems or uttered the word depression. Instead she pointed out specific ways in which his work was suffering. She cited specific examples of how Bill’s work was different from his usual strong and team-based performance. She expressed concern for him and said something needed to be done, for the sake of the company’s needs and his. She suggested that he contact the company’s EAP (Employee Assistance Program), explaining that the company offers such services at no charge.

Having his supervisor speak with him about his performance was a wake-up call for Bill. He went online and completed a screening questionnaire for depression (some companies do not have an EAP so on-line screening can be an important resource for employees). His score was high, suggesting he was depressed (but not making a diagnosis) and urging him to speak with a medical or mental health professional. Bill went to see his primary care physician (PCP) who ruled out any physical problem that could account for his low mood and problems doing his work. His PCP told him he had a depression that could be treated effectively with medications and counseling, which he pursued. His wife joined him for some of the counseling sessions with a psychologist and was helped to understand how depression was affecting him and their marriage. He also took a serotonin reuptake anti-depressant. After about 6 weeks, Bill felt better and his work noticeably improved. His supervisor made a point of meeting with him to remark how pleased she was with his work and team participation.

To maintain his health and mental health, Bill started attending fitness classes in a neighborhood Y and he and his wife went dancing once a week. He was careful to not drink too much, which he had started to do after the downsizing.

This story illustrates what good organizations can do to assist their employees who may develop mental health (or addiction) problems during tough economic times – or for that matter during any economy – since healthy employees are productive employees. The supervisor had been trained to identify performance problems early, to meet in a non-judgmental way that focused on work not illness, and to suggest what resources were available to her colleague. The company had online screening for mental health and addiction problems (which are accessible widely and at no cost for those organizations that do not bring these in-house) and an EAP to assist, if an employee chose to use it. Bill himself pursued stress reduction activities like exercise and time with a loved one, though many organizations build this into their wellness programs or as a benefit in their health insurance. Finally, the supervisor knew also to monitor Bill’s performance and acknowledge his improvement when it occurred.

An enlightened approach to mental health in the workplace is a good investment. Disciplining or replacing effective employees who develop problems is difficult, costly and often not as good a strategy as enabling employees to recover from the problems they have developed. Everyone won in this real story: Bill was back to working well and actually grateful to the supervisor who intervened in such a thoughtful and helpful manner and his company had the Bill they needed back. It shows how attending to the mental health of employees as a corporate policy and practice is good for everyone’s business.

 See my comments in the “Check out these websites” tab about the Partnership for Workplace Mental Health (www.workplacementalhealth.org). 

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Why do people with mental illness or addiction seem to smoke so much, and what can they do to quit?

Taken in part from “Quitting Smoking for Good” published in the Huffington Post on March 29, 2010.

Yes, people with mental illness or heavy users of alcohol or drugs not only seem to smoke so much, they do:  they consume near to half the cigarettes smoked in this country!  Over 70% smoke (compared to about one in five of the general population – whose smoking rates have dropped from 50% fifty years ago). About one in two people with depression and anxiety conditions smoke – twice the rate of the general population. Three out of four people with alcohol and drug problems smoke – a rate comparable to people with bipolar disorder or schizophrenia. Notably, these individuals report a desire to quit at the same rate as do others (70%).

There are a number of good reasons to explain the huge disparity in smoking between people with mental and substance use problems and the rest of those who light up. The nicotine in tobacco has been shown to improve mental concentration and can improve mood, especially in depressed individuals. Smoking is well known as a way of coping with stress, and the greater the stress the greater our need to combat it. The pleasure of smoking is no small factor (Freud did get it right when he wrote that the pleasure principle warrants respect), particularly in people whose mental states make it hard to engage in and feel the pleasures of relationships, work and play. What’s more, quitting takes support from friends and families and quit rates are increased by medications prescribed by doctors – both resources that are often limited in people with these conditions. Finally, doctors have not done such a good job of asking about smoking, and offering to help.

Tobacco use is the greatest preventable cause of death and medical disability in the United States. Tobacco kills and contributes significantly to the development of killers like heart disease and cancer. Yet its deadly impact is preventable. When people stop smoking, their risk of death and disability drops steadily and progressively. It is the tars and byproducts of inhaled tobacco smoke that cause lung damage and serious health consequences. In fact, when nicotine is absorbed but not inhaled (like with patches, gum and nicotine “inhalers” which deliver nicotine through the skin and membranes of the mouth and throat) it is not a dangerous drug, even when used for long periods.  

The good news is that there are various treatments now available that are proven to help people quit smoking.

Medications include NRT, or nicotine replacement therapy, which comes as a patch, gum, lozenges, inhaler, or nasal spray; some NRT preparations are available over the counter and some require a doctor’s prescription. Buproprion, customarily used as an antidepressant, is effective for people with or without a history of depression and can reduce craving and thus improve quit rates. Varenicline  seems to work like nicotine does in the brain; it enters the nicotine receptors on neurons, reducing craving and improving quit rates. It is not a good idea to combine Varenicline with NRT agents. All medications have risks and side effects as well as benefits, so be sure to understand both before you start.

Counseling may be through individual, group, or telephone format, andfocuses on providing encouragement and support from all who can provide it (the doctor, smoking cessation counselor, friends and family) as well as problem solving – or helping people develop skills for those moments they used to rely on a cigarette to master.

Combining medication and counseling adds to the effectiveness of each one, and increases your chances of successfully quitting.  For your sake, keep in mind that smoking is one of the hardest addictions to control. What is common is that most people try many times before they finally quit. But don’t lose faith – when your time comes the results are priceless.

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A daughter asks how to recognize when psychiatric medications are causing problems in elderly people?

 A reader with an aging, elderly parent asked about symptoms that might signal a need to adjust or monitor medication in seniors. She also asked what else might have us reconsider the choice, dose or time of administration of a medication.

These are critical questions and their answers could fill a textbook, even if we confined our discussion to psychiatric medications – and we know that elderly people with mental illnesses are also highly likely to be taking medications for very common physical conditions like heart and lung disease, diabetes, Parkinson’s and cancer.

So, I will only itemize a number of warning signals and urge that you trust your feelings. You know your aging relative(s) better than anyone else, even a doctor or a nurse. Don’t be hesitant to press for evaluation and answers since you have firsthand experience about what is happening.

The warning signs of problems fall into a number of categories:

-          Thinking: side effects and interactions with other medications can produce (increased) confusion, memory problems (especially forgetting – which can result in repeating the same question or answer), difficulty expressing what a person wants to say, or misunderstanding what is happening – even sometimes difficulty separating what is real from what is imagined (which we call psychotic thinking). 

-          Feeling: medications can and do effect mood. They can produce nervousness, low mood, hopelessness, restlessness (usually seen by pacing or fussing), irritability and angry outbursts, loss of pleasure in everyday life, and sometimes the opposite where a person feels on top of the world.  

-          Behaviors: the list here can be almost anything but be especially alert to when your relative shows a significant loss of self-care with poor hygiene (not washing, bathing, brushing teeth, shaving), or dressing in dirty or strange clothing. Pacing, agitation, outbursts or alternatively being very inactive, quiet, removed or inwardly preoccupied can also signal important changes in how the brain is working. In addition, loss of coordination as seen by being unstable on their feet, swaying from side to side, bumping into furniture or doors, or feeling dizzy or faint when standing up from a seated position can also indicate problems. Be aware as well of significant changes in sleep or appetite because these two can suggest that something is going awry. 

The most common causes of these problems are:

-          A new medication causing side effects or producing unwanted effects (doctors often call these adverse effects, like a bad allergic rash, high blood pressure, or being toxic to one of the body’s organs like the kidney, liver or heart). 

-          A new medication interacting with medications a person is already taking producing (different) side effects or unwanted effects, or actually increasing or decreasing the strength of existing medications (by raising or lowering the blood levels of those medications or limiting the body’s ability to excrete them). Polypharmacy (the prescription of a number of medications, not just one – even for a mental health condition, not to mention for other illnesses) has become so common it also puts seniors at risk for greater problems with their medications. 

-          Dehydration or not having enough water in the body for it to function normally. This can happen in hot weather or with fever (both of which cause excessive perspiration which is water loss) or from eating poorly. 

-          Overuse of prescription or over the counter pills especially pain pills (like aspirin, acetaminophen (Tylenol and others, ibuprofen (Advil and others), and a variety of narcotic pain pills (like codeine, Percodan, Percoset, Vicodin, and oxycontin).  

-          Drinking too much alcohol in the form of spirits, wine and beer.  

-          Acute illness or trauma where the flu, a pneumonia, urinary tract infection, a broken bone or serious trauma can reduce the body’s ability to handle existing medications, causing disturbances in their normal blood levels. 

-          Increasing age makes a difference. As we age, as a rule, our body becomes less able to process or manage all kinds of things, including medications. What may have been an OK dose at 65 may not be at 75. The effects of increasing age have prudent doctors prescribe according to the adage start low and go slow referring to the dose of medication prescribed.  

-          Weight loss may signal the presence of a physical problem or be the result of mental illness or a side effect of a medication. Loss of weight may result in what was the right dose becoming more than a person needs (or can tolerate). 

-          Inattention to proper monitoring is when a medication that needs to have blood levels (like lithium) is not done and the levels become too high or when adverse effects of a medication (like reduction in white blood cells from clozapine) happens and it is not picked up. The results can be serious side effects or illness. 

-          This list is not comprehensive. I hope, though, that it illustrates the delicate balance that exists between or bodies and medications and the need to be mindful that problems can and do happen. 

Remember, you do not need to make the diagnosis of what is wrong. But you are the doctor’s eyes and ears, especially with elderly people with limited capacity to explain what is happening to them. Be a strong advocate and inform the treating doctor (or nurse in the office) of what is happening. If an explanation is not clear then press for an evaluation (and any needed action) before something bad happens.

For more information about geriatric mental health go to:

The Geriatric Mental Health Alliance of NY at http://www.mhaofnyc.org/gmhany

The Geriatric Mental Health Foundation at http://www.gmhfonline.org/gmhf/consumer/index.html

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A reader asks what is the connection between stress and illness?

 A reader asked about the role of stress in chronic illness, such as cancer. My answer applies to any chronic illness including mental illness, heart and lung disease, diabetes, and cancer.

Stress is part of life – inescapable and part of its excitement and drive. But chronic stress, where we are experiencing its effects day after day or out of proportion to the immediate challenges we face, affects the body in many unwelcome ways. Chronic stress:

-          Effects the heart and blood vessels, straining the heart and raising blood pressure

-          Undermines the capacity of our immune system to fight infection and combat illnesses like cancer

-          Increases our risk of what are called “autoimmune” illnesses such as rheumatoid arthritis, lupus, chronic fatigue syndrome and multiple sclerosis

-          Alters our moods and increases the risk of depression and other mental disorders, or aggravates existing problems

-          Impairs our capacity to tolerate pain

This reader asked about a specific program called “The Healing Code”. While I cannot assess what this program claims I can say that a variety of stress reduction techniques make a difference in how we all cope with stress, acute and chronic. We all need people who care about us and support our self-esteem and efforts to take care of ourselves. Sleep, nutritious eating and exercise are foundational to good self care and stress management. Yoga and meditation are excellent ways to control stress and improve our outlook and wellbeing, as can be acupuncture and various forms of massage. Staying away from people, places and substances that are harmful to us are equally important.

Finally, as important as are stress controlling efforts they are no substitute for recognized treatments for any medical condition, be it a mental disorder, cancer or any other health problem. Stress reduction techniques are complementary – which is to say they add to conventional medical treatments. Good medical care is a combination of what you do for yourself and what a good doctor can provide.

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A clinical colleague asked: what do we know about the risk of relapse from cocaine?

 My answer begins with our recognizing that drug addiction is a chronic brain disease where individuals compulsively use a substance despite its clearly harmful consequences, to them and others. There is an expression: “the man takes a drink, the drink takes a drink, the drink takes the man”. This is one way to understand how an addicting drug (whether a drug or alcohol) actually changes the brain and impacts a person’s ability to act in their own interest. The film, Leaving Las Vegas, which starred Nicholas Cage, painfully portrays this process.

Relapse is extremely common in addiction. The National Institute on Drug Addiction refers to addiction as a “…chronic, often relapsing brain disease.” If you, a loved one, a friend or co-worker have an addiction you may have to do battle with relapse for a lifetime.

Stress is often identified as triggering relapse. Some of the more common stressors include conflict with an important person (or people) in your life; emotionally distressing feeling states like guilt, anger, depression and anxiety; a life change that is disruptive and perhaps shameful like losing a job or the breakup of a relationship or marriage; the influence of peers (this is not only true for youth); and for some people whose behaviors have got them into trouble with the law it is their release from court oversight that can open the door to relapse.

The relapse rate for cocaine appears higher than for many other drugs. Cocaine first exerts its powerful effect on a part of the brain, where we feel pleasure, by flooding cells with dopamine, an essential neurotransmitter (or brain cell communicator). But that pleasure is short lived and the brain is depleted of the dopamine it needs for normal functioning, and mood, and craves for more. The person addicted knows that relief is just a snort away. Cocaine is also now inexpensive and pretty easy to get.

Neuroscientists continue to search for medications that can prevent addiction and reduce craving. We already have drugs that block the effects of some addicting substances (like narcotics and alcohol) though their use is not widely sought by people with addiction to these substances. As Newsweek Science Columnist Sharon Begley recently wrote, “Addiction is a behavior, with social and psychological causes, so behavioral therapies that target those causes last longer than medication and are better at preventing relapse.” (March 13, 2010, p. 20).

We have treatments that work – behavioral and medicinal.  By narrowing the gap between what science knows and what is achieved in clinical practice we can produce the greatest gains in the public mental health in the years to come.

What do you do in the Emergency Department when there is a life threatening mental health problem?

You have been struggling for months to get your son, your daughter, your parent or spouse to the emergency room for a serious mental illness. Your loved one is ever more distrustful, locking, even barricading, the door and windows, not leaving home nor letting hardly anyone in, eating poorly, not bathing, and pacing incessantly.  You have tried everything you can think of to get them to go for help but they refuse. Your anxiety mounts as you see their condition worsening before your eye creating a dangerous situation.

Finally, for reasons you can’t explain, your loved one agrees to go to the local hospital emergency department (ED) – and you get there as fast as you can, knowing that can change on a dime. You think, finally, a chance to get him into the hospital so treatment can begin and maybe take hold. In the ED your loved one waits for a couple of hours, grows restless but you manage to keep him there. Finally, he is seen by the doctor – after you tried unsuccessfully to get a few words in edgewise with the doctor who has 10 more people in the waiting area, and who knows what other responsibilities in the hospital.

The doctor emerges from the exam room and she signals you for a word. She tells you she is discharging your loved one since while he clearly has a mental illness he does not want admission and there is no evident “danger to self or others”, the term that captures what is legally required to admit someone who does not want to be admitted. She says she will give you the phone number of a clinic to call for an appointment. Your heart sinks. You dread what lies ahead, even if you were not sure what could be accomplished in the hospital. Your loved one pulled himself together with the doctor, however briefly, and promised to get help (a promise you know will not be kept). What awful event has to happen before he will be admitted, or will that even be too late?

What can you do to prevent this outcome? While there are no guarantees you want to convey a message that needs to be heard. To do so, you need to know what the doctor needs to know and deliver that information – short and sweet. Most important is that danger exists: you need to say that the situation is dangerous, and it is getting worse. And that there will be grave consequences to the patient, family and doctor if safety is not immediately achieved, namely by hospitalization.

Here is how one family I know succeeded in preventing the nightmare of leaving an ED without having achieved what they came for. The adult children told the doctor that their mother had left the gas on in the apartment while nailing shut the windows and barricading the door. They made a point of catching her before she went into the examining room with her patient (their mother) and saying that their mother had felt hopeless and spoke about being an increasing burden to her family. She had said that they would be better off without her. Her hopelessness, guilt and distrust meant she would not tell the doctor; in fact, she was apt to provide a cover story that would get her discharged from the ED. The family told the doctor that if their mother went home she would likely try again and die from the gas, or start a fire or an explosion, when she lit a match to smoke. They stressed that neither the family nor the doctor wanted that to happen. Their mother was admitted on an involuntary doctor’s order after she refused an offer of admission.

Involuntary admission is always the least desirable intervention. I know patients who avoid the mental health system and psychiatrists for years after such an event. Early intervention, voluntary treatment, and shared decision making (often helped by an advance psychiatric directive) are what work a lot better. But sometimes, when all fails and danger and fear mount the hospital becomes a necessary, short term and emergency action — if only you can get the mental health system to respond!

You will have a lot of explaining to do to your loved one later on. But given the choice of discharge to a dangerous situation or actively providing the doctor with information that clearly supports involuntary hospitalization, which will you choose? If you chose the latter, make a point of explaining why you did what you did to your loved one – but not until there is a good moment when you can convey your love, your fright, and your determination to help.

A mother asks about her adult daughter and whether certain drugs can damage the brain?

A mother wrote and asked about her adult daughter and whether certain drugs can damage the brain?

She wrote: My daughter had been stable and working part time for the past 5 years after 20 years of illness (a serious mental illness with psychotic episodes and co-occurring substance abuse problems). She had been taking 15 mg of Abilify (an antipsychotic medication) and was doing pretty well, functioning at a relatively high level. She relapsed into drugs last October and began using cocaine even while on 70 mg of methadone. She never completely stopped the Abilify although she took much lower doses.  She was voluntarily hospitalized in a psychiatric facility for 4 weeks in January.  She is now back living in the community and attending a day program where she is tested for drugs 3x a week.  She went back on the Abilify but she has not really stabilized.  Her doctor at the hospital said that her brain was very sensitive to using cocaine and methadone at the same time.  He suggested further damage to her brain. 

She asked: Is that possible?  Have you heard of someone not returning to a previous state of functioning due to the use of cocaine and methadone simultaneously?  Are we not waiting long enough?

My reply: Two troubling ways in which a person’s brain can be badly affected by using street drugs are from 1) the drug and what it is mixed with and 2) from untreated mental illness.

1)   Abuse of cocaine, in its pure form, leaves the brain depleted of dopamine, a neurotransmitter that affects many parts of the brain’s function. Repeated use of cocaine also appears to have an effect on the blood vessels in the brain. The more cocaine used, the longer it takes the brain to recover from this depletion or vessel damage. On top of that, when someone takes cocaine there is no knowing what they are taking. Street drugs are cut with all kinds of additives and impurities. Some are just filler but others are meant to give the drug more kick since it has been diluted before it is sold. So, using cocaine, or any other street drug, means using more than what a person intended. The additives themselves may cause damage. Since we cannot know what else was in the white powder, we cannot say what else might be doing harm to the brain – but the risk is there.

2)   Psychotic illness has been called “neurotoxic”. This means that the illness itself, untreated and unchecked, can cause damage to the brain. Serious mental illnesses, like schizophrenia and schizoaffective disorder, are characterized by psychotic symptoms – or loss of reality and the presence of hallucinations and delusions. Individuals who have repeated episodes of psychosis and refrain from getting effective treatment are at risk to do more poorly in their lives over time. Hypertension is an example of a progressive disease that produces mounting damage if untreated (to blood vessels, and ultimately to the heart). The brain, like our blood vessels, needs to be protected from disease. While debate exists as to how cocaine causes problems in the brain, whether directly to the nerve cells or the way they connect to one another, the consequences can be grave.

Treatment can and does work, but far too often those who can benefit do not get the care they need. As I say on my home page, less than 20% of people with a serious mental disorder get properly diagnosed and effectively treated. Understanding mental illnesses and what treatments work are essential in rebuilding a life (as it is for families to know how help your loved one). It is never too late to start.

For more information on cocaine and other street drugs, go to The National Institute on Drug Abuse website at http://www.drugabuse.gov/

For more information on untreated psychosis, a major psychiatric journal reported on important findings that pertain especially to people early in the course of their illness. The journal citation is: Perkins, DO, Gu, H, Boteva, K, Lieberman, JA: Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia; American Journal of Psychiatry, 2005;162:1785-1804

How do antidepressants work?

Antidepressants work. Especially for people with serious depression (see The Good News About the “Bad” News About Antidepressants, published on February 12, 2010 in the Huffington Posthttp://www.huffingtonpost.com/lloyd-i-sederer-md/the-good-news-about-the-b_b_457464.html).  Many people ask, how? Many doctors answer speaking about brain chemistry, particularly mentioning brain chemicals, called neurotransmitters, which they say are not doing their job in making brain cells work well together. Some say there is a deficiency of a neurotransmitter, like serotonin or norepinephrine.

Well this is a charming explanation, like saying the sun is a big ball of flames. Indeed, the sun looks like a ball of flames, and you don’t want to get too close, but there is a lot more going on than that. As for what is going on in the brain in people with severe depression, and how antidepressants (ADs) work, no one really knows.  Maybe ADs work by producing greater concentrations of mood altering neurotransmitters, like serotonin and epinephrine, at specific sites in the brain thought to effect mood? Maybe these neurotransmitters permit nerve cells to protect against other cells and transmitters, like glutamate, believed to produce anxious and depressed mood states? Maybe neither of these. In twenty years we will be saying how little we knew twenty years ago.

But not knowing is not a reason for not acting. Much of what is done in medicine is done for what we call ‘empirical’ reasons: namely, studies show it works (empirical means not from theory but from observation and experiment). Empirically, we know that ADs work – and they are often safe and well tolerated. Which is why doctors prescribe them and many, many people take them, with benefit.

The question you or your loved one may want to ask is “do I need an antidepressant?” The answer to that question can be determined by asking: Is this a depression, with its characteristic symptoms, not a passing mood, grief, or another condition? If so, has it persisted for weeks, regardless of what I do to try to beat it? Does the depression affect my ability to function as a family member, at work, at school? And what options exist for treatment of my mood problem, including medications but also counseling, exercise, controlling drinking or drugs that affect mood, and support of family and friends?

Above all, don’t give up. Depression itself produces feelings of hopelessness and helplessness. Depression can be deadly, driving people to suicide and worsening serious medical conditions like heart disease, diabetes and asthma. Up to 75% or more of people with depression, including serious depression, can improve. That may take time and trying different treatments until the right one works for you.

Don’t let depression get you, before you get the best of it.

William Styron’s book “Darkness Visible” is a , short, poetic account of depression and suicidal feelings, which he survived.