ECT: Shock Treatment

Shock treatment (Electroconvulsive treatment, ECT) sounds barbaric and if you or a loved one have ever been recommended it I'm sure it's extra frightening. On occasion I'll recommend for my patients to have ECT and I need to do a lot of teaching and reassurance. I will share with you what I tell my patients. If the proceedure is demystified it becomes less frightening.

The whole concept of ECT arose when while at an asylum two patients had grand mal seizures and for some unexplainable reason, they improved! That was an era when patients would be placed in asylums for years or forever and because of the stigma were often left and forgotten by their families. There were no psychiatric medications available; after all, psychiatric medications are relatively new to us, anti-psychotic have been around since 1945, antidepressants early 1960's, prozac 1986. Cold water treatments, spinning chairs, straight jackets and insulin shock were the mode of the day.

It was postulated that if a seizure was induced, the symptoms would remit and the patient would improve. Unfortunately, any ways were attempted to cause a seizures and there were deaths along the way. Placing electrodes on both temples with a jolt of electricity was tried and was found to be effective. I know a seasoned psychiatric nurse who tells me that in the 60's she, along with strong mental health techicians, would help hold the patient's arms and legs while they seized vigorously. In this day and age the treatment is done under brief general anesthesia and there is barely any movement. There is a brief pulse of electricity and you hope for a good seizure that lasts 45-90 seconds.

ECT is very helpful for stubborn, difficult to treat depression. As opposed to the typical antidepressants that have a likelihood of 60-80% of being effective with depressed patients, ECT is about 70 to 80% effective and these are usually the most recalcitrant depressions. It can work faster than antidepressants, sometimes improving depression, at least somewhat, after the first or second treatment.

Side effects are generally not too problematic. The general anesthesia helps prevent seizure-related problems like fractures of the vertebrae. The main concern the effect on memory and new learning. There are two ways of doing ECT, unilateral with one electode on the right temple and one on the forehead and bilateral with electrodes on both temples. Unilateral treatments seem less effective with more treatments needed to effect a change, but they do not cause as much memory loss. I have had patients that do well with regular ECT and memory is not effected whatsoever. If memory is affected, however, it generally improves gradually over the subsequent few weeks and up to 3 months. There are some who report that memory is indefinelty affected, however, neuropsychological testing does not support this. Recent studies indicate ECT actually improves memory, probably because depression so negatively impacts memory and as the depression improves, so does the memory. There have been brain biopsies studies of rats who have been given multiple, repeated ECT and no evidence of damage to the brain tissue itself has been found.

Overall, ECT is a great form of treatment. It is not a treatment that should be avoided, infact, it can be life saving. The only contraindication is anything that would increase intracranial pressure, eg. brain tumor. The ultimate question I am asked is that if a family member or I are recommended ECT would I agree to it, and the answer for me is...sure.

Benazir Bhutto, rip

How tragic when one voice of reason is snuffed out. No one has absolute truth that's why it is so important for a society to support and tolerate many ideas. That's what makes America great. The extremists prove over and over that America is a great and blessed nation...not always right or appropriate in it's actions but blesssed with diversity of people, culture and ideology. May Ms. Bhutto rest in peace, Pakistan be comforted and many in Pakistan live on to carry on Ms. Bhutto's dream.

Deal or no deal? Gambling and other Addictions

Addictions have a life of their own at times. It appears that what for one person can be a non-issue to another may be disaster. Take a beer, mixed drink, gambling, sex, food, or anything that is pleasurable, in moderation or controlled fashion is perfectly fine. Genetically, however, some people are programmed so that there are no breaks. Recent research indicates a different way the endorphins respond. It seems that there is a much more robust increase in endorphins to the point where the problem becomes more complex. The reactions are so intense that it feels like what heroine addicts experience. They become addicted to their own opiate system and it becomes what is called an "auto addiction." It's not their "fault" but it is a major challenge life brings that requires a lot of attention and hard work to reclaim their lives. Unfortunately, it affects all those who love them. It's hard to admit to the condition but once people do so and they get help it can be a life changing event.

Adoption: good idea or not?

As a child psychiatrist I see a lot of children who have been adopted, and with good reason. It is a major event in a person's life, how can it not be an enormously emotionally loaded event. Research notes that adopted kids have 9 times greater likelihood to have psychiatric issues. Reasons for this may be numerous. The developmental struggle when the adoptee is trying to develop their sense of identity, the genetics that are very strong (after all, the bio parents may have gotten in their predicament because they were impulsive, risk taking, unable to take care of their child, etc.), attachment issues if the child was old enough to expierence the separation and loss of the primary care-giver, etc.

It is important for people planning on adopting to realized that some of these factors are so strong that love isn't enough to change the emotional and behavioral ups and downs that may follow! It is important to realize that the decision to adopt will be life changing both for the better but also for the more challenging. Now, there are wonderful adoptive parents that have been challenged in tremendously painful fashion that have persevered and stuck with their child, working hard to overcome the challenges and getting to the point where there was a turn for the better years later as the child matured. I have been impressed and inspired by parents like these. Not everyone can do this, in fact I 'm not sure I would be strong enough. When parents have told me that their child has never told them they loved them and they are 8 years old, they have invariably told me this with tears in their eyes. Yet, two families that come to mind have been wonderfully blessed by their children who became awesome teen-agers and who were finally able to reciprocate and express their love to them. They are special young people who were blessed with parents who wanted them so badly and were willing to sacrifice for them. If you are thinking of adoption, go into it with open eyes but be willing to persevere no matter what life brings you, sometimes there are greater rewards in one's sacrifice.

Autism and Bipolar

Though i have not seen formal literature that supports a connection between autism and bipolar illness, i have seen too many kids with that combination. Though Bipolar illness is overly diagnosed these days, i have seen Kids with undeniable bipolar and undeniable autism. It has been noted long ago that autistic kids with aggression responded well to either lithium or antipsychitics, both of whom are treatments for bipolar.

Pot use in teens

It seems rare that I come across a teen who has not used pot. For the most part, most don't use excessively. When they do use regularly, however, a common scenario occurs: memory starts getting poorer over time, grades begin slipping and academics become less important and much of the teen's socialization centers around pot use. There is something called "amotivational syndrome" that occurs. A person begins to slowly sink into a sense of complacency and apathy, not caring about what used to be important to them. They feel lazy and unmotivated. What makes the problem worse is that the change is so gradual and not noticed. Because of how subtle and incidious the personality change is there is a denial of the changes that have occurred. It's often not until the person stops the use and is abstinent for a while that they will report noticing a difference. Often they notice that they can think better, clearer and they feel mentally sharper. They feel their energy level come back and they feel more alive. All this comes as a surprise because they were oblivious to the downward drift and the toll the pot was having on their body.

I have seen people who appear to have mood symptoms that appear bipolar normalize when they stop they use. Mood swings, anger control and unpredictability all improve. It takes pot a good 30 days to clear out of the system so the results aren't exactly overnight.

PMS medications

If you suffer from PMS, actually the proper term is PMDD: Premenstrual Dysphoric Disorder, taking care of yourself is very important for both yourself and your loved ones. You sometimes can't help your reactions and emotions no matter how much effort you muster. Afterwards you deal with the aftermath. No one is happy with the circumstances, especially you.

It's important to look into your various options. Consider the following:
1) natural products can be quite helpful. Evening primrose and vitamin B6 can be excellent. There are some preparations that incorporate several supplements at once and can be very helpful.
2) SSRI antidepressants such as Prozac and Zoloft can be very good. They can even be taken just the week prior to your menstrual cycle and discontinued upon start of flow with good results. Daily use can be good but not necessary if the mood issues are just menstrually related, If medications are necessary throughout the entire month, they can be increased for the week prior to menses if the regular dose is not enough to control premenstrual symptoms. The antidepressant option may not be good if there is a personal or family history of bipolar disorder, it can make things worse.
3) Oral contraceptives are sometimes helpful. The typical 1/35 pills, those which are the same color for 21 days with 7 days of placebo, carry a 10% risk of causing depression, however and so may complicate things, so be aware of these. The triphasic pills change color and hormone content every seven days and seem much better and a lower risk.
4) If there is no potential for substance abuse, the use of anxiety meds such as Xanx, Ativan or Valium can be helpful. There are addictive if used consistantly (daily) for three months or more, but used for one week out of the month on an ongoing fashion shouldn't be a problem. This option is not good if there is a personal or family history of substance abuse, you don't want to create a larger problem.

Medications for childhood depression

Important to consider if your child is depressed and may need medication is the following:
1) have you tried conservative approaches first, eg therapy, multivitamins with selenium, omega-3 fatty acids? Do not use St. John's wort unless you talk to a physicain first.
2) have you ruled out a physical factor, eg, low thyroid, drug use, medications such as oral contraceptives, antibiotics for acne, etc.
3) if there is bipolar in the family or you suspect bipolar illness in your child, see a child psychiatrist and not your family doctor of pediatrician! It may be more complicated and antidepressants may make things worse.
4) After the above has been considered, then just about any antidepressant should be ok. Prozac has been best studied and is great, so is Zoloft and Celexa. Wellbutrin can be good if there is ADHD also but sometimes isn't as good for depression.
5) though rare, antidepressants can increase suicidal ideation. This seems to occur more in kids prone to bipolar, hence #3 above. If this arises in you child, call your doctor immediately or have your child evaluated at your local hospital ER.

Most of all, invite open dialogue with your child and be observant. Always err on the side of caution and if you feel there is a risk of self harm or suicide, get help!

Autism and Aspergers medication considerations

Because we don't have medications that directly affect the actual root cause of autism and Aspergers we target symptoms and treat them accordingly. Sometimes the results can be surprisingly good and at other, modest at most. The key is to find the most appropriate medicine with the least side effects. The following are my first choices, based on effficacy and side effects. There are other options but these are my favorites.

For aggression:
Antipsychotics: all are ok, look at the ones with less side effects: Abilify, Seroquel have less side effects, other may cause weight issues (Risperdal and Zyprexa) and Geodon can have cardiac conduction issues
Anti-seizure meds: Trileptal, Depakote(watch for weight gain) and Topamax (watch for cognitive/memory decline)

For perseveration:
SSRI's: Prozac, Luvox-don't use SSRI's if there is a family history of bipolar
Inosital-be patient, stick with it, it may take 6 weeks to see results, don't be afraid to push up the dose to high doses

For hyperactivity and inattention:
Focalin-xr, Adderall-xr-both can be sprinkled if swallowing issues exist
Clonidine, though potentially too sedating has been surprisingly good for some kids
Consiider Provigil, especially if the stimulants not helpful

Don't over look the benefits of a casein-free diet! Casein is the fat in milk. It can be great for many kids, especially if there has been a history of colic and intolerance to milk as an infant.

Don't overlook the benefits of a sensory diet and OT interventions! Having an outpatient OT to guide you in your management at home can be invaluable. You may need to push your insurance carrier to cover it and you may need to ask your pediatrician or child psychiatrist to give you an order for it.

OCD treatment, psychiatrist's thoughts

OCD is often not treated aggressively enough. If you are being treated for OCD, expect to be prescribed high doses of SSRI"S (PROZAC, LUVOX, ZOLOFT, PAXIL, CELEXA AND LEXAPRO). Though benefits are seen as early as 3-4 weeks, maximal benefit is seen at the 3rd month. if all is better, consider backing off to a typical dose after 6 months. This maintenance dose should continue for three years. After three years 1/3 of OCD patients can actually be cured. It's not always this easy, however. If OCD and bipolar coexist it makes it much harder to treat because SSRI's make bipolar balance worse, in that case, medications like Neurontin can be helpful. Don't overlook the benefits of the vitamin B Inositol, I've seen it work.

Winter blues aka seasonal affective disorder

There was a winter in Chicago where there were 5 or more weeks without sunlight. We were very busy that winter in the office. People were complaining left and right about the dreary days. The Prozac flowed like honey to ease the pain that the lack of sunlight caused. Lightboxes were ordered and Wellbutrin was prescribed, all in the hopes of some relief. Fortunately, these interventions helped. I wonder what it was like in the days prior to antidepressants. I guess people were grumpy and irritable and you stayed away from them, if they got too bad there was always the assylum. Though I take a cautious approach with medications, and prescibe them almost hesistantly, I'm glad they are available and they add to the quality of our lives. Sometimes we psychiatrists prescribe medications because it is a matter of life and death and others we prescribe because of quality of life issues.

St John's Wort for depression

Without big drug pharmacuetical company backing St. John's Wort has never become too popular in the states. It really is too bad since it is a nice, clean antidepressant. It shouldn't be used if there are signs of biploar tendancies or a family history of bipolar because, like all antidepressants, it can make the depression worse or throw a person into mania and psychosis. I have had patients that have done very well with it and others that have felt very anxious or manic with it. If there is depression, I would recommend a visit with a physican or a psychiatrist. Especially if there is a possible bipolar issue, see the best psychiatrist you can as it can be very tricky to manage.

menopause and memory

Many women note that when they enter into the perimenopause phase of their life that their memory starts to suffer. They notice a dramatic difference in their cognitive functioning. I have had wonderful success adding Ginko biloba 80mg twice a day to their regimine with good success. The report improvement within a relatively sort period of time. There seems to be low risk as far as side effects are concerned.

School Psychiatry

I have been a consultant on site at a high school district for the past 19 years. It has been a wonderful experience. I was initially brought on staff as the special ed director noted that a significant majority of the special ed students had underlying mental health issues. When their health needs were not adequately addressed they required a greater level of school intervention including residential placement. Because psychiatric illness is often difficult to diagnose and medication management of symptoms can be quite difficult and challenging, observation of a multidisciplinary team can be helpful to give insight into a child's function and academic and emotional needs. Teachers and staff oftentimes spend more time with the youths than their own parents and they have a classroom full of other children that serve as "controls". It's also reassuring for staff when they know that a psychiatrist has experience understanding and managing the extremes in symptoms and behaviors and nothing is intimidating. The psychiatrist knows enough neurology and medicine to direct and triage treatment and recommendations. A child psychiatrist will be familiar with options for intervention such as day treatment, hospital, residential settings, community health centers, private practice, etc. It often does "take a village to raise a child" and we psychiatrists are one of the village people.

Autism, Aspergers and medications

Risperdal was recently approved for treatment of aggression and mood lability with Autism. Unfortunately, for the psychiatric community it was nothing new. We have been using antipsychotics for treatment of the symptoms of autism for years. There is one positve however, there is hope that this might mean more pharmaceutical monies directed toward treatment of autism spectrum disorders.

Autism is a complex disorder that is confusing and poorly understood at the present. So far we know there are some complex genetics involved, there may be a predisposition that is triggered by something, (eg like MMR vaccine), there is a bowel connection with inflammatory bowel wall and frequent bowel issue like chronic constipation and there may be nutritional issues with casein, gluten intolerances and magnesium ?deficiency. At this point we have to address as many issues as we identify: sensory, dietary, bowel, communication, social, need for supplements, etc. Hopefully, in 5-10 years we'll look back and wonder why we had it all wrong and were grabbing at straws. We have to do the best we can with what we have.

Psychiatrists in the mission field

I went on a mission trip to Ecuador with the folks from Maranatha and Adventist Midwest Health in January. I expected to help as a support team member as much as I could in the medical and surgical endevours but I was surprised how busy I was practicing psychiatry. In my short-sighted, narrow view I didn't think there would be a need for my specialty services. I was faced with the reality that mental illness knows no limit to region, culture or language. I saw people with depression, bipolar, alzhiemers, OCD, ADHD, panic attacks, people who had experienced domestic violence, sexual abuse, etc. I saw pain and suffering like I do in the states with an added twist: poverty and lack of resources, both for therapy and and medications. I'm not sure of the follow-up the people will have or if they responded to the medication I started them on, but I prayed that the consultations sent them in a positve direction, that the medications helped and that they could continue them and improve the quality of their lives.

Non-stimulant ADHD medication: amantadine (Symmetrel) use in children

I'd like to share anectdotal reports of my use of amantadine in children. Amantadine is a medication that is not used much in child psychiatry. It was originally developed for the treatment of flu symptoms. It was later found to be helpful in Parkinson's. I ran across an article about using it for the treatment of ADHD in the late 80"s. I have always kept it "in my back pocket" in case I needed an alternative to traditional ADHD medication when there was a history of tics, bipolar or an intolerance to stimulants. I have had some very good results in the treatment of ADHD with amantadine with very few side effects. The most common side effects are a decrease in appetite, weight loss and upset stomach. Dizziness can also occur.

It can be a a good option that shouldn't be overlooked.

Amantadine comes in liquid and 100mg capsules. The maximal dose is 100mg three times a day.

ADHD medications with Bipolar children

There is much co-morbidity (co-existance) of ADHD in bipolar children. The concern, however, is that stimulants sometimes cause an upset to the delicate balance of mood. It is not uncommon to see more anger issues, depression and even psychosis when stimulants are added. It is important therefore to be careful when using stimulant medication with bipolar children. Strattera (atomoxetine) is in the same camp since it exerts antidepressant effects and can cause manic activation in bipolar children.

Safer medications to consider in children with bipolar to address attention issues include tenex, provigil (though I have seen it increase anger on occasion), amantadine, buspar and to some extent wellbutrin (though it can cause manic activation it seems less likely compared to other antidepressants).

Depression in young children

In 1987 I attended a lecture entitled "Does Depression Exist In Children?". We were coming out of the psychoanalytic era in which depression was seen as a complex study of intrapersonal conflicts. We had thought that depression couldn't occur because their personality structure was not mature enough to engage in depressive conflict. Well, anybody who has had a child with depression and suicidal thought knows that to think that depression is not possible in children is absurd. We in the field of child psychiatry have come a long way in 20 years. Or have we?

One concern is the issue of bipolar disorder. Sometimes when you see depression in children or adults it may be the initial onset of a cycling mood disorder. It is very important, therefore, to rule out the possability of early onset bipolar since the use of an antidepressant can have disasterous consequences. We rely on research to help give us guidance. Research is indicating that we have to suspect bipolarity when: 1) there is a family history of bipolar and 2) there are vegetative symptoms of depression (insomnia, decrease appetite, decrease in concentration, low energy, etc) in prepubertal kids. Other tip offs are: severely disrupted sleep patterns, psychosis, atypical depression (sleeping too much and eating too much), adverse responses to antidepressants or stimulants, etc.

What is a challenge is putting the pieces of the puzzle together in order to make sense of it all.

Asperger's and casein free diets

I have been very pleased with the response of some of my Asperger's patients with casein-free diets. Casein is the protein in milk. It is not only in dairy products but used as fillers in processed foods such as hot dogs and bologna, etc. One young man (about 8 years old) who had classic symptoms of Asperger's and was quite irritable, conflictual with peers and staff, and obsessive-compulsive/perseverative, did so much better on the casein restriction and all the social difficulties and irritablitiy and perseveration diminished. Because he kept insisting he wanted his milk back, we started him back on the milk products and his symptoms all returned. What was interesting in his history was that he was colicy as an infant and after several milk/formula changes he did much better on soy milk. It is my opinion that though at some point he resumed dairy products, he was still intolerant and it created the symptoms we were seeing. While we was the results werre seen within a short period of time ( a couple of days), researchers recommend a good month trial on the diet retriction.

Ginko Treatment for Dyslexia

I recently came across a small research study on the use of Ginko Biloba for dyslexia. At 80mg in the morning, the majority of kids in the study did so much better within 6 weeks. I am going to be recommending it to my dyslexic patients and see if indeed we see the same results. Ginko has been studied in the elderly with good tolerance and hopefully, since kids are not as fragile as the elderly it will be ok for them. The drawback is the unknown longterm effects of this on children. What we child psychiatrists wrestle with is the lack of long term information with the medication we recommend. As opposed to common thought, not everything that is natural is safe. (just because it is natural doesn't mean it's innocuous, take lithium for example).

Bipolar Children

When I was in training in the late 1980's, the concept of Bipolar illness in Children was unheard of. It was supposed to occur in late adolescence and early adulthood and so we "didn't see it' in younger children. It came as a surprise when I saw an 8 year old with classic, undeniable symptoms that "walked like a duck, looked like a duck and quacked like a duck". The fact that bipolar occurs in children makes sense because when adults with legitimate diagnosis of Bipolar are interviewed they typically tell you that they date back their symptoms to childhood. Often times they describe years of misdiagnosis until it finally makes sense.

We used to think that 10% of ADHD kids would "convert" to Bipolar but in reality the "ADHD symptoms" were probably an early manifestation of Bipolar.

We psychiatrists are at a disadvantage in that we do not have solid neurologic or blood testing that can give us a definitive diagnosis, instead, we have to base our hunches on history provided by parents and patients and trying to put the "pieces of the puzzle" together, eg, family history of Bipolar, response to previous medication, etc.

Websites such as www.bpkids.org are excellent as parent resources.

Tis the Season

What a wonderful season! Full of excited people and festivities left and right! There are those who love the season and those who are stressed by it...I choose to love it. It takes some work to get around all the busy-ness and capture the true meaning(s). Family is fun, growing and loving. I'm quite greatful for this. Our second annual family cruise is coming up...what a wonderful idea.

Hope the season is treating you right, if not, look at how to change it...take charge, as much as within your ability.

Doc