Healing the Addicted Brain

If you or someone you loves struggles with an alcohol or drug addiction of any sort, I highly recommend that you promptly buy Healing the Addicted Brain. Dr. Urschel communicates solid treatment information in an accessible way. Somehow he manages to translate relatively complicated concepts like cognitive behavioral approaches or psychopharmacological options into quick, accurate chapters. And, Dr. Urschel talks to those struggling with substance abuse in a respectful, informative manner. This is one of those books that will save some lives.

an uplifting read

I suggest giving yourself a holiday treat and reading Mitch Albon's new book Have a Little Faith. It's an uplifting, thought provoking, quick read, and I don't think you have to be of any specific religion to enjoy it. Have a great holiday everyone.

health impacts of social ties

In case any one missed Clive Thompson's wonderful NY Times Magazine article "Are Your Friends Making You Fat?" which discusses Christakis and Fowler's study on social ties and health, the article merits a read (despite the gimmicky title).

The article describes the finding of a contagious like spread of obesity, amongst other things, through social circles.

The article doesn't shy away from also discussing researchers with opposing views, for example those who see the data as primarily emphasizing the power of shared environment. Kudos to Thompson though who rather than oversimplifying, goes the next step voicing Christakis and Fowler's response to such criticism. Too much detail to get into here, but read the article!

sleep apnea & golf

This little pilot study found a positive impact of treating sleep apnea with CPAP on -- of all things -- golf scores!

Continuous positive airway pressure (CPAP) is provided via a nasal cannula/mask worn at night to treat obstructive sleep apnea (OSA). For those with OSA breathing stops during sleep for 10 seconds at a time, due to collapsing soft tissues at the back of the throat. CPAP helps keep airways open but is immensely annoying to wear. Patients thus sometimes avoid it although treating OSA can be important in a variety of medical situations including post-stroke, heart failure, pulmonary hypertension. And, although CPAP also may benefit cognition in Alzheimer's dementia, general daytime alertness, and mood and quality of life in those with depressive symptoms.

In this quirky pilot study, OSA patients who used CPAP improved golf scores more than controls. Kudos to the researchers for finding a fresh approach for assessing treatment efficacy in a way that is so tangible, fun to review and which may help motivate OSA patients to use CPAP.

Lesson from cancer #3 -- kindness of strangers

Yesterday morning was grouchy -- as with their dad at work on a Saturday the kids were quick to whine. So I came up with the brilliant plan to spoil us all and go out for breakfast at Salonica Restaurant, our local diner. Amidst the morning's chaos and as I now have a proud 1/8" of hair, I didn't think twice about going out in my bandanna.

The specter of breakfast rapidly improved moods. The big kids launched into a vigorous game of hangman. I encouraged my son to use more body parts and so give my daughter more chances to spell the word. However, generally hanging was inevitable. Meanwhile, my little one launched into his eager drawing games somehow involving bombing bad guys. The warm bustle of the restaurant added to our burgeoning festive mood which further improved with the arrival of plate-sized waffles and pancakes. It had somehow turned into one of those wonderful all-consuming moments with kids.

Which suddenly became bittersweet when I went to the cash register to pay. The gruff man became inexplicably awkward and then blurted, "You don't need to pay. Somebody left this for your breakfast." He pointed at $25 lying on the counter.

I had momentarily forgotten that I had cancer or that this might be obvious to others. I had momentarily forgotten how sometimes the most joyous times with my kids are bittersweet when fear sneaks in. Even though odds are I'm fine.

The stranger's anonymous generosity made me acutely aware of how happy the moment was and added a joy that someone had quietly witnessed. Someone understood some part. Someone knew that amidst our joy, we could stand a little encouragement. So cancer's lesson this time? The kindness of strangers is real. We need to accept the possibility that we are being supported -- even when we don't notice.

And, to whoever gave my family that quiet gift, I send thanks. You have warmed a sometimes chilly chapter. Thank you.

Is a medical illness causing ... depression?

This clear description of medical illnesses which can contribute to mood symptoms is worth a read. And, I'm hoping the link serves as a reminder that everyone with a mood disorder merits a thorough medical check up.

exercise for academics

Dr. Ratey also has an article available via his blog suggesting the importance of exercise for academics. I work with many dedicated students who give up exercise when academics get intense -- and then mood or anxiety symptoms inevitably tend to increase. I'm hoping a peek at Dr. Ratey's article will nudge all to make time for exercise!

exercise for ADD

Dr. John J Ratey, Associate Clinical Professor at Harvard Medical School and author on the subject, gives medscape a succinct interview on exercise as a treatment for ADD (and for all that ails you). Dr. Ratey opines that every physician at every appointment for just about anything should be inquiring about patients' exercise habits. Fantastic. By the way, he has a website and blog both well worth a read.

psychiatry & preventative care - nudge

Some ask me why does a psychiatrist discuss preventative health issues?

Well, it is my pet peeve actually. Why don't shrinks routinely do this? Preventative care can work magic for physical health. And of course physical health can contribute immensely to mental health and happiness.

I'd like psychiatrists increasingly to move in this direction! We are docs who are fortunate enough generally to see clients more often and for longer than primary care physicians. We have an opportunity to hear about clients' lifestyles, medical conditions, motivations and choices in detail. So we have a unique vantage point to give a nudge in the right direction for preventative care. And so much of pursuing care requires overcoming anxiety and finding ways to nourish ones self -- subjects those in this field are well suited to help with.

Certainly I have clients who say "don't mention the word exercise to me again!" And I certainly have clients who roll their eyes when I mention folate and dark green veggies for the umpteenth time. All in all, though, clients put up with the marriage of these subjects with psychotherapy and psychopharmacology with grace ... and gradually over time appear to benefit from it.

new stellar study: Mediterranean diet associated with lower depression risk

An excellent study just published in the preeminent Archives of General Psychiatry found that those who ate a more Mediterranean Diet (ie loads of veggies, fruits, nuts, legumes, fish) developed depression vastly less often than those who did not eat such a diet.

SSRIs during pregnancy

A Danish study was just published in BMJ showing a very small but real increased risk of congenital heart defect in infants exposed to SSRIs during pregnancy. A fact that merits consideration as women make tough decisions about managing mental health concerns during pregnancy.

the spoon theory

A client just shared this wonderful link with me. The essay offers a good way to better understand the experience of those struggling with illness. While the author writes of her experience of lupus, her metaphor is apt for most mental or physical illness.

another good read: Try to Remember- Psychiatry's Clash Over Meaning, Memory and Mind

Try to Remember: Psychiatry's Clash Over Meaning, Memory and Mind by Dr. McHugh describes the "repressed memory" movement and his crucial involvement in challenging it. He notes the need for data based treatment grounded in common sense. While I found the book fascinating, it may be a bit dull for those not absorbed by the subject.

worth a read

Here's an amazing article that is quite a reminder to, when possible, seize the day.

chicago trib article - uncommunicative docs

Sounds like many just aren't tolerating doctors who are uncommunicative or who don't listen. Interesting article.

money & happiness?

I enjoyed this thought-provoking article on money and happiness. I was just told this link wasn't working, but it should work now. Worth a read.

interesting study

A study from the Netherlands found that anti-platelet medicines (like aspirin) are associated with more brain microbleeds. Unclear what this study published in Archives of Neurology
means. Might just be an association and not a causation (ie despite careful study still possible that those with more risks for microbleeds take more aspirin). So not a reason to stop these often life-saving meds, but surely an interesting study and something to talk about with your doc. Same old story. Take meds with care. I'm posting on this one as a reminder that this applies to over the counter meds too.

generic

I like Dr. Wang's simple description of what generic medications are and why they cost less.

eat your veggies and exercise

Ever more reasons to eat your veggies and exercise.

Read this quick summary of recent cohort studies showing a likely association of the mediterranean diet and physical activity with lower Alzheimer's dementia risk or at least a possible slower decline in cognitive function.

The mediterranean diet combines plenty of veggies and beans with moderate fish and alcohol and meager meat.

chamomile tea?

A randomized placebo controlled trial showing chamomile extract helps with generalized anxiety disorder was just published. Perhaps a cup of chamomile tea when stressed could do some good. Of course don't let it get in the way of your green tea drinking. But that's another post.

(By the way, not the first line treatment for generalized anxiety disorder at this point ...)

choice in health care

In Dr. Sowell's recent article he underlines the need to protect physicians' ability to make individualized treatment decisions for patients. I am not clear on the correct health care solution. I do, however, appreciate how clearly Dr. Sowell explains this absolutely essential point.

one brick

Check out One Brick.  This organization coordinates an online volunteering calendar for a bunch of causes one event at a time -- so no need for long term commitments.  Just peek at their calendar for something of interest and sign up.  A wide range of events are listed from theater ushering to knitting blankets for the homeless.  Helping out others makes most of us feel better and of course does some good along the way. One Brick offers another way to go about it.  

Dr. Pausch's wisdom: the last lecture

With over 10 million viewings on you-tube, most of you have likely seen The Last Lecture.  On the anniversary of his death,  Dr. Pausch's wisdom continues to shine.    

stimulants & risks & benefits

I don't want to raise alarm bells as I am loathe for patients to have undue stress or stop needed meds.  However, I have many clients on stimulants (Ritalin, Focalin XR, Concerta, Adderall XR, etc.) for attention deficit hyperactivity disorder (ADHD).  And,  Madelyn Gould's new study funded by the FDA and NIMH suggests increased risk of sudden death for kids on stimulants.  The risk is amazingly, super duper tiny but nevertheless looks probably real. 

The study is getting press as tragedies tend to.  And, what an unbelievable tragedy each child in Gould's study represents.  My prayers  go out to these families along with my thanks for furthering our knowledge.  No matter the specific interpretations -- no one can read this study and not know to prescribe with immense care.   

Before reading further -- please discuss this study and stimulant use with your own prescribing doctor!  Don't change a thing based on my ramblings.  Every person deserves individualized care.  There is no easy or right answer for all.  

However, generally I'm plugging for everyone to keep context in mind.  Stimulants also offer benefits that immensely increase safety!   Kids with ADHD are at higher risk for accidents than most kids, including serious accidents like burns and head injuries.  And stimulants decrease the very impulsive behavior which can lead to such injuries.    Furthermore, stimulants decrease motor vehicle accidents for ADHD drivers.   And car crashes are one of the biggest dangers out there for adolescent kiddos!   Substance abuse with its endless risks also decreases with stimulant treatment of ADHD.  These safety benefits should vastly outweigh the rare cardiac risks of stimulants.   

For this reason I'm continuing stimulants for ADHD clients -- unless new data emerges or clients prefer to discontinue them.  The FDA agrees.  The FDA is recommending parents to not stop these medications.  The FDA also points out a number of flaws in the study -- which indeed is imperfect.  A nice medscape video blog you might want to listen to from Dr. Findling further concurs.  Gould's study nevertheless will inform my work by emphatically reminding me to:  

1. fill parents in about the risks and benefits.  Parents deserve to know the scoop and make their own decisions.
2. consistently maximize psychosocial measures, therapies, good diet without additives, regulate sleep patterns and regular exercise for kiddos.   These steps might help avoid or minimize dose of stimulants!  
3. avoid stimulants for patients with cardiac disease.  
4. remind parents to contact me about any physical symptoms -- especially including complaints of chest pain, palpitations or shortness of breath.
   

Basically, I'm getting repetitive on this blog.  I'm back to the old message that all meds have risks and benefits.   Sometimes the risks are worth it and sometimes not.  You deserve to have all of the information available to weigh those risks and benefits with your doctor or psychiatrist. Talk to your kiddos prescribing doc.  Keep context in mind.  Good luck sorting it out.  

lemonade out of lemons: Marcy Brenner's story

Here's a link to a preview of a documentary made about Marcy Brenner's fight with a life threatening metastatic cancer. I'm thinking many would find her beautifully told story and her music mighty uplifting and thus am sharing the link ...

a must read: The China Study

OK. I'm sick of me spouting off about books. However, I just read The China Study. How could I not add my two cents about Dr. Campbell's incredible book? This is the work of a true world expert on nutrition who reflects on his lifetime of stellar work and what it means. He even manages to make the subject interesting.

Dr. Campbell started his life as a kid on a rural dairy farm who never thought twice about eating meat and animal products as a way of life. However, Dr. Campbell's lifetime of study culminating in the study of China's dietary habits, led him to see an animal based diet as a significant contributor towards diseases haunting Westernized countries (including cardiac disease, diabetes and cancers).

Dr. Campbell voices dismay at how our governmental agencies/health organizations have not adequately communicated this information. Instead so many offer watered down bits and pieces of info. This guy and his data are convincing. Let me put it this way. This book has me giving my kids water instead of milk.

book plug: The Care & Keeping of You

The Care & Keeping of You is a fantastic book for pre-teen girls about physical development.   Over a million copies have been sold for a good reason.  The book doesn't bring out even one persnickety remark from me.

I love how the book is framed as a "how-to" book for taking care of your body as it changes.  Its intro evidences this nourishing tact:

With your body on the brink of some pretty big changes, it's time to start taking control of your health and well-being...

Then the book is filled with useful and even sometimes gritty details about anticipated body changes as well as how to nourish and keep your body clean and healthy.  Few moms would remember to get into all of these useful details, making it a really useful supplement to mom daughter chats.

Moreover, the book encourages body acceptance -- so key for girls and few girls listen to Moms on this subject:

You don't need to measure yourself against anyone at all, including friends... You're you -- a one-of-a-kind original -- and you're beautiful in your unique way.

And the pages are stuffed with age appropriate drawings and succinct info that will keep your kiddo's attention.  And, the book covers the gauntlet of body issues from how to get gum out of your hair to physical changes to eating disorders to shaving.  Even the touchy subjects are addressed in frank but child appropriate ways.

This whole subject can be painful to a Mom who adores having a little girl.  For example, me.  However, what a stupendous resource to help Mom and daughter address the inevitable.  

book review: Get Out of Your Mind & Into Your Life: The New Acceptance & Commitment Therapy

I do think many self help books are decent resources so hope to review a bunch here.   Get Out of Your Mind & Into Your Life by Steven Hayes, despite the corny title promotes a type of treatment called ACT (acceptance & commitment therapy) which has promising data behind it.  

The ACT approach instructs you to stop taking your thoughts so literally.  Just because you think something, that doesn't make it true.  ACT promotes allowing yourself to have these thoughts and yet knowing they are not you, just thoughts.   Just words floating by.  Just the product of language.  Hayes offers techniques to minimize the power of unhelpful thoughts/words and to help you gain perspective that they are merely words.

Interesting and helpful concepts.  He suggests that sometimes when you try hard to not think an unhelpful thought this acts as a Chinese finger trap.  The more you struggle, the more caught in the thought you are.  He explains:

Avoidance only strengthens the importance and the role of whatever you are avoiding - in other words, when you avoid dealing with your problem, it only grows.

In interview he further elaborates:

The basic research underlying ACT shows that entanglement with your own mind leads automatically to experiential avoidance: the tendency to try first to remove or change negative thoughts and feelings as a method of life enhancement. This attempted sequence makes negative thoughts and feelings more central, important, and fearsome--and often decreasing the ability to be flexible, effective, and happy.

However, the author proceeds to go nuts with metaphor after metaphor, which I find empty of meaningful input almost leading me to give up on the book.  Such as:

By assuming the stance of willingness and acceptance you can open all the blinds and the windows in your house and allow life to flow through; you let fresh air and light enter.

Yikes.  However, just when I get ready to dismiss Hayes, he returns to data based useful information.  For example he interestingly discusses how evidence supports accepting physical pain as a means to increase pain tolerance and functioning.

Training people how to accept their pain and how to watch it or "defuse from" their thoughts about it ... greatly increases their tolerance of pain (Hayes et al. 1999) and decreases the amount of disability and sick leave downtime caused by their pain ...

And then Hayes shows how acceptance similarly works with anxiety.

Unwillingness to have anxiety predicts having anxiety in many different forms... ten minutes of acceptance training made panic-disordered person more able to face anxiety... Similarly, for anxious people, teaching them a simple ACT acceptance metaphor, the Chinese finger trap ... reduced avoidance, anxiety symptoms and anxious thoughts...

Bottom line.  The ideas are useful.  The book is a trifle painful.  I'd suggest buying it and giving it a good skim, reading those parts that are helpful.  On the other hand, I see rave reviews for the book so possibly I'm just getting persnickety.  

book review: The Explosive Child

I promised I'd get back to work here at some point.  So here goes.  Re-reading a book I recently suggested to clients, it dawned on me that most parents would benefit from The Explosive Child.  I certainly have.  Thus the post.  

Dr. Ross Greene taught me during residency. His book, The Explosive Child, is just as pragmatic and helpful as Dr. Greene was in person.  I actually don't think you even need a fiery child to benefit from his wonderful communication tips.  

Dr. Greene explains that volatile kids shouldn't be treated as "bad" kids. Rather these kiddos have a learning disorder -- they have failed to develop adequate flexibility or frustration tolerance. 

Therefore, Dr Greene explains parents should focus on not punishing but on teaching. He explains: 

"Your role ... is that of surrogate frontal lobe.  That is, you are going to be doing the thinking for your child that he is currently incapable of doing on his own; you are going to serve as his tour guide through frustration ... "

Dr. Greene describes his collaborative problem solving approach.  This includes three ways to handle conflict with a kiddo.  The adult can demand the kid obey (plan A).  This tends not to work with explosive kids unless you are in the mood for an explosion.  

Or, the parent can just forget the whole thing and let it pass (plan C).  Reasonable for less important issues.  

Or, plan B.  Generally preferred. Plan B involves collaborating with your kiddo to find a solution.   Empathize, encourage your child to explain his concern and explain yours and invite the child to voice solutions to the problem.   Dr. Greene offers a load of explanations and plentiful colorful examples to show how pragmatic and effective this approach is.  

It is hard for me to imagine parents who would not benefit from the  book.  Actually, I was just reading bits out loud in the car to my husband.  Eh hem.

A perfect book?  Not quite. I don't like the off-hand dismissal of behavioral management such as rewards and consequences. I think Dr Greene intends to emphasize the need to discontinue ineffective techniques.  Often these are behavioral.  However, no need to throw the baby out with the bathwater.  Routinely, I encourage families to reward via celebrating success.   Even in my home, we have spontaneous parties or dinners out -- when the kids are behaving in an especially lovely manner.   I am loathe to have such rewards dismissed.  I could further gripe that the book gets repetitive. 

I still vigorously recommend the book for every parent.  Not necessarily for a light fun read.  But for the peace and well being of your family.  A darn good reason to buy a book, I think.  

learning from cancer : lesson 2 get a Kindle

Sorry I have been out of the blogosphere as I have been working to get my head and my schedule around the travails of having cancer.   My cancer isn't so bad, no worries.  

However, it has had a nasty impact on my coffee consumption.  My temporary exit from this blog has corresponded with my exit from drinking coffee.  After my diagnosis, I immediately changed any habits which might have contributed.  That coffee, that glass or two of wine a week, that Diet Coke habit, the tofu addiction.   Thank goodness, yesterday I finally looked up coffee, and it just doesn't look like much of a cancer culprit.  So, here I sit with my first cup of coffee in weeks. And, needless to say, I'm blabbing away online again. 

My thoughts today are admittedly not profound and my research is admittedly absent.  I do promise I'll get back to more professional topics over time;  there are endless ones I am eager to blog on.  Oppositional defiant disorder, learning disorders, dementia, herbal supplements, complex partial seizures and the list goes on.  I'll get there.

Today, though, I am focusing on the little joys in life.  They just loom larger in the face of illness.   The scarlet tanager out the window, the sweet smell of kids, the warm smoothness of a coffee cup and the spring breeze  are just a bit more lovely.   

And, I  meander towards my off-beat focus today.  There is a new joy I have discovered -- which I'm hoping might cheer up many and thus want to share here.  Not poetic or profound.  However, I'm thinking mighty powerful. My parents gave me a gift to help me get through this time -- a Kindle.   

I anticipate a body of research on the mood enhancing and anxiety quelling powers of owning a Kindle to emerge over time ...  How could it not?!  I was able to download the complete works of Shakespeare for $0.99 and now carry it along where ever I may go.  I carry Jane Eyre without an oz of extra weight for a mere $0.99 more.  Actually, for free Crime and Punishment, Oliver Twist, Pride and Prejudice are added. Further, professional texts which usually require a step stool and strong arms to access, now are readily available electronically.  

Via the Kindle, the greats of thought and words can wander about through life with me!  Their words inspire or educate at the flick of a button.  The little machine recalls the page being read of every book.  Underlined quotes  are magically copied and filed for reference.  Even when the thing is off, it alternates etchings of great writers.

Admittedly I run with and treat a bookish crowd.  So perhaps these words are an over-generalization from a little clinical and personal world.  Nonetheless,  I enthusiastically and adamantly recommend you  buy a Kindle if it's possible to scrap together the hefty price-tag! (Now to those cynics out there please note -- I unfortunately do not get a cent from Amazon in any way for this plug.) 

Note, I especially recommend purchasing this if you suffer from an iota of mood struggles or anxiety or a rough patch in life.  Of course there are risks to this recommendation, like most of my recommendations.  Here, the lovely old book smell is missing.  The crisp sound of turning pages will be replaced with an all too work-like click.  And there will be yet another dreaded extension cord which must not be lost.  And, perhaps most disturbing, the grand joy of meandering around bookstores may forever be a trifle dimmed. 

Nonetheless, the potential of carrying the world of knowledge and thought in a purse.  The joy of having an omnipresent productive distraction for any painful moment.  The thrill of carrying a library --  seems worth many risks. 

learning from cancer: lesson 1

So my goal was to create a primarily professional blog.  However, something personal has happened which might really help someone out there to hear about.  So -- much as I am private by personality and profession --  I need to blab on it.  Here goes. 

Two weeks ago I felt a lump and within two weeks had a bilateral mastectomy with reconstruction for breast cancer.    For those who know me -- no worries -- odds are I'll be fine.  I await further results for specifics.  

In the meantime, I'm learning.  Or, as a dear friend said when she heard of my diagnosis, "take what it gives you."  I'm taking. 

My first take.  This disease needs yet more advertising.  Sure everyone hears about breast cancer all of the time.  We buy pink kitchen utensils or clothes with pink ribbon emblems.  But do women really get the message: to check for breast lumps?!  Really!  I mean it.  No matter your youth or perfect health or squeaky clean family history.    Get regular mammograms, too, of course.

My own doctor had missed my lesion just a couple of months earlier.  Even though she is a wonderful doc.  Even though I (as a doc) had explicitly voiced concerns plus a complaint of increasing fatigue.  I even had asked to have my thyroid checked for fatigue.  But it was me who found it.  Unfortunately months later.   I found it not because I ever was wise enough to do self exams, but by blind luck.  

Over the last two weeks as I have consumed every post, blog and study on breast cancer, I have learned that mine is a disconcertingly common story.  Doctors miss breast cancer.  Every day.  There are so many sad stories.  There are so many women gravely ill who don't need to be.   I read stories of women in their twenties who were told they were too young and healthy and shouldn't worry about a lump.  They got follow up down the road and had advanced cancer.  I read stories of young and nursing women who were told they just weren't used to the changes in their nursing breasts, not to worry.  Only to later find they had advanced cancer.  I read of extraordinarily healthy women struck with this disease from teenagers to triathletes.  Cancer just was not expected.  The stories go on and on.

Further, I read post after post online of women of all ages asking what to do?  Women who have found a lump ask on website after website.  Women have a concern.  Somehow, despite all of the endless media attention to breast cancer, so many women don't know -- to get that breast  lump's tissue under a microscope yesterday!  OK.  A specialist in breast cancer might sometimes determine diagnostic mammogram or ultrasound is enough.  However, remember it is simply not a big deal to have a biopsy done.  The relative risk or discomfort compared to cancer is miniscule.  In the worst case scenario --  you didn't need the procedure.  The lump was benign.   FANTASTIC!  Unfortunately, this was not my story.

In my story, my cadaver saved me.  I had a cadaver in gross anatomy class in medical school who had died of cancer.  I remember the feel of his tumor under my hand.  The tumor was in his liver.  When I felt the lump in my breast, it felt just the same.  I have always felt peculiarly grateful to the cadaver.   Such a gift to give your body after death to those who need to learn.  To allow us to slice and probe.   My gratefulness is acute again now.  That unknown gentleman long deceased may have saved my life, insuring my prompt attention.  I immediately KNEW what I felt and acted aggressively accordingly.

So what is a woman to do?  Every woman of any age out there (men actually have a risk too although much smaller) should do breast self exams.  Please go to the breast cancer website and learn to do it properly.  But, if you don't.  At least be sure to feel and check and mash around and look for lumps or bumps or anything unusual.  If you feel something like a frozen pea or a marble in there, odds are it merits immediate attention.  Don't panic, there are benign conditions.  But do not allow anyone to tell you to wait.  Don't accept waiting for three months for a diagnostic mammogram.  You might need to beg, call many times, call various clinics, call various hospitals, work the system.  I certainly did.   It was not easy to find the people to help me and to get the appointments lined up.  But my insistence led to superb medical care.  To amazingly wonderful doctors.   They're out there.  Find them.  Insist on nothing less.  Good luck to you.

fill the kids in

So this morning I briefly and as brightly as I could muster, filled my kids in on some unfortunate family medical news. 

Promptly, my kids taught me about child development yet once again.  My son replied, "what, did you think we didn't know?!  We do have ears and eyes."  And after a couple of sweet comments, the kids went right back to what they were doing before -- just as they should.    

Taught me to fill the kids in.   Don't wait.  Keep spin positive.  They know anyway.  And then the door is open to chat.  And, children's resilience will surprise you.  

not any old green tea

Sure looks like green tea deserves rave reviews for health.  Some propose green tea benefits us via the radical scavenging and antioxidant effects of its polyphenols.   

There is indeed data to support the stuff as promoting health.  A prospective study of 40,000 Japanese found those who drank more than 5 cups a day to have 26% lower mortality than those who drink less than 1 cup a day.  Other studies have found decrease in hypertension and diabetes with green tea consumption.  Another found the tea may decrease colorectal cancer risk.  Preliminary animal  studies even suggest green tea could mitigate obesity, liver fat accumulation and metabolic syndrome.   All studies have not found benefit, though, and clearly more good studies would be lovely.

I'd drink it while waiting for those studies though.  I don't see a lot to be worried about drinking the stuff.  Just watch out for the caffeine, especially those who are anxious or insomniac or who are recommended to avoid caffeine by their doctors. This actually can be a real problem. I had a health conscious anxious client with sudden sky-rocketing anxiety and insomnia.  Eventually we pinned down the vast caffeine in his well-intended increased green tea consumption as culprit.

Furthermore, it seems a good idea to think twice about what specific green tea you consume.  A dear friend and traditional Chinese medicine doc raised a point I had not been aware of -- the specific type of green tea matters.  She said the available green teas out there have widely varying amounts of one of the main health-boosting, cancer fighting components, EGCG, and that it is difficult for consumers to know which ones contain it.  Also, how you brew and consume the tea makes a difference.  Easy to imagine this may impact study outcomes as well. She mentioned that sprinkling dry tea on food (but NOT cooking it) and eating it can be of benefit and suggested using the following tea brand.  And, I quote her here:

In a nutshell, when the tea is heated, via processing and brewing, and comes into contact with air, EGCG is quickly oxidized.  In fact, often the processing that companies use to improve taste is often what destroys EGCG ... [there are however] tea growers in Taiwan who grow, process and package tea to preserve EGCG via laboratory standards." 

  

So time for tea, it seems.   Not just any old green tea though.  

tune in -- sorry postponed

If you'd like to hear me chat live, please tune in to Jennifer Litwin's The Shop Cop on Voice America internet radio on this Thursday April 30th at about 12:45pm central.  We'll be chatting about children and the lousy economy.

-----  Sorry the above interview is postponed.  I'll update the time and date when I know!  -------

divorce rules for parents

Even when divorce is absolutely the best thing for a family in the long run, the process stinks.  And amidst stress, it can be easy for parents to lose sight of the kiddos' perspective.  Here's some ideas for divorce rules for parents:

1.  Kiddos are egocentric little beings -- as they developmentally should be.   So they often see all that happens as due to their own actions.    Tell them the divorce is not their fault.  Tell them again and again.  This is a tough idea for little ones to grasp.
2. No matter how mad you are --  remember that your ex-spouse remains your children's parent.  If you speak poorly about your ex-spouse, you are insulting your own children.   So don't talk your ex down.
3. Similarly, don't argue with the ex when kids are around.  Even if you are right and your ex is completely wrong.  Doesn't do the kids a whit of good to hear it.  Often breaks their hearts -- as most kids love both parents.
4. Keep kiddos out of the middle of communication -- don't use them as messengers.  For so many reasons.  
5. Divorce obviously is stressful for children too.  Regular routines can soothe.  So build in old routines with kids into your new lifestyle.   If you used to play cars with the little one on Saturday mornings, keep doing so any Saturday you can.   etc.
   
6. Likewise keep consistent routines between houses. In some divorces  this can be quite a trick to pull off.  Worth it for the kids though.  They benefit from keeping the same bed and meal times and similar limits from house to house.    
   
7. Remember that children sometimes speak with behaviors rather than words.  Of course you have to keep limits.  But talk about the emotions involved, too.  Plus it doesn't hurt to speak with behaviors yourself, too.  

   (Hard to explain so let me offer an example.  If your younger child made a "design" with his marker on the wall.  Set the limit first.  (Time out or consequences like cleaning the wall etc.) Afterwards, you could tell your child that you miss him so much when he goes -- that you feel like drawing on every wall in the house!  Maybe even every wall in the city!  You could find a big piece of paper and tell him you can pretend it is a wall and scribble on it together.  He could even take it home with him.)

8. Small point but key.  This is not a time to be late picking up your children.  Time to become an early bird, actually.  And as reliable as Swiss clockwork.  This behavior will help assure them that you will not desert.   No matter what you say, this fear will linger.  A reader below highlighted this issue recommending  parents not cancel a visit for any reason "short of death!"  Cancelled visits can make a child feel he no longer fits into your life.
   
9. Give kids transitional objects for when they are not with you.  Helps children feel you are nearer.  Let an older child keep your favorite sweatshirt.   A mom's indestructible piece of costume jewelry for a little girl to wear works.  Most children benefit from a photo of you in the backpack or by the bed.
10. Find therapy to help children deal with the divorce.  While you're at it, a parent should consider checking in with a therapist about parenting during this complicated time.  
    
11. Don't despair.  Sorry about the long list.  I know it is a complicated time.  But, I have worked with amazing, wonderful parents who despite divorce are an absolute team when it comes to parenting.   And, kids thrive.  Moreover, I have met wonderful parents who vigorously prioritize children's well being  -- where the other parent is not on board.  The kids still can thrive.   No family is perfect.  Fortunately for us all, children are forgiving.

take care of your heart

A quick reminder for women with depression to take especially good care of your heart.  

It  has long been known that depression is associated with heart disease.    Recent data analysis confirmed this relationship between depression and heart disease.  This study even suggests an increased risk of death from heart disease for those on antidepressants.  It appears unclear if the antidepressants themselves increased risk or whether depression severe enough to merit antidepressant use increased risk.  Certainly depression makes it hard to take care of yourself in so many small everyday ways that matter to physical health.

So please get close medical follow up.  Talk to your primary care doc about this association between depression and heart disease.  Request particularly careful cardiac follow up.  And, eat those veggies.  Exercise.  Take good care.

sad story

I am still waiting for Senator Grassley to step up and take responsibility for the inappropriateness of his call for certain executives to suicide.  Although surely unrelated to the comments,  this sad story this morning drives home the point.  Our leaders in government can set the example for the rest of us and focus on respecting the sacredness of every individual's life.   

helping out

People helping out and feeling good.  Seems those things tend to go together, huh.  Check out this inspiring story.  This will probably be the only sports story I'll ever post --  so enjoy!

FDA website lists meds under review

REMINDER:  FOR YOUR SAFETY DO NOT CHANGE MEDICATION OR MED DOSES OR STOP TAKING MEDICATIONS WITHOUT TALKING TO YOUR DOCTOR FIRST.  

Alright my anti-medication readers who so vigorously disagree with some of my meds perspectives -- I owe you a debt of gratitude. I appreciate that you have raised my awareness of a FDA website that lists medications that are under review for safety concerns.  I have added this link to my "helpful links" on the right side of this blog.

Meds are listed on this FDA site if possible new risks have been reported.  These listed safety concerns have not been confirmed.  But I think it is mighty useful for docs and patients to just know that a new specific safety question has been raised about a given medicine.

For example, Abilify is under review for liver toxicity concerns as of Feb 2009.  Doctors are informed by letter if a new toxicity for a medication is confirmed.  However, when a medication is under review like this, it still can be useful to know.  For example, if a patient on Abilify has nausea it may merit a check of liver function tests (bloodwork).

Meds have risks and side effects.  Meds often are still worth taking for their benefits.   However, awareness of risks is essential so we all can watch out for them and consider them in the decision process.  

For example, the wonder medicine penicillin has saved hundreds of thousands of lives but also causes a life threatening allergic reaction called anaphylaxis in at least .01%.  And, about 1% of those who get anaphylaxis die!  Because this is well known, if someone taking penicillin gets a rash or short of breath docs know to be very careful and consider stopping the med.  And, patients are often warned of this potentiality.

Most importantly, if you feel lousy in any way at all -- let all prescribing doctors know about it in detail.  And keep all prescribing docs updated over time.  Meds side effect should always be considered a possibility.  

skip the tomato

So despite my child psychiatry training and soap-boxing, I need to admit that I routinely fail as a mom  - -  as none of my children consume vegetables.  In fact they will go to absurdly and ridiculously gargantuan extents to avoid this food group.  

So feeling guilty for the health ramifications of this, tonight I served an especially humongous amount of veggies for each child.   A heap of green peppers.  A mound of red peppers.  A pile of carrots.  And, as an afterthought added one little, itty bitty baby tomato -- a known nemesis.   I generally would see water gulping and gag reflexes.  Truly mind boggling displays to behold. 

Tonight after looking at the dismayed faces around the table though,  I offered "... if you eat the rest of the vegetables with NO drama then you can skip the tomato!"   With overwhelming glee and endless declarations of love for the Mom involved, the mounds of vegetables disappeared rapidly and without a single complaint.  Only one little cherry tomato left on each plate.

Moral?  Perhaps that I am slow to learn.  You'd think I would have come up with that one before, huh?!  Seriously, though, that for kids -- like the rest of us -- so much lies in perspective.  That whole old glass empty versus glass full thing.  Perhaps a hopelessly stale metaphor.  But I never cease to be amazed how much of my work revolves around helping clients with similar concepts.  Time for me to take it to the dinner table.  

book review: Good Business

I have raved about Dr Mihaly Csikszentmihalyi before, but I can't resist doing it again.   Turns out that his practical, data based focus on how to build happiness in this world is just a mighty useful focus for many of us.   Here I'm recommending his book Good Business: Leadership, Flow And The Making of Meaning -- a wonderful, thought-provoking and perhaps especially helpful book in the current economic climate.  

The ebbs and flow of the business world needn't impact happiness or morale.   Dr. Csikszentmihalyi explains how beyond money for basics, money has little to do with happiness.   Rather finding flow increases happiness.   The professor adapts this subject to the business world by calling on business leaders to focus on nourishing "flow" and so increase happiness of employees, customers and themselves.  In this way, he describes:

leaders and managers and even the concerned employees of any organization can learn to contribute to the sum of human happiness...

For those who did not read Dr. Csikszentmihalyi's book Flow: The Psychology of Optimal Experience or my post blabbing on about it, let me explain.  The professor describes flow as that state of utter concentration when time passes without awareness and in fact one loses track of ones self.  One is lost in the moment.  Often this happens in hobbies or --  if you are lucky -- work.   The professor's research shows that it is not actually leisure like a pina colada on the beach that brings the most happiness  -- but rather achieving this state of flow.

In this book, the professor gets mighty practical, letting the reader know the nuts and bolts of building environments, businesses and organizations which foster flow.  He explains:

 The best strategy for creating such an organization is to provide the conditions that make it conducive for workers to experience flow.  Realistically, it is not possible for anyone to influence directly whether another person will enter flow, but by shaping the environment appropriately, one can increase considerably the likelihood of its occurring.

Important components include the physical environment,  a work level which both challenges and does not overwhelm, work that suits an individual's interests and talents, plentiful control or autonomy, abundant feedback and clear goals.   A larger purpose and meaning also is essential.  I don't see why his keen advice can't adapt beyond business to offer benefit in a vast variety of settings: from school to academia to government and even to the home setting.  

Csikszentmihalyi doesn't aim small in this book.  His final sentence encourages leaders to help business to "fulfill its potential to help make life happier for us all."  Not a bad aim for any of us, huh?

bad economy good for kids?

Dr. Cooper from Northwestern goes a step further claiming the bad economy is actually good for kids.  Interesting.  

children in a sinking economy

How can we not be preoccupied with the economy?  We struggle to pay for items which we used to take for granted.  We see a mind boggling 1.4 trillion dollar planned tax increase, budget doubling  national debt to 15 trillion dollars,  unemployment up to 8%,  and one in every 560 homes in foreclosure.

So we all worry and gripe and plan and go on and on about the economy these days.  Can't hardly sit through a meal or a TV show or read a website or seemingly a blog without a reference to the lousy economic plight.  What does this mean to our kiddos?

The stress for children is mainly via the adults. When parents droop or lose their temper more easily or ruminate anxiously, our children notice.   They fret.  Kids are always watching us, even as they work to stay in their own little worlds.  So, what can we adults do to help children stay on a positive developmental trajectory during these challenging times?  

I offer a corny mnemonic.   Parents and adults around children need to C -H- I- L -L.  Here I go over steps which can help healthy kids.  Next post will focus on kiddos with anxiety/mood disorders or who struggle despite these basics.   For most kids adults just need to:

 CHILL & take Care 

• Parents need to chill themselves first -- get things in perspective, ramp up their support systems and take care of themselves.
• Turn off the media bombarding your family with bad news.  This is a chance to turn off cable or fail to replace a broken TV.   
• Reach out to supports -- church, synagogue, meditation, women's groups, book clubs, knitting clubs etc.   Rediscover lost hobbies.  Many are affordable.  Take up running, drawing, sewing, singing.  Volunteer.  Have family meals.  
• Take care of yourself first.  In whatever way works for you.  Many especially benefit from the basics during stressful times -- such as regular healthy meals, regular sleep schedules and exercise.  Sometimes therapy or seeing a psychiatrist can be of help.   The most important thing for a happy/healthy child generally is happy/healthy adults in the home.

Be Honest but brief and spare kiddos gritty details.

• Children are way smarter than many adults give them credit for.  Kids definitely know something is up in the home.  However they will imagine the worst or that they are to blame if you don't fill them in.  
• So consider filling them in.  For example, "hey, if anything seems a little strange about how I am acting lately, it's just because I was a bit worried about the economy -- that's about money.  I was preoccupied making a plan.  I have a good one now."   
• Even older kids don't need to know much more than this.  Although some like to offer more details and even in planning.   Especially older kids can really help and feel good about it.  They can babysit for spending money or do more chores to help out overwhelmed parents.  Just  prioritize the message that a plan is in place -- which can help adults as well.  
  
• Or, for very little children keep it quick  "sorry I was grumpy -- I was worried about money.  I fixed it.  Lets play blocks!  Don't go on and on. 
• By the way, if your child of any age looks disinterested, no worries.  That's perfectly normal and healthy.  Let the kids be kids.  

be Incredible.  

• it can help for parents to throw in reassurance with Incredible positives quickly and surely.  
  
• For instance, "Don't worry.  I'm figuring it out.  Some things will change.  But I'm excited some of the changes will be wonderful for us all!"  
• Be creative and find some lemonade to make with these lemons for your kids' sakes.  The ones you come up with yourself will be far more helpful than anything I throw out here as you are the expert on your family.
  
• However, for example, "I'm excited that we'll all work together more as we figure this out.  That will feel good."  
• Or, "won't a garage sale to make a little money be fun this weekend!  Would you like hot chocolate afterwards?"  
• Or, "we are moving in with Auntie.  It will be a little crowded which will be hard sometimes.  But can you believe how lucky you are to have a sleep-over with your cousins every night?!"  
• Or, my own kiddos inevitably fall for the shopping comment: "wow that is the positively coolest toy ever!  I think you definitely would love that.  Absolutely do not forget to put that on your Christmas (or Birthday) list the minute you get home!"   Most are forgotten long before Christmas.  
• I use the word "Incredible" for this step because it aims to feel "huge" to the kids and might feel like an "incredible" leap to you.  Can be incredibly helpful, too.

Learn.  This is an opportunity for kids, like the rest of us, to learn.  

• Most kids learn vastly more from example than from words.  By modeling how to cope with a tough situation in a proactive and positive way -- adults can offer kiddos a gift which they can refer back to for the rest of their lives.  
• Don't most of us tell stories about how prior generations got through various tough times?  The stories of my mom's family moving in with the grandparents during the great depression has been a standby here.  The stories of how my amazing grandmother would go everywhere with two wheelchairs -- her son's and husband's -- is one my family looks back to for strength.  
• Especially with older kids didactic learning can help.  Even little kids can help read numbers on pricing and pick out foods at the store.  Kids also can learn to save and use coupons.    Sharing your knowledge about carefully managing money will be a gift to your kids life long and a way to empower them now.

Love.  

• Much as they often act otherwise ... kiddos actually don't depend on cell phones/computers/new toys/video games.  They count on consistent love and support.  
• As consumerism fades by necessity, this is an opportunity for families to revisit priorities and to ramp up the time spent on love and support.  
• No child I have ever worked with has been damaged by being told too often loving, kind and honest words.   These words are priceless.  
• Part of that love is also the lemons out of lemonades bit.   This is a chance to make children feel heard.  Parents can invite input from kids about how the family can save money.  Open ended questions can help.  And, no matter how outlandish the idea, listen.   And, where possible act on the idea.  Encourage children to think of ways the family can be happier/healthier too.  
• As examples,  I have worked with a teen who asked his family to spend money on healthier food and with parents who have decreased text messaging and Internet access both to save money and their children's time.  A lot of love in these financial plans.

not just miniature adults

The whole news story and my post below reminded me of a favorite metaphor.  The metaphor helps remind me to see children as children, not just little adults.  It helps me remember to keep in mind their developmental stage. 

 I am clueless about art history generally, so don't quote me on the art bit.  However, I recall a college art professor showing us paintings from medieval times.  The children looked peculiar; they had adult proportions which were merely shrunk to a child's height.  Not right at all. Clearly, children are not just miniature adults. Kids have proportions all of their own. In so many ways.

think like a child

Try to see things through children's eyes and you'll have more luck helping them.  Read this wonderful news article.  

anesthesia & learning disorders

Of course, we should keep an eye out for learning disorders in all kids.  However, new data shows a significantly increased risk for learning disorders in those who underwent multiple procedures  under general anesthesia young -- before age four.  More than a third of these anesthesia exposed kids had learning disorders.  This is about double the normal rate for learning disorders.  

Sometimes general anesthesia is unavoidable.  However, if a child's planned exposure to general anesthesia is for an optional procedure, a parent might want to review this data with the pediatrician first.   We don't know whether the anesthesia itself even causes the increased risk, so don't overly worry.  It is just worth taking anesthesia seriously and keeping an especially close eye on exposed children.  If a learning disorder is picked up early, it is so much easier to address.  

vitamin D

A whiff of UV light and our skin gets busy making vitamin D.  However, most women in the US have insufficient or deficient levels of Vitamin D.  This is probably contributed to by our increasingly indoor and nocturnal lifestyles.  And, perhaps we are heeding dermatologists' warnings about the importance of minimizing sun exposure with its risks of skin cancers and wrinkles.  Nothing like a warning about wrinkles to push women inside.   The dermatologists also recommend sun block use - which blocks much UV light and thus lowers vitamin D production.  

While the sun is the biggest source of Vitamin D, diet is another good option.  Salmon, mackerel, tuna, sardines, milk and eggs offer a decent dose of vitamin D.  Cod liver oil of the good old days gives a giant dose of  the stuff.   Although lord knows how anyone could stomach it.

Why am I blabbing on about such a written about topic?  Well, for starters, it looks just so good for our health.  Vitamin D appears protective against stomach, gall bladder, pancreatic, lung, colorectal, bladder, prostate, kidney and breast cancer , as well as  autoimmune disease, osteoporosis and heart disease.   

And,  I'd like to highlight recent intriguing data suggesting vitamin D also appears to have a postive impact on mood.  There are studies indicating that mood disorders may be associated with low Vitamin D levels -- see review.  

Why not just use vitamin D supplements? Well sure that's a reasonable option.  Don't take mega doses though, as like other fat soluble vitamins the stuff can be toxic at higher than physiologic levels.   The supplements might help depression and some call for taking at least 600 IU a day of Vitamin D in depression.  The supplements even have some data looking promising for mood.  

However, if you have read this blog before, you won't be surprised that my bias is to try the holistic approach first for my clients.   I routinely recommend that my patients with slightly low vitamin D levels first try a whiff more of sunshine and increase eggs/ salmon/skim milk etc. in diet.  If levels remain low on re-check -- then we reconsider supplements.  

not the place for medical debates

I had planned to post on schoolyard bullying.   I am preoccupied though.  Although perhaps the topic is in the same realm.  I just learned that  Senator Grassley who told AIG executives to suicide, is the man who spent the last year or so attacking my teacher, Dr. Biederman.  So I will digress ...

I was taught by many remarkable teachers at Harvard's Massachusetts General Hospital.  There the chief of pediatric psychopharmacology professor Joseph Biederman was one of them. 

The residents learned from his unrelentingly strong opinions.  Dr. Biederman would scold us if we were not aggressive in our treatment of children.  He would question our hesitance.  Dr Biederman would ask why we would want to wait until the child grew sicker before treating him adequately?   Why not treat now? He encouraged us to think about the risks of not treating a child,  as well as the risks of treating.  And, if we talked about the patient's psychotherapy for a diagnosis where there was not data -- he would refer to the therapy as "tushy massage."   Research should guide treatment.  His humorous comments drove home the point.   Dr. Biederman handed out reprints by the handful, emphasizing the role of research for clinical care.  

Dr Biederman has been the target of attacks led by senator Grassley.   The primary complaint -- Dr. Biederman failed to report to university officials 1.4 million dollars in earnings from pharmaceutical consulting fees from 2000 to 2007.    The payment largely was for giving talks across the country and for consulting fees.  Routinely talks are begun with disclaimers where the physician note any industry pay.  Of course the failure to report was unwise.  But does anyone keep up with academic hospital paperwork?  Moreover, when did paperwork become more important than good research and clinical care?  Where is any data that his research was subsequently flawed?  And, why assume because the man received money from drug companies, that his work is compromised?  Do we assume that of politicians? The pharmaceutical and health products manufacturers gave over 28 million dollars just in 2008 to politicians.   Grassley himself ranks 30th in congress in receiving contributions from pharmaceutical and biotechnology manufacturers.   In any case, what physician becomes an academic psychiatrist in order to make money?  It is one of the lowest paying medical specialties.  Grassley recently is further expanding his attacks on Biederman.  

Perhaps Grassley chose Dr. Biederman as an easy target for political posturing.  Biederman's opinions have long been controversial, and  he can sound ascerbic.  And, great psychiatrists long have been vehemently battling his ideas out in journals and academic circles.    Those of us in the field have listened and learned.  I have often disagreed with Dr. Biederman, for what that is worth.  I am vastly less aggressive with medications and more holistic.  However, that is besides the point.  When a politician attempts to influence this process, not only is a great individual wrongly targeted.   The discourse is taken out of the realm of ideas and moved into the realm of politics.  Not a more neutral place.  Not the place for medical debates.

here comes the sun ...

I hope you are taking a nice sunny spring vacation.  That tropical trip, that walk in the park, that day at the beach -- all are actually good for you.  We need to get out in the sun.    

Outside on a sunny day you are exposed to in the neighborhood of 500,000 lux of light.  On even an overcast day you get 50,000 lux.  In a typical well lighted office you are closer to 500 lux.  Turning a few extra lights on just doesn't do the trick.  

When you get out in the sun your body cranks up its own endogenous melatonin synthesis.  Melatonin is remarkably good for you -- helping you sleep at night, fight potential cancer cells, perhaps avoid ulcers and even battle the immune changes of aging.    Sure you want to keep sun block on to lessen those ultraviolet (UV) rays which can cause skin damage and skin cancer, but the rest of the spectrum appears to be good stuff!  Even UV light helps us make vitamin D, but that's a story for another day.

The hypothalamus receives info about light from the eye's retina's photoreceptor cells.  The hypothalamus's suprachiasmatic nucleus relays the light status on to the pineal gland -- a little tiny piece in the middle of the brain -- which turns on the enzymes which make melatonin.  So the light you are exposed to directly informs your brain's production of melatonin.

Melatonin is also in some foods like rice, sunflower seeds, mustard seeds, anise seeds, celery seed, tomato, ginger and banana.  The melatonin you eat also seems to get into the brain.  So why not work these foods into your diet.  

And if you are depressed I recommend redoubling efforts to get out in the sun and push melatonin levels up.  A recent review found that a chemical compound similar to melatonin called agomelatine is looking powerful as an antidepressant, perhaps even rivaling the traditional antidepressants.  While psychiatry clarifies the therapeutic role of this chemical, why not simply spend time outside.

If you hate going out or have medical concerns that keep you in, consider talking to your doctor about trying a light-box.   While data primarily supports its use in seasonal depression (seasonal affective disorder), sitting in front of a light-box each morning for 30 minutes helps many people.  There are a host of light-boxes available.  (By the way, if you have bipolar or manic-depressive disorder, the light-box may trigger mania so be sure to first discuss it with your psychiatrist.)  Dawn simulators are clocks that basically awaken you with gradually brightening light in the morning.  Some find these helpful, too.

Melatonin supplements are popular and those chemically manufactured look pretty safe.  Supplements are a big subject which I'll blog about another day.  Generally, when available I favor the natural approach  --  and so recommend people simply get outside.    

By the way, the flip side also may matter.   Turn lights out and go to sleep at night.  Suppressing night time melatonin release with artificial lights may be bad for your health.

Grassley's comments

I will try to steer clear of politics here, as so often politics are divisive and depressing -- not the goal of this blog.  

However, Senator Grassley's comments yesterday that AIG executives should commit suicide or resign is so vastly inappropriate on so many levels that I must comment.   First, it evidences a lack of understanding of the seriousness of suicide in our country.  Suicide is not something to joke about or use for rhetorical purposes.  Suicide is a horrible problem.  Worldwide about one million souls die by their own hand each year.   In the USA about 11 people per 100,000 suicide.  And suicides have multiple victims including suffering friends and family members.  The callousness of Grassley's comments to those who are suicidal or those who have loved ones who have committed suicide or are at risk is unacceptable.  

Second, his comments show a lack of respect for freedom -- such a key element of happiness.   A previously private company has lost all freedom to make business decisions.   What business does government have micromanaging any of us -- including the extraordinarily wealthy?  If the government has buyer's remorse, perhaps the government should reconsider its spending habits.   

I suggest Senator Grassley immediately retract his statement and make educating himself about suicide a priority.   Perhaps he could model taking responsiblity for one's actions.  He could even read my post on helping those who are suicidal.  The senator could choose to be a voice supporting suicide prevention in this country.  If he can not recognize how wrong his words were, I suggest he resign.  

six words

This one is admittedly corny and not so psychiatric.  However, words have so much power.  And, keeping caring deeds in mind can help us all ... so I couldn't resist including this link.  Enjoy the article.   

tell kids your real life stories

Tell your kiddos real life stories from when you grew up, especially those stories with helpful morals.  Even if the kids roll their eyes at the often repeated tales, keep on talking.  The stories help families over time.  Check out this wonderful article on the subject.

what to do when a loved one is in danger from himself

I have had a client's family member recently asking me repeatedly how far to go?  When to step in and protect a loved one?  How?  What to do?

Of course tender loving care for your suffering loved one should be an ongoing priority.  I touched on this in a blog a couple of days ago.  Again, bake him cookies.  Watch funny movies with him.    Go for a walk in the woods together.   Offer warm supportive words often and repeatedly.  

However, in the case of an emergency, such support is not enough.  If a patient is sending signals that he is acutely in danger of killing himself or someone else, then the family has no choice.  The choice is clear.   Immediate action is mandatory.  Call 911 immediately.  Perhaps obvious, but if you are unsafe you should be getting yourself away from the loved one first thing.  After calling 911, then also call the family member's doctors and psychiatrists and therapists.  Page them.  Leave voicemails.  Email.  Write letters.  Let all professionals know the information you know.    Hard though it may be to deal with.  You can also make use of the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).  Calling this number is free and accessible 24 hours a day, every day with calls being confidential.  This phone line is available both for those who are suicidal and those who are worrying about someone who is suicidal.  There are a host of other resources and phone lines available.  

And, don't dwell on the consequences of these protective actions on your relationship with the loved one.  You can work to remedy any damage to the relationship down the line.  The person even may be grateful.  A client I once called the police on to hospitalize for acute suicidality has sent me numerous grateful cards over the years and now is leading a productive, happy life. 

If a patient is more slowly killing himself such as with alcoholism or drug abuse or anorexia or other ways, this question becomes more complicated.  For example in anorexia, at what level of malnutrition to step in?  At what weight?    Again, I think if there is a question of survival in the near future, the family and friends must step in even if they're not sure.  This may or may not do good in the long run, but there are no other choices.  A trial of refeeding inpatient which will allow the individual's brain to function better,  just may allow survival long term.   I have written on this in a case report which details these notions further so please check it out if interested.  

How to make this happen?  In these more chronically frightening cases, too, call the loved one's doctors and psychiatrists and therapists.  Leave them messages repeatedly. Inform the professional about what is going on.  Do not assume the professional knows just how bad it is.  Your loved one may not have told him or her the whole story.   Crucial details may have been left out.   If this does not lead to prompt action or if your loved one doesn't have a doctor? Then, encourage your family member to go to the emergency room with you for an assessment.  If he or she allows, stay during the assessment and share your inside information on what is going on.  Health providers can be of more help when they have more information.  Again, if things become more acute, call 911.  And, if the person has children social services may also be of help.  One number to try is 1-800-4-A-CHILD.  

And take care of yourself through this.  There is only so much one can do to help.  It is a wonderful fantasy to hold onto that we can save those we love.  We can not.  Of course we can help -- as outlined above.  If you are reading this, it sure seems likely you are one who already is helping.  You have sought out a remote resource here.   Your loved one is lucky to have you.  Good luck with it.

book review: SOS! Help for Parents

I fear I have insulted at least one parent by recommending SOS! Help for Parents by Lynn Clark.  Perhaps the offense lay in the cartoon illustrations which emphasize the already simple points of this classic little book.   I don't mean to insult anyone's intelligence by recommending this book.

But parenting basics just aren't so complicated, and I appreciate a book willing to show that.  The tricky part is implementation and sometimes mental health professionals can help with that.   This book also offers details and examples to help with that so I recommend reading it.  Of course no book or rule applies for every kid or every situation.  However, the book's "rules" are generally so simple and true:

• Rule #1 Reward good behavior (quickly & often)
  
• Rule #2 Do not "accidentally" reward bad behavior
  
• Rule #3 Punish some bad behavior (use mild punishment)

Techniques for increasing good behavior are likewise simply explained:

•  Use active ignoring for mild misbehaviors.  Remove attention from a misbehaving child.
•  Reward good alternative behavior or "catch your child being good!"
• Use what Clark calls "Grandma's rule": "After you do your chore, then you get to play."    It is easier to do an unpleasant task if it is followed by fun.  ie after you complete your homework, then you can play video games.  
• (Don't reverse "Grandma's rule"!  The unpleasant needs to be done first!)
• Set a good example (ie don't scream unless you'd like your kiddo to do the same!)

a tribute to Dr. Ackerman

Dr. Ackerman was my hero.  I never dreamed a dermatopathologist could be a hero.   I was terribly sad to find out today that he recently died.     

Dr. Ackerman is famous in the world of pathology and wrote at least 700 papers and 60  books in his field.  However, he was blunt and peeved some.  My family, however, he helped.  He called on New Year's Eve a few years ago, knowing how much pain we were in -- worrying.  Dr. Ackerman had just returned from a trip and looked at my daughter's slides from her melanoma like lesion.  He thought other elite institutions were timid with diagnoses by calling it cancer-like or melanoma-like.   

The old doctor put it bluntly with a somehow friendly and elegant insult of every other famous professional involved.   Something along the lines of "utter hogwash."  Dr. Ackerman gave plenty of intellectual reasons explaining why the pathology was actually benign.  But, what I heard was the clear strong emotion in his voice.  He was sure.  And, he understood where we were coming from.  My child was his priority.  He wanted to protect her from overly aggressive surgeries.  One person mattered.  

Dr. Ackerman, a final time I send grateful regards.   I recall your work.  I aim to remind my clients -- who often struggle with self worth and futility -- that one person matters.  So often vastly more than they know.  You did.  Thank you.

.  

influenza of the mind -- helping a family member with depression

PLEASE COMMENT!  COMMENTS WITH FURTHER SUGGESTIONS COULD BE REALLY HELPFUL ON THIS ONE, I THINK.  THANKS MUCH.  --JB

Family members often feel guilty when they learn someone in the family is suffering from depression.   They wonder what they did to cause it.  They reexamine every harsh word, every careless deed.  Or, they feel themselves saddened or helpless. 

These inclinations are misguided and unhelpful.  Those in wonderful families can be as tortured by depression as those in challenged families.   In the vast majority of cases, this isn't about the family.  Give up the guilt.   The etiology of depression is multi-faceted with biology playing a critical role.  I think it is more productive to respect this biological component while maximizing family support.

Depression can feel like an influenza of the mind, washing over an individual with illness.   A client recently told me how easy it was to ask teachers and friends to help her when she had the flu.  She knew how to ask.  They knew how to respond.  TLC poured in.  She described how much impossibly harder it was to ask for similar help when her severe depression relapsed.  I borrow her comparison of depression to influenza, hoping it can make families feel in more familiar territory helping out a depressed loved one. 

So what are families to do?  First, accepting the diagnosis and the biological component actually is a big step.   Then the family members productively can look at how to help.  

Second, family can simply be there and know that being there matters.   Part of being there can be listening without judgment or advice.  Advice  doesn't register anyway.  Judgement can be silencing.

Third, I have never seen a client damaged by too many supportive words or deeds.   Amidst a depression self esteem is battered -- no matter the success of the individual.  Let the family member know you care for him or her.  Endlessly.  In many ways.  Call.  Text.  Email.  Send tokens.  Provide healthy meals.  Help with chores or work.  Take on child care.  Know you may not hear back or hear adequate thanks.  It can be hard to respond when ill.

Fourth, help bring in mental health professionals promptly.  Offer to schedule the initial appointment or to find available psychiatrists.  Offer to accompany your loved one to appointments.  Offer to join for appointments.  Encourage ongoing compliance or second opinions if your loved one is hesitant to follow up.  Leave the mental health professional voicemail giving updates or information, especially anything worrisome.  While the therapist may not be able to return your call due to confidentiality concerns, he or she still hears your voicemail.  If you are worried about immediate safety call 911.

Finally, don't underestimate the helpfulness of distraction.   Take your loved one to movies.  Go on walks in the woods.  Send books or videos.  Meet for meals.   Even if the family member is unable to enjoy these things fully,  you are helping to pass the time.  And, time is key.  Time needs to pass for an antidepressant or therapy to work or for depression to fade.  And with treatment and attention depression indeed does tend to fade.   Slowly but surely.  

budgeting happiness in the era of the slumping DOW

How to keep spirits up on the day when the DOW hits a many year low?   Note the less than happy faces.

Happiness actually has been a trifle neglected in the world of psychiatry.  The various mental health maladies or personality disorders gain vastly more attention.  

Nonetheless there is a superb body of research in psychology and sociology.  My idol amongst the researchers is the once University of Chicago Professor Mihaly Csikszentmihalyi who wrote Flow, Finding Flow, Flow and the Psychology of Discovery and Invention, and The Evolving Self, amongst others.  He has a multi-faceted, evidence based and profoundly thoughtful view on the subject.  Here I'll touch just on one little research based point and hope to entice you to read his books.   The point is a trifle obvious, as the most powerful ones usually are.

Ignore the recently ridiculous DOW.  Vast wealth really has relatively little to contribute to happiness as long as basic needs are met.   In fact, studies even suggest success doesn't lead to happiness 

and outside circumstances or events may have only short lived impacts.

Amongst innumerable other findings, Professor Csikszenmihalyi's work highlights how people are actually happiest when absolutely absorbed in whatever absorbs them.   Great happiness occurs when there is achieved a level of focused attention where one loses track of time passing, loses track of surroundings, loses track of problems and, in fact, loses track of him or herself.   This the professor calls "flow."  The person needs to be receptive internally to flow to allow it.  An activity at a proper intensity and skill level and interest level can nourish it.  There are a zillion activities which can feed flow.  Work, guitar, cello, singing, drawing, crafts, dance, soccer, even perhaps blogging.  Which specific one doesn't matter, except to the individual.  The individual's all encompassing focus does matter.

So when planning and budgeting why not keep such passions and happiness prioritized?  No matter the economy, it makes immense sense to invest time, money and effort into those areas in which you or those you love are able to become utterly and completely immersed and lost ... and happy.  

A sampling of professor Csikszentmihalyi's words from Flow:

"... happiness is not something that happens.  It is not the result of good fortune or random chance.  It is not something that money can buy or power command ... "

"... The best moments usually occur when a person's body or mind is stretched to its limits in a voluntary effort to accomplish something difficult ..."

"Concentration is so intense that there is no attention left over to think about anything irrelevant, or to worry about problems.  Self-consciousness disappears, and the sense of time becomes distorted.  An activity that produces such experiences is so gratifying that people are willing to do it for its own sake, with little concern for what they will get out of it, even when it is difficult or dangerous..."

"In our studies, we found that every flow activity, whether it involved competition, chance, or any other dimension of experience, had this in common: It provided a sense of discovery, a creative feeling of transporting the person into a new reality.  It pushed the person to higher levels of performance, and led to previously undreamed-of states of consciousness.  In short, it transformed the self by making it more complex.  In this growth of the self lies the key to flow activities."

kids with ADHD deserve individualized treatment

[BEFORE READING PLEASE NOTE: DO NOT CHANGE YOUR CHILD'S TREATMENT IN ANY WAY WITHOUT FIRST DISCUSSING IT WITH YOUR PHYSICIAN OR PSYCHIATRIST.]  

An amazingly dedicated mom, traveling hours on behalf of her elite athlete child and working multiple jobs let me know in dismay about her struggles with her child's attention deficit hyperactivity disorder (ADHD).  After severe side effects to high doses of stimulant medication   -- considered a gold standard for treatment of attention deficit disorder --  this mom had discontinued all medications, targeting holistic measures instead.  However, she was concerned about the child's ongoing attentional and academic struggles.

I think this good mom's dilemma is not unusual.  People long for natural measures and are frustrated with the shortcomings of medical approaches.  They sometimes see medications as given cavalierly.   They worry that stimulants like Ritalin, Concerta, Focalin and Adderall are household names.  They sometimes fear the term ADHD is indiscriminately thrown at kids who don't really have it and therefore should be managed differently.

Perhaps the problem here is a lack of communication and attention to the individual child and situation.  I don't aim to provide a comprehensive overview of the field of ADHD diagnosis or management but rather to emphasize the need for individualized treatment.  Somehow this specific child's situation appears not addressed.  His athletic status perhaps not adequately factored in to medication dosing.  The mom's holistic bent perhaps under-appreciated or inadequately discussed.   The heart of psychiatry is the biopsychosocial approach which incorporates all such intricacies into diagnosis and planning rather than simplistically prescribing a med.  

Treatment needs to meticulously revolve around the individual child -- his lifestyle, his preferences, his health and his side effects.  For example, when a child truly has biological ADHD and merits medication and is in good health, stimulants can be a good choice.  However, stimulants can minimally raise blood pressure and heart rate.  For many this doesn't matter.  When prescribing to an aspiring athlete, though, the stimulant caused increases in heart rate or blood pressure might matter.   Feeling physically better might be the priority.  Thus his dose should be kept on the low side even if he can not perfectly attend.  Or, for example, stimulants can cause decreased appetite.  For an athlete keeping dosing low to protect appetite might be worth slightly worsened attention.  Regular eating is important for athletic endeavors.   On the other hand, for another athlete perfecting attention might be the ideal -- it might not only help school but also athletic performance.  Here dosing might be more aggressive.

So while most data shows that good doses of stimulants for ADHD tend to be more effective for symptoms -- that doesn't mean it is more effective for the child as a whole.   Some children lose a certain zip to their personality when fully medicated.  Not diagnosable but the kid just doesn't feel as good.   Others become hyper-focused bringing out other symptoms or problems.   Still others miss a certain creativity which the wandering thoughts of ADHD offers.  

Others vastly and meaningfully benefit from aggressive treatment.   For adults a bit more focus and work might go more smoothly, allowing business to prosper.   For some children and teens improved attention brings not only better grades but also improved self-esteem with subsequent better behavior.  For drivers treating ADHD often is the top priority as it decreases accidents and increases safety (1,2,3).  Medicating ADHD might even help vulnerable individuals avoid substance abuse.  So decisions are complex and benefit from individualized treatment with careful  discussions between family and prescribing physicians.  Long term regular follow-up with the same caring doctor over time can facilitate this and  allows the doctor to more promptly adjust treatment as new research becomes available or as the child develops over time.   

Thoughtful discussions also can include additional measures which can  help: regular plentiful sleep schedule, minimizing food colorings and additives, regular balanced meals with plenty of fiber and protein,  behavioral management strategies, and careful school collaboration.  For milder symptoms maximizing such holistic measures may be the right first step, even before meds.  Back to the soapbox, though.  Again, this depends on the specific child and situation.

parents can and should fix kids' obesity

 The obesity epidemic hits kids too.  Between 16 and 33% of children and adolescents in the US are obese.  This is a huge deal.  80% of these kids will become obese adults with the dramatic medical consequences that come with that including heart disease, some  cancers, diabetes and osteoarthritis.    61% of obese children have another risk for heart disease like high cholesterol or hypertension.  During childhood these kids are also at risk of sleep apnea, joint  problems and low self esteem. 

 If you have concerns about your child's weight, the first step is to see your pediatrician.   There are serious medical conditions that can cause obesity. There are serious medical complications of obesity which merit prompt treatment.  And, your pediatrician can let you know whether your child is indeed obese and how to best address this for your specific child.  It is essential to have your pediatrician review any proposed game-plan, including mine.   I do not know your child and can not know whether he should be exercising or changing diet in any way.    Each child has a unique health status and merits individualized recommendations!   Also, if your kiddo has mood, anxiety, eating disorder or other mental health concerns, see a child psychiatrist too.  

Even once you get the pediatrician's input, it is hard to know where to start.  Despite the prevalence of the child obesity problem, there is no clear consensus on how to treat it.  A number of varying approaches show small benefits.  Studies differ so that it is hard to compare results in a meaningful way.  Thus I use some cherry picking of data and creative license here.  I combine elements of the parent centered approach and steps that make developmental sense to me as a child psychiatrist.   Steps that I have seen make good impacts in clinical work and as a parent.

Many have tried to educate children about healthy eating and exercise.  Apparently with limited benefit.  This makes sense.  The obesity problem probably has little to do with intellectual understanding.   How many children spontaneously do things that are good for them just because they know it is a good idea?  Spontaneously turn out the lights at night?  Spontaneously turn off the TV or video games?   Kids tend to be driven by the joy of the moment.  That's part of what makes little ones so charming -- we adults forget our troubles watching children's carefree absorption in the moment.  Children generally only do healthy stuff when adults make them or because it's also fun.  For even the best of kids, a lack of adult supervision and many would be off eating marshmallow fluff and playing Wii all day.  They're kids.  

So the logical way to treat child obesity is for parents to act as agents of change.  Parents provide the majority of food that children consume.  Or, they provide the money for it.  Or, they provide the childcare who offer it.  Or, they OK the visits with relatives or play-dates who provide food. 

My bias is that ideally parents should change behaviors without the children even being aware they are the target.  Again, why not just allow kids to be kids?  Why not protect children from pre-mature increased self-awareness or self-criticism over dietary indulgences or weight?  Kids instead can be absorbed in their developmental jobs -- be it playing princess or building Legos or blocks.  

With an overweight child the parent's job is simple.   Just not at all easy.    For most children, the parent simply needs to increase the child's time spent in sports and activity,  increase the quantity of vegetables and fruit in the diet, increase the quantity of whole grains  and decrease the fat and sugars consumed.  Furthermore, meals need to be regular --  without skipped meals.  Avoidance of sugary drinks including soda, juice and sports drinks is key.  Most importantly for this herculean task, the parent needs to keep in mind the long term picture and take this mission as seriously as that of fighting any chronic medical illness.

And when children become aware of changes? Which of course they will.  Simply answer the useful truth.   Lying to a kid is rarely a good idea.  Let them know you have become determined to increase the family's health.   And if they gripe?  Remember they'll grow accustomed to changes over time.  Although there is no point in telling them that.  A child lives in the minute.  The next meal usually feels eons away.  

What about quantity?   I recommend that the child dictate quantity for all healthy items but not special treats or desserts.   Let the child's body  self regulate.  If a child is hungry between meals allow plenty of fruits and vegetables. 

And, don't worry if you are an overweight parent.   The magic of a parent's love --  for many a parent it is simply easier to take the tough steps to change a child's lifestyle than to change his or her own.   No reason not to take advantage of that.  Just try not to allow the child to see you eating unhealthful foods or hear you talking about it.   Children imitate.  Furthermore, there is no need for your kiddo to hear about your  body insecurities.   Such words might feed the child's body concerns.  

Moria Golan PhD has published results supporting the efficacy of parents as agents of change.  She completed a study of overweight kids where half of the kids went to intensive sessions where they learned about exercise and diet.  The other half stayed home while parents went to classes.  Both groups lost weight but the kids who stayed home lost significantly more weight.  Over the years the advantage to the kids who stayed home grew greater.  The other group grew more overweight.  So the parent as agent of change approach looked significantly effective.   In fact, over years parent focused treatment led to 50% more weight loss for the kids than other techniques for children 11 years and younger.  Data also supports the power of modeling.   Parents can impact a child's fruit/veggie intake by themselves eating more of the good stuff.  

While I'm less optimistic about the efficacy of this approach for teens, I see little downside to including aggressive parent improvement of the family's lifestyle in the comprehensive treatment.  And, teens are still often ruled by the passions of the moment so a parent's behavioral guidance can help.  Parents more easily can keep in mind long term health impacts of today's behavior.   

Of course there are tired parents with limited resources  where this approach must sound overwhelming.  An extra chore -- especially in this economy -- can wear one down.  Keeping in mind the power of small changes over time might help.   Creative solutions could even help support the child's health and the tired parent.  For example, parents can assign a child chores that support his or her health -- any that involve walking or movement.  Assign the child to dog walking duties, dog feeding duties, taking the garbage out, vacuuming etc.  Or, take steps that save money plus support the kid's health.   Regularly provide the child water instead of gatorade or juice. 

Finally this is a tough job for any parent.  Whenever possible, I recommend involving specialists in the field, in addition to pediatricians.  A nutritionist can help parents make good food choices.  A parent guidance therapist can help parents achieve change.  A couples therapist may help squabbling parents work together as a team for children's health.   I have seen divorced parents come together for a child's well being.   For a kid where weight has had a negative impact on self esteem, a child therapist also might help.

TV stinks for kids

Perhaps too obvious for a blog.  However, the links might interest some.  TV generally stinks for kids.  We have long known that.  It simply makes logical sense.  Time spent watching TV is passive.  Their little bodies aren't getting the exercise they all so desperately endlessly need.  Their brains aren't figuring out how to interact with others or how to build a creation or how to play a game or imagine various worlds.  

I'm not a purist, though.  There's not much data factoring in what show on TV is being watched.   Of course that inevitably matters.  At younger ages at least some TV is dramatically educational.  Who could argue against the educational "Word World" or "Reading between the Lions?"   Of course, these educational shows are not the ones my children prefer, although hopefully other parents have better luck.  Mine have an overwhelming drive for such cotton candy for the brain as  "Tom and Jerry"  and "Scooby Doo."  You can see, I break my own recommendation and allow TV in small, controlled doses.  Because, of course, parents of young children sometimes just need the break TV provides.  Allowing a young child to watch a carefully selected show might allow the parent to come back refreshed and have a better interaction with the child thereafter.   Or, it might allow needed time for a parent to cuddle with a child who rarely sits still.   Or, for an ill child who is suffering, TV might afford a valuable distraction.  The affordability of DVDs which allow the child to watch carefully selected shows without the insidious rot of ads sneaking in, must improve the process a bit.  

However, it is hard to think of one popular show for a teenager that does an ounce of good.  Unless your kid is magically drawn to National Geographic series or the History channel and the like.  If that's the case,  take advantage of it.  Fantastic.  Nothing wrong with some passive learning snuck in around the edges.  

However, in general, TV is just not good for children.  It needs to be limited vastly.  What could feed an adolescent girl's body insecurities more than "Top Model" and the like?  What could glamorize the gang culture more than exposure to glorified violence and some MTV videos?  Add in the well documented increased sexuality on TV over the last decade, and the average U.S. teens exposure to TV 23-24 hours/week.  How can that not effect development?  

Not surprisingly, a new study shows TV during teenage years correlates with adult depression.  The study adds to a vast body of research suggesting we should all keep the TVs off.  Studies show little kiddos who watch more TV, eat less healthfully

in the US and in other countries.   And little children who watch more TV tend to be more overweight.  For obese children, amount of TV viewing is not only associated with degree of overweight but also with hypertension.  Even a TV on in the background while a child seems to ignore and play, has been found to disrupt the child's play behavior.  Language development even may be negatively influenced.  Exposure to childhood media violence has even been found to predict young adult violent behavior.  

Admittedly, most of these findings are just associations not causations --  as careful as the studies may have been.  Maybe parents who let their kids watch too much TV or violent TV tend to be those who don't set limits in other ways.  However, it doesn't seem wise to bet on that with children's health.  No harm in turning the TV off.  

communication matters

Another simple but critical soapbox.  The soapbox: when patients demand to be exquisitely informed, they simply do better.  When doctors step up and offer detailed information, most patients make excellent use of it.  The time is effectively and well spent.  So if your doctor isn't communicating well, tell him or her.   Everyone slips up.  But, communication matters to outcome so push the issue.  Or, if your doctor routinely does not communicate well, consider transferring care to a new one.  And, consider pulling in second opinions.  The more information the better.

I learned this with my daughter's care.  The initial doctor we saw for her melanoma-like lesion made a diagnostic error -- which is understandable.  We all err.  The lesion was unusual.  However, the doc was clearly rushed and did not listen to the request to take off the lesion, and that this specific child would indeed sit still for it.   Treatment of the lesion was delayed many months, meaning additional surgeries with general anesthesia.  All of which she was perfectly still for.    She is fine, years later.  But the episode informs my work.

By no means are all docs careless.  The story further included innumerable wonderful ones along the way who offered vast information and time.    Every patient deserves such thorough education.  Every doctor should routinely strive to offer it.  There is data supporting this soapbox in a variety of medical situations (diabetes, renal disease, depression in cancer, asthma, pre-surgery anxiety etc. )  There is even data suggesting doctors can learn to communicate better, and it doesn't even necessarily need to take more time.   

antidepressant when nursing ?

Although delighted with her newborn, one of my clients with a history of severe mood symptoms needs to clarify her plan.  What if she has a resurgence of depression post-partum?  She toughed through pregnancy off of medications, despite some depressive symptoms.  She now breast-feeds and needs to know what re-starting antidepressants would mean to her brand new little tyke?

Before discussing meds, let me emphasize that postpartum moms with depression/a history of depression deserve close treatment and follow-up!  Moms with a history of mood disorder are at a huge risk of a relapse postpartum.  It is such a vulnerable time with extraordinary demands.   And, of course, the well being of two -- mom and baby -- depends on the mom's health.   Depression is a risk factor for suicide.   A history of psychiatric disease vastly increases suicide attempt risk postpartum.   Even the quality of mum's interactions with the baby can be effected if depression kicks up.   All involved treators -- including the pediatrician, lactation consultants, OB, other involved docs -- all should be told and reminded at each visit about a mother's psychiatric history.   

The question for some moms will be whether to nurse their baby or not -- while they regularly take absolutely necessary antidepressants.  For some moms the depression is so severe that using every method available to treat it is mandatory.  The risks of not treating the depression are unacceptable.   Antidepressants are a must.  Good doses of the most effective antidepressant are the clear priority.

For other moms the depression is not so bad and the question changes.  For these mothers nursing might be the priority instead.  The question here may be whether to start antidepressants or not?  And, at what dose or schedule?

Health permitting, nursing is hands down the best way to feed a newborn.  The American Academy of Pediatrics recommends nursing exclusively at least the first six months and ideally continuing  for the first year of life.   Looks like pretty darn good reasons for this.  Nursing is associated with decreased death and illness in the first year of life.  And, the fatty acids in breast milk appear to help the baby's brain develop.  Nursing benefits the mom -- decreasing risk of breast, ovarian and uterine cancers.

However, nursing often means babies are exposed to moms' meds.  Psychotropic medications are routinely secreted in breast-milk, meaning the tyke would consume any med the mom takes.  The amount the baby is exposed to depends on:  the specific medication chosen, the mom's medication dose, the baby's liver function (ie how well the baby can metabolize the stuff) and the timing of nursing.  The baby's liver function depends not only on his health but his age.  A preemie may metabolize very slowly.  A full term newborn's liver still only metabolizes 1/5 to 1/3 as quickly as an adult's liver.  But by age 2-3 months a baby's liver often works faster than adults!

All antidepressants enter breast-milk.   However, the baby's exposure to meds  looks generally low.  The baby's exposure may be decreased by keeping med doses as small as possible.  And, the baby's exposure can further be decreased by a careful nursing schedule.  This may only be doable in older babies who nurse less frequently.  If a mom nurses at the times when her blood level of zoloft is lowest, for example, then the baby's blood level can be decreased by 20%.  For a once a day med like zoloft (sertraline), mom's levels would be lowest immediately before the next dose.  Bless the moms who partook in this study or try this technique.  Sounds tremendously difficult.   The body often dictates when it is time to nurse.  For an already tired, depressed mother of a newborn, scheduling nursing around med doses seems like a lot to juggle.  On the other hand, it does give the mom a way to take needed medicine and yet take steps to minimize her baby's exposure.   So the option merits consideration.

What does antidepressant exposure to the baby mean anyway?  Big complications from tricyclic antidepressants, prozac (fluoxetine), paxil (paroxetine) and zoloft (sertraline) look rare. Some consider paxil (paroxetine) and zoloft (sertraline) as first line choices.  

 Other antidepressants have less data but also so far don't look so bad.   There have been reports of baby  jitteriness, irritability, excessive crying, feeding difficulties and sleeping difficulties.  There has been a seizure reported for one baby where the mom took Wellbutrin (buproprion) while nursing.

Even though they look pretty safe, any mother considering an antidepressant should sit down with her psychiatrist and review the current risk data on that specific medication at length before taking a single pill.   New risks and concerns about medicines come up over time.   If the mom does nurse while taking antidepressants, the baby should be followed closely by the pediatrician who needs to be informed about the tyke's exposure and reminded at each visit.  My old soap box.  Medications can be wonderful and life saving.  However, take them with thought and care.

No matter the medication decision, treatment and support for the new mom needs to be maximized!   Therapy needs to continue.  Phone visits can supplement in person, if getting out with a new baby is undoable.  And, this is the time for family/friends to babysit/drive to help postpartum moms attend therapy.  Adding in group therapies can help.

Family and friends need to step up and help out the postpartum mom in other ways, too.   Protect the mom's sleep!  Poor sleep is associated with depressive symptoms. Can a relative help the mom get naps ?  Can the dad do night time diaper changes? And, this is the time for family and friends to get creative with their support -- bring casseroles, grocery shop, clean house or babysit so the mom can get a shower or exercise or relax.  And, mothering a newborn can be isolating.  It is hard to get out with a little one, especially in crummy weather.  Mothers can lose touch with work colleagues or busy friends.  Isolation can feed depression.  So, this is the time for family and friends to make a real effort -- go visit.    Plan coffee or lunch routinely.  Help the new mom find a mothers support group or "play-group" for newborns.  

economic asthma ? !

 A connection between asthma and mental health has been recognized for centuries.  This seems inevitable.  Hyperventilation makes a person nervous.  Difficulty breathing isn't relaxing.  Asthma attacks can feel like panic attacks.  Not surprisingly, easy breathing is just important for feeling good.  How could anxiety and asthma not interact?

Lately, though, this connection has become more clear to me.  A number of my clients have been suffering from out of control asthma.  Thinking back, I realized this worsening began over the last few months, as the economy plummeted.  So, is it possible that the economy is effecting anxiety levels which in turn is effecting asthma control?  If yes, then, do government economic policies effect our health?   

A beautiful 2008 review of the relationship between mental health and asthma confirmed a remarkable connection.  Those with current severe asthma are 2.65 times more likely to have an anxiety disorder than those without asthma.  Current severe asthmatics are more than 4 times more likely to have panic attacks, phobias or social anxiety. Even those with mild lifetime asthma have a 1.51 times increased risk of having an anxiety disorder.  There is even a dose/effect relationship!  For every incremental increase in the number of days of poor mental health, the worse the asthma status.

It then seems key for asthmatics to control anxiety, especially during these anxiety provoking economic times.  Simple behavioral steps can decrease anxiety:  Address financial concerns head on/meet with a financial advisor.  Then, stop thinking about it.  Turn off the TV and stop watching the financial news.  Eat right.  Sleep right.  Exercise.  Spend time with friends and family.  Distract yourself with hobbies.  Do things that help keep it all in perspective.  Read to children, walk in the woods, volunteer at a hospital or shelter, visit a church or temple, help someone out etc. 

Behavioral techniques like deep breathing, relaxation exercises, yoga or meditation may help. Therapy can too -- even if financial constraints means only a few visits are doable.   Consider a therapist who incorporates cognitive behavioral techniques.

And, consider seeing a psychiatrist for anti-anxiety medication. There are a host of medications which treat anxiety.  When carefully prescribed, many of these medications are generally as safe, or safer, than many asthma medications.  But, admittedly, anxiety treatment in asthma needs more  research.  There are concerns about the safety of psychotropics in asthma.   Some worry SSRIs could worsen bronchoconstriction/asthma.   And, there have long been concerns about benzodiazepines causing respiratory depression.   Also, be sure to tell your pulmonologist about the medications your psychiatrist prescribes to avoid drug-drug interactions!    And, of course, follow up closely with your pulmonologist and asthma treatment throughout!

martini and Zoloft?

A patient called me and asked me if there is anything wrong with mixing a martini & Zoloft (sertraline)?   

I recommend avoiding mixing any psychotropic medications of any type with alcohol.  Alcohol interacts with a host of medications in a variety of sometimes unpredictable ways and alcohol looks hard on the brain, anyway.

Alcohol interacts with metabolism of other substances.  Anyone who has had alcohol with a meal versus on an empty stomach has experienced this.   If you combine alcohol with food, you become less intoxicated.  This happens because food slows gastric emptying.  This gives alcohol more of a chance to be metabolized in the first pass leading to lower levels.  

Alcohol is broken down by alcohol dehydrogenase (ADH) and p450 enzymes in the liver. Some p450 enzymes are also responsible for the break down of a bunch of medications commonly prescribed by psychiatrists.  Alcohol can compete with the medicine for enzymes, slowing the break down of medicine and raising the blood level  --  making your body feel like you have increased the dose!  This can be unsafe.  Or for a chronic alcoholic who isn't currently drinking, some enzymes can be hyperactive and lower medication levels which may interfere with treatment.  There are also pharmacodynamic interactions.  Here without changing the level of medications in the body, alcohol has an additive effect with them.   An additive sedating effect, for example.  

Alcohol can raise tricyclic antidepressant blood levels.  Alcohol can block first pass metabolism and can damage the liver which likewise slows metabolism.  Increased levels of tricyclic antidepressants can slow cardiac conduction and can be deadly.

Atypical antidepressants (like the very sedating trazodone or  Remeron (mirtzapine)) can have significant additive sedative effects with alcohol.  Sedating matters --  for example, if you are driving.  

SSRI antidepressants (like Zoloft, Prozac (fluoxetine), Paxil (paroxetine)) also could have additive sedative effects with alcohol, although generally SSRIs are much less sedating than the antidepressants above.   

A real concern is the additive effect of the underlying depression and the depressant effect of alcohol.  The alcohol may get in the way of treatment.  Alcohol effects neurotransmitter levels that antidepressants act on, like serotonin.  

Furthermore, alcohol is probably lousy for the brain anyway.  It looks like the more alcohol consumed,  the lower cerebral blood flow  and perhaps even the  smaller the total brain volume.  Although keeping things complicated, light drinking has shown to be associated with a decrease in progression to dementia in those with mild cognitive impairment.  Still, I recommend my clients avoid alcohol.  If they choose to drink anyway, I suggest they keep quantities small.

birth control pills and mood

I met with a woman whose mood plummeted shortly after she changed birth control pill (BCP) formulations.  She changed formulations because she had seen a new doctor in a new place, not for any medical reason.   No one chatted with her about dangers of this switch.

I worry this is typical.  BCPs tend to be prescribed cavalierly.  The vast majority of women have at some point taken "the pill," so we just don't tend to think of it as a big deal.  It is part of our culture.  And, birth control is crucial, and BCPs make it so easy.   And, the formulations of the pill have so improved  --  decreasing side effects/risks.  

But it still should be seen as a big deal.  That's my very simple soap box.  Women need to be reminded there are lots of other options, some very good!  And, if BCPs are the choice -- they merit monitoring & education.   I'm sure most docs do this.  But, I hear about the ones who don't.

Although rare, BCPs can:   increase stroke risk,   change cancer risks  (increasing risk of cervical cancer & liver cancer, lowering risk of endometrial & ovarian cancer), raise blood pressure,  increase risk of deep venous thrombosis, and increase risk of heart attack. I have no doubt each of these can be debated ad nauseum.   However, even a peek at the literature shows BCPs merit thought and care.

And, if put on BCPs, women who have a history of depression appear to have a 25% chance of worsened mood before menses!  For some already depressed clients, a worsened mood any time of the month is a very big deal.  

So, what to do?  Women deserve a leisurely consult with a good gynecologist.  Let the doc know RE family medical history, personal medical & psychiatric history (including any depression).   And, be sure to discuss the widely varying BCP formulations available & any other reliable birth control options.  

And, if you decide on BCPs?   Just, chart your mood.   For most women the mood actually will not dip. You just want to catch it early, if mood does dip.   And, always let all of your docs know when you start a new med, including BCPs.

insomnia!

My poor client emailed that she is having a rough time with sleep.  

Some of the stuff to think about is obvious.  No caffeine, regular bedtime, regular awakening time, quiet room, dark room, no naps, morning exercise, daytime daylight, no work in bed, no TV in bed, keep the bed just for sleep, not going to bed hungry, not eating a huge amount before bed.  Then add in behavioral steps like relaxation training (progressive muscle relaxation, breathing exercises) and restricting time in bed.

And,  see your medical doctor.  So many medicines and medical conditions cause insomnia.  Ask him/her to look for medical causes and treat them! And, review with your doc whether you have a specific sleeping disorder including restless legs syndrome (RLS),  Periodic limb movements (PLMS), Sleep apnea?  Each merits a specific treatment.

Then ask your psychiatrist whether there is an underlying psychiatric cause for the insomnia such as  depression, mania, anxiety or anorexia.    Maximize treatment.

And, if all of that doesn't work or offer answers, and your psychiatrist prescribes sleeping meds?  Just take them exactly as prescribed and with care. Over-sedation can happen if you combine sleeping medications with other sedating medications or alcohol, or if you take more than prescribed.  Over-sedation can cause apnea which is lousy for the brain.     

And, sleeping medications really need to be taken at a reasonable bedtime.  Taken too early or too late at night, and you may forget conversations or be unsafely sedated when up and about.  And, keep sleeping medications -- like all medications --  locked up.  Only the prescribed person should take the medicine ever, and kids need to be kept safely away.

That being said, some sleeping meds are FDA approved for longer term use, and I've seen many clients benefit from them.  Ambien CR (zolpidem tartrate)  and   Lunesta (eszopiclone) are non-benzodiazepine sleeping medications that seem to impact GABA receptors, like benzodiazepines.  Rozerem (ramelteon) offers an alternative for patients who prefer taking a melatonin agonist.  

  

spinach for mood ?!

My clients have heard this one ad nauseum.  But I wonder if they might like to look at the links to why.  Eat your spinach.  

Really, the stuff doesn't taste so bad.  And, it is loaded with folate which probably helps mood.   Those with lower folate levels tend to be more depressed.  Those with lower folate levels tend to respond less well to antidepressants.  Veggies are incredibly good for you anyway.

Now, if you loathe spinach or want to branch out?  Well, other folate sources are out there like beans, citrus and dark green just about anything.  All should be a plus.

What about supplements?  Generally, I like dietary change rather than supplements, but folate supplementation after a depression has been suggested.  Certainly, eating plenty of green leafy veggies seems a risk free endeavor for all.   And, if you're a woman of child bearing age, why not take a pre-natal vitamin anyway.  It has loads of folate which helps prevent neural tube defect in babies, and for this purpose really needs to be taken even before getting pregnant.  

vicodin?

A thoughtful client called asking if it was OK to take a family member's vicodin for pain? The primary care doc was unreachable and pain was terrible.

I am always grateful when clients call instead of just trying to self medicate! Basically, if you are tempted to take a friend's/ family member's meds, it is a good sign that you need to call your doctor! You are being under-treated or are getting sicker. Either merits a call.  

Even over the counter meds are not always benign. Combining meds can get tricky even for well trained docs. (Jonathan E Alpert MD, PhD is a wonderful teacher on this topic, see his chapter in MGH Guide to Primary Care Psychiatry)

This client already was taking tylenol. Vicodin contains tylenol as well as narcotic pain med. So these would add up to too much tylenol, not great for the liver and even potentially lethal.  And, the client already was on meds that can be sedating.  Adding in vicodin could knock a person out and cause respiratory depression, depending on dosing --  not a good thing and even again potentially lethal.

Bottom line? Don't take other's meds! Call the doc, even if it is a hassle! If the doc is unreachable?  You still deserve immediate help, that's what urgent care centers/emergency rooms are for.  If the doc complains about the call?   Keep in mind there are plenty of wonderful docs out there. You deserve good, attentive care.

Yaz ?

A client emailed me asking if it is OK to take the birth control pill Yaz for skin, prescribed by a dermatologist.  The client worried it would negatively effect mood.  Emotional lability and depression are listed as side effects.

Well, the mood chart is key.  I strongly recommend that everyone with any mood issues keep one long term.   The mood chart lets you track your own reaction.  If your mood swings down after you start up the new medicine, the new med might be culprit.  Of course, it could be other things, but that's just what keeps it interesting.  

Yaz is different than other oral contraceptives.  It is uniquely made of drospirenone & ethinyl estradiol.  FDA approved Yaz for acne vulgaris, premenstrual dysphoric disorder and contraception.  However, if it isn't also used for birth control, is it a wonderful idea to take hormones?  Yaz isn't risk free.  The FDA actually warned Yaz for being overly sweeping in their advertising.  Are there other equally good options?  Discuss with the prescribing doc.   

If the dermatologist says Yaz is best?  Keep in mind that feeling good about your skin might make it easier to get out.  And, getting out and about with friends/family and doing things you love inevitably is key for mood.    

increments

So one person too shy to post, called & asked "but how do I make the things in my plan happen?"  Not so complicated.  Not necessarily easy.  Examine the patterns of thought and behaviors that stand in the way.   Pick a pattern that is not overly difficult to change.  Change it.  One change at a time.  A therapist often can be of help.  One client, finding more power in her own vocabulary calls these changes "increments."  I like that.