Marks Psychiatry

I saw a segment on The Today Show this morning about the millions of antidepressants prescribed. Questions arose as to whether or not this is an indication of Americans wanting a quick fix or are doctors over-prescribing the medications. This opens a pandora’s box of issues ranging from who should treat depression to the state of health care (e.g. doctor’s offices becoming mills where many patients are churned in and out with little time to talk). I could go on about many of these issues, but only have time for one today and that’s the issues of what is unhappiness versus depression?

People experience depression differently, but there are a set of criteria that we use to diagnose depression. But rather than list the criteria, let me paint a picture of a depressed person for you. Symptoms vary depending on the person and the severity of their illness, but generally speaking:

• people who are depressed may have trouble experiencing pleasure in anything
• their limbs may feel heavy
• they may sleep all day or have trouble sleeping
• they may have trouble thinking and concentrating such that it affects their work
• they may have constant anger and irritation that is unusual for them
• they may go days without bathing because they just don’t care
• some people describe noticing that colors look duller
• some even feel like life isn’t worth living

This is not an exhaustive list, but some the symptoms depressed people may experience.  This is in contrast to feeling down after a relationship breakup, or having trouble getting out of bed to go to a job you hate. No amount of medication is going to prevent people from feeling bad when bad things happen. I tell patients, whatever problems they have will still be there with medication. The difference is, for a person who is depressed, medication can strengthen their foundation so they can more effectively use their emotional resources to deal with their problems. Depression exhausts your emotional reserves so that you may be unable to handle the stresses of life in your usual way. There are some who have poor coping mechanisms and have trouble dealing with the day to day problems of life and are not depressed but may feel chronic distress. This person may respond better to therapy to help them handle their problems differently.

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A study published in the American Journal of Psychiatry, June 2007 issue addressed the effect of sibling relationships on a person later developing depression. We’ve known for years that troubles in childhood significantly impact one’s future risk of developing depression or other emotional disturbances. However, the childhood troubles mostly focused on our relationship with our parents and there has been little focus on our relationship with our brothers and sisters.

The study included 229 men and what is most interesting to me is that they initially recruited these men from 1939 – 1942 as college sophomores ages 18-19 and followed them for 30+ years. They completed questionnaires every two years and many are continuing to be followed. Upon entering the study, their parents were also interviewed and they obtained extensive family, social and medical history on each participant.

All of the men began with no mental health problems and the study found that those who had poor or destructive relationships with their siblings were more likely to develop depression by age 50. These results held true when they controlled for hereditary factors such as a family history of depression. This further supports their findings that developing depression later in life was not simply due to having a genetic predisposition to depression. They also found that poor sibling relationships predicted a greater tendency to use mood-altering drugs.

There were many limitations to the study and many unanswered questions, but it does introduce a vulnerability in our development that can permanently alter our future relationships. If further research reinforces this link between poor sibling relationships and depression, we could have a focus of family intervention that could change the course of someone’s mental health future.

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We don’t fully understand the mechanism of insomnia (defined as difficulty initiating or maintaining sleep). But some theorists believe untimely central nervous system arousal plays a large part. Our brains are always on, however when we think hard about something, our brain is more activated or aroused than when we are not consciously thinking about something (acting on autopilot). Caffeine to too close to bedtime can increase brain arousal as can bringing work home and doing stressful work before bed. We don’t know how long it takes for the mind to wind down after doing stressful work, but I compare it to lighting coals on the grill, getting them red hot then white, cooking your food, then having warm coals smolder long after you eaten your meal.

Unfortunately people can reinforce the nervous system arousal by getting into bed, watching the clock and worrying about how they are not falling asleep. This anxiety about the insomnia can produce more of a stimulating affect on the brain than the original stressful activity.

I usually talk with patients about their bedtime routine, emphasizing the need to have a wind down period before bed and a preparation period. So for example, think about what time you to be asleep. If this is 11pm, then you need to start preparing for bed around 10pm. Preparation can’t be finishing up those last stock trades or worse yet, getting off the treadmill. Preparation would be things like brushing your teeth, bathing (warm bath with dim lighting or relaxing shower), thinking about what clothes you will wear, etc. Because these activities are routine, your mind can rest and wind down. By 10:30 you could plan to be lying in bed with the expectation to be asleep within the next 30 minutes. Some people meditate or read a passage to help them fall asleep.

Leaving an hour in your evening to prepare for bed usually doesn’t happen. Usually what I see is a person will consider their bedtime to be 11pm, they calculate that if they go to bed by this time, they can get 7 hours of sleep. Then 10:50pm they are peeling away from the television and quickly jumping in the shower (or waiting until the morning), they slide into bed by 11:10 and watch the clock while they think about that intense Sopranos episode, which then leads to thinking about their boss and how their coworker is undermining them, etc. They may drift off to sleep by 11:45 – 12. There goes the 7 hours as the alarm is set for 6am.

Does this sound familiar? How do you prepare for bed? I welcome your input on what makes you fall asleep.

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I’ve always been a firm believer that brand didn’t matter much and you should save your money by passing up the $6 Advil for the $2 Ibuprofen. When I was in medical school and residency, we learned generic names for drugs so as not to give too much credit to the drug manufacturer and recognize the drug for it’s chemical properties (and not it’s brand name).

From time to time, I would hear of certain drugs that seem to be more effective than the generic version, however most of them were cardiac meds or non-psychiatric medications. Since the more popular antidepressants were developed in the 90’s, we (psychiatrists) didn’t have to think much about this issue because these drugs were still under patent until recently. Now some of the more popular antidepressants such as Prozac, Paxil, Zoloft and Wellbutrin are all off patent and available as generic.

What does this mean? (if you know about generics, you can skip this paragraph) Prozac is the brand name developed by Eli Lilly (the company who first developed and manufactured the drug). The chemical name is fluoxetine. Lilly paid for the development, research, and production of fluoxetine. To recoup their investment, they are allow protection for a certain number of years from any one else manufacturing fluoxetine. Once the patent expired, other drug manufacturers were allowed to produce fluoxetine and sell it. Now that’s there’s an open market for selling it, the price drops considerably.

Back to the original point…in my experience, most of my patients do just as well on the generic versions of their medications. Unfortunately I’ve had some for whom the generic was a negative experience. The most common things I’ve seen have been with sertraline (generic Zoloft) and buproprion (generic Wellbutrin). I’ve had a very few have a return of their depression when switching to sertraline and a few experienced ringing in the ears with buproprion. I emphasize this as happening only with a few patients out of many on these medications, but it’s been enough for me to reach the disappointing conclusion that for some medications, brand name does matter.

I still don’t think people should refuse to take generics, because it may not make a difference and the price differential is so great that it could be very expensive to refuse all generics to avoid the small chance that it generic may not work for you. Also, there may be a difference in quality of sertraline depending on the manufacturer and it’s hard to keep up with which company produces the version that works differently.

What’s the conclusion? If you switch to a generic or start a generic drug, you and your doctor should keep an eye out for a change in your status. Also, if you start on a new medication and it doesn’t seem to work or has bad side effects, think about whether switching to the brand version to see if it makes a difference before abandoning the drug.

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I’ve frequently prescribed benzodiazepines (benzos) such as Klonopin and Ativan for patients with anxiety. For some patients who are particularly anxious in the evenings, taking the medication can help relax them to the point of falling asleep easier. I usually tell them it’s not a good long term solution for sleep and the most obvious was the habit forming potential and the need to resolve the sleep issue without the long term use of medications. However, another important reason is that benzos decrease slow wave sleep. As mentioned in a previous post, stages 3 and 4 are slow wave, or deep sleep and necessary for us to wake feeling rested. So a benzo can knock you out for several hours which can make you feel better in the short term, but in the long term you need adequate amounts of the deep sleep that you get in stages 3 and 4 to have healthy and restorative sleep.

So how has the pharmaceutical community addressed this? Medications like Ambien, Sonata, and Lunesta have no effect on stage 3 and 4 sleep. In fact, in studies Sonata was shown to increase stages 3 and 4. Do these medications work? Well, for me anecdotally (meaning this is not a scientific study, but based on my practice experience with a limited population), I’ve had the most success with Ambien. I’ve had several patients complain of a bad aftertaste – a kind of metallic taste when taking Lunesta. Brushing their teeth forever didn’t help. BUT, everyone is different and I always tell people, what works for one person may not work for someone else.

Ambien has it’s own quirky side effect that is fairly rare and that is nighttime eating. For those who it affected, I was told they would wake up in the morning and notice plates in the sink or partially eaten food on plates and would not remember leaving their bed.

Despite this issue with Ambien, it’s probably better than taking a benzo for an extended period of time because it doesn’t affect your sleep architecture. But it is important to discuss this with your doctor as all medications have pros and cons and your doctor should prescribe something meets your needs.

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You may have heard this term used before, it refers to the different stages that make up our sleep. Understanding these stages of sleep help scientists and clinicians target treatments for insomnia.

Sleep is divided into two stages – Non-rapid eye movement (NREM) and Rapid eye movement (REM). NREM is further divided into four stages, numbered 1-4. Stage 1 is the drift off into drowsiness and it usually lasts about 5 -10 minutes. If you were awakened at this time, you’d probably feel like you never fell asleep.

In stage 2, brain waves slow and eye movements stop. You may observe some muscle twitching in someone in this stage of sleep. Stages 3 and 4 are deep sleep and brain activity will show slow delta waves. Stages 3 and 4 are responsible for the restorative effects of sleep and allowing us to wake feeling refreshed.

NREM sleep cycles throughout the night usually lasting 90-110 minutes for each cycle. This means usually 90 minutes after falling asleep, you enter REM sleep, which is when we dream. When we cycle through NREM, it goes Stage 1, 2, 3, 4, 3, 2, REM. Therefore, we enter into a lighter stage of sleep when we are dreaming. Our brain has heightened activity but our muscle groups are paralyzed. This paralysis is temporary and normal during this stage of sleep as it prevents us from acting out our dreams. Some disorders of sleep inhibit the muscle paralysis and the person can sleep walk or act out their dreams while their brain is still sleeping.

There are several REM periods throughout the night, the first one lasting about 10 minutes and each subsequent one getting longer. It is thought that the last REM period lasts about 1 hour. This means you can have several dreams throughout the night, but since the last one is the longest, it is this dreamtime that you are most likely to remember.

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This may seem like an obvious statement, but it’s not.  Our culture rewards hard work and often that comes at the expense of sleep.  Millions of people do not get enough sleep each night and it can have serious consequences to our physcial and mental health.  I’ll be doing a series of posts on sleep as I feel it is a very important, yet often undervalued component of our overal health.

Good sleep starts with good sleep hygeine.  What is sleep hygiene?  It is our rituals and behaviors that affect our sleep.  There are many things one can do to develop good sleep hygiene, a few suggestions are as follows:

• Have a consistent bedtime each night - our bodies work on a circadian rhythm and need to have regular sleep and waking times
• Wake up at the same time each day - even on weekends!  Our body clocks need to be reset each day as not everyone’s clock is on a 24 hour day.  So waking up at the same time each day can help maintain consistency.  If you do this routinely, and get enough rest, you should be able to wake up without an alarm clock.
• Avoid daytime naps - you can only sleep so many hours in a day.  If you get several hours during the day, you will have a harder time falling asleep at a set time.
• Exercise regularly - regular exercise promotes restful sleep.  But don’t exercise too close to bedtime or your body will have a hard time settling down.
• Avoid caffeine, alcohol and nicotine close to bedtime.  Although alcohol can make you sleepy and relaxed, it disrupts the quality of our sleep.
• Maintain a cool and quiet room.
• Avoid fluids too close to bedtime - if you drink a large beverage just before bed, you may be awakened in the night to go to the bathroom.  Even if you fall back to sleep, you still have interrupted sleep.

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Individuals with an disorder such as bipolar disorder can behave in ways that make them question whether their actions are part of their personality or part of their illness.  For example, two common symptoms with bipolar disorder are hypersexuality and hyperreligiousity.  However, defining what is “hyper” is not always an easy task.  It can be very difficult to tease out what is the person’s personality and what is being driven by the disinhibition that you can see with a manic episode.  It is often during a euthymic period (neither manic nor depressed) that a person can do some introspection and get a sense of who they are.  It can be sobering for some to realize their free spiritedness, high sex drive, etc. may have been their illness.  They are then left to figure out who they really are.

In a similar way, chronic irritability that may seem a part of someone’s personality could be persistent depression that once treated significantly improves.  In these cases, a person may feel relief to know they are capable of feeling happy or having a good outlook on life.

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