Marks Psychiatry

Dr. Ravi Dhingra and colleagues out of Harvard recently analyzed data from the Framingham Heart Study and found that people who drank at least one 12 ounce soda each day had a 44% increased risk of developing metabolic syndrome. The soda could be regular or diet and caffeinated or decaf. This suggests that it’s not just caloric intake that results in the metabolic syndrome.

What is metabolic syndrome and why is it relevant to psychiatry? In simple terms, Metabolic syndrome is seen as a precursor (condition that comes first) to developing type II diabetes. Mood stabilizing agents used in psychiatry such as Zyprexa, Geodon, Abilify, Seroquel and Risperdal all increase an individual’s risk of developing metabolic syndrome. These drugs can be very important in treating people with bipolar disorder and schizophrenia. We sometimes use it for other purposes such as difficult to treat depression. Many people will take Seroquel for sleep. But we now have to carefully monitor patients taking these drugs for the development of metabolic syndrome and weigh the risks/benefits of prescribing these medications.

Metabolic syndrome is defined by having three or more factors:

1. Waist circumference greater than 35 inches for women and 40 inches for men;
2. Fasting blood sugar of 100 mg/dL or taking insulin;
3. Blood pressure of 135/75 mm/Hg or taking blood pressure medication;
4. Serum triglyceride levels of 150 mg/dL;
5. HDL cholesterol less than 50 mg/dL for women and 40 mg/dL for men.

Why is the soda consumption important? I thought it is significant that even diet sodas are linked to metabolic syndrome. Often people think they are protected from weight gain issues if they consume caffeine free, diet drinks and will consume them in large quantities. This is important information for anyone maintaining healthy eating habits. But those taking any of the mood stabilizing agents mentioned above, it is especially important to be cautious about soda consumption so as not to multiply one’s risk of developing metabolic syndrome.

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In psychiatry, a prodrome refers to the period of time a person may exibit psychiatric symptoms that may not be serious enough to generate medical attention, but significant enough to cause problems in the person’s functioning. This period precedes the development of the full blown psychiatric disorder.

One example of how this may manifest is as follows: You may notice the person isn’t quite right for some period of time. They may have mild depression or be irritable or overly suspicious of others raising concerns about their mental health. Since the problem comes and goes, no one may say much about it. The person may feel like they are losing control or feels depressed, but also may not say much to others about it. Then it seems things build and the person has a “break down” with more obvious depressed, manic or psychotic symptoms.

A person may have a prodromal period lasting months to years. We often see prodromes in illnesses such as bipolar disorder and schizophrenia. Since the incidence of these illnesses peak in early 20’s for males and late 20’s for females, the prodrome may be seen as early as late teens or early 20’s. Studies show early medical intervention during this period can make a big difference in the course of the person’s illness.

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An article published in the October issue of the American Journal of Psychiatry (164:1539-1546) concluded that the earlier in life a person develops major depression, the more likely they are to have long term social and occupational problems. The authors studied a group of 4 thousand people ages 18-75 with major depression from both primary care and psychiatric offices. For each individual, they established the person’s age when they had their first depressive episode. The age groups were defined as childhood onset (age less than 12), adolescent onset (ages 12-17), early adult onset (ages 18-44), middle adult onset (ages 45-59) and late adult onset (age greater than 60).

The authors found that pre-adult onset (age less than 18) was associated with higher rates of never being married, impaired social functioning, more lifetime episodes and impaired occupational functioning. The people in this group also tended to have more medical problems and concurrent psychiatric illnesses in addition to depression. This is in contrast to those who developed their first episode in middle or late adulthood. These individuals experienced less comorbid psychiatric and medical illnesses and were overall higher functioning.

These aren’t encouraging findings, but it makes sense that the longer a person is depressed or struggles with depression on and off throughout their lifetime, the more opportunity for the illness to impair their quality of life.

Many people have difficulty with the idea of needing a medication “forever” and may spend years resisting treatment. We know that depression causes significant disability in some and rivals other illnesses such as heart disease in lost time from work and over decreased productivity. This study is another in the growing literature that describes the long term affects of having depression long term. Getting good, consistent treatment early can help one’s course so that developing depression early in life does not have to result in having your life permanently derailed.

[tag]depression, depression treatment, early depression[/tags]

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The Substance Abuse and Mental Health Services Administration published a report on the incidence of depression in adults by occupation. They found the 2 occupational categories with the highest incidence of depression were personal care services and food preparation. They also found that that 7 percent of all full-time workers experienced an episode of depression in the past year.

Personal care service is a broad category but included childcare workers, home care aids and animal caretakers. Food preparation included cooks, bartenders and servers. The lowest rates of depression were found in the job category of engineers, architects and surveyors.

The report offers no explanations for these findings. However, it did show that part-time workers and they unemployed had higher rates of depression, 9.3 and 12.7 respectively compared to the 7 percent of full time workers. This suggests that working full-time is somewhat protective for developing depression.

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The short answer is nothing, if you don’t want to have close relationships. There are people who really are content to live as an island. But most people aren’t built this way. The usual scenario I see is the person who spends their young adulthood (20’s and 30’s) charging forward with their career, with limited intimate relationships (usually because they don’t have time) and then at 45 or late thirties for women, decide they are tired of being alone now want to settle down.

There is nothing wrong with choosing to delay marriage or a serious relationship because of other priorities. In fact, it’s better to be honest up front about your focus rather than string someone along feigning interest just to keep them around. However, it can be very difficult to connect with someone quickly if you’ve spent 10 – 20 years being self-centered and avoiding closeness. Once you decide you want a companion, you have to learn how to be a companion who can meet other’s needs.

What does emotional unavailability look like? I think another term that could be used is psychological independence. They don’t need anyone. This person usually feels threatened and uncomfortable when people ask too many questions. Rather than see this positively as someone taking interest in them, they see it as prying or being nosey. They may be easily suspicious of other’s motives; having difficulty trusting others. They may feel smothered by their partner’s attention or desire to spend time together. This often comes from needing to feel in control. When they start to fall in love, they feel less in control and prefer to push the other person away to regain some control. Staying too busy is a passive way of avoiding closeness. In your mind, you have a legitimate excuse for not “wasting” time building relationships.

There are other ways a person can demonstrate emotional unavailability; these are just a few. As you can see these behaviors are not conducive to building intimacy and connectedness in a relationship. The person, who is emotionally unavailable and wants to have a serious relationship some day, should expect to need a running head start to learn how to be close to others. Don’t expect it to all come together just because you’ve met your financial or career goals. You’ll still have some work to do break old habits so you can be a better partner for the person you choose.

The other side of this coin is emotional neediness. I’ll discuss this in a future post.

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Panic attacks can be extremely disabling, so much so that often individuals who have had a panic attack have already made a trip to their local emergency department. What is a panic attack? There are many physical symptoms associated with it, but in general it is a discrete period of intense fear accompanied by physical symptoms such as chest pain, racing heart, sweating, nausea, dizziness, and fear of dying to name a few.

With panic disorder, a person has unexpected panic attacks and persistent worry about having future attacks. The age of onset is late teens to early 30’s. It’s unusual to develop panic disorder after age 45, but is possible. The course is usually chronic over a person’s lifetime and waxes and wanes over time. A person can have a cluster of attacks that last for an extended period, and then go years with no symptoms.

Agoraphobia is a preoccupation with having another panic attack such that the person avoids being in situations where they fear they may have an attack and not be able to escape. They fear being trapped while having attack. Sometimes the anxiety associated with the fear of having an attack can become greater than the attack itself. Not everyone with panic disorder develops agoraphobia.

Panic disorder is common in cardiology settings, and typically those suffering with panic disorder have had some type of medical workup. The medical workup is important because there are medical conditions that can cause panic attacks. These conditions would include hyperthyroidism, seizure disorder, vestibular disease (such as inner ear problems), and cardiac disorders such as an irregular heart beat. The lifetime prevalence is generally thought to be 1-3% in the general population, but as high as 10-60% in medical settings.

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Dealing with a chronic illness is difficult on many levels. But how do you handle someone having a terminal illness that lingers on?

Let’s look at Judy

Judy’s mom has a medical illness that was diagnosed when Judy was a teenager. Her mom was in and out of the hospital for years then seemed to get better after she underwent a new procedure. Fast forward and Judy is 20; the affects of the procedure are wearing off. Mom is in and out of the hospital again, every visit seems it will be the last. Because of her illness, her mom missed key events like her college graduation, her bridal shower and almost missed her wedding. Mom always gets better, but it is still very stressful and sad to see her mom sick.

Another dimension to this is Mom demands a lot of attention when she is sick. So much so that Judy felt very little support from her mom during her pregnancy. Judy didn’t feel she could complain, because after all, Mom is sick. Judy gives birth and Mom is there, but takes a downturn shortly afterward.

Baby is 10 days old, Judy is exhausted and she gets the call that Dad is taking Mom to the hospital. Judy’s mother-in-law is helping with the baby, so Judy decides to take advantage of the help, get a good nights rest and go to the hospital in the morning. Judy knew the routine, she would spend a few days pampering her mom who would get better and be discharged. But this time Mom didn’t make it through the night.

Judy is racked with guilt and furious with herself for not being able to have the last loving goodbye conversation with her mom. But would Judy really have known this time was the last time and engaged in a goodbye talk? I don’t think Judy ever wanted to have a goodbye talk. How do you have that kind of talk?

No matter how much you anticipate someone’s death, you’re still not ready to concede that a person who is well enough to have a conversation with you is close enough to death to have a mutual goodbye discussion. You want to believe they can always get better until they don’t.

Judy had to let go of her focus on not saying goodbye. This was actually a diversion from the real issue which was the fact that Judy was angry and resentful toward her sick mother for not being there for her at milestone moments. Her Mom garnered so much attention over the years because of her illness, Judy felt lost in her shadow. Judy never discussed this with her mom and instead would put on a smile and give her mom all the attention she required, especially in the last months. Judy still has to deal with her resentment, but she realized her selfless attention to her mom was her goodbye that reaped much greater reward than a tearful goodbye speech.

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There seems to be a lot of buzz about Provigil lately. I’ve mentioned in a previous post that Provigil is used to treat wakefulness disorders such as narcolepsy, sleep apnea and shift-work disorder. Psychiatrists and others have used Provigil off label (non-FDA approved reasons) for other indications such as an adjunct to antidepressants, to counteract sedation from other medications and to help with cognitive slowness and other memory problems.

More recently researchers have found Provigil to be helpful in treating bipolar disorder patients who were depressed. Two studies in the August 2007 issue of the American Journal of Psychiatry (164: 1242 – 1249 and 164: 1143 – 1145) show some benefit to bipolar depressed patients when they were treated with 100-200 mg of Provigil.

These are preliminary results, but this is very promising and could be huge for the treatment of bipolar disorder. It is not uncommon for patients with bipolar disorder to have their mania managed with mood stabilizers but still bottom out on the depressed end. What’s even more positive are the findings that Provigil did not significantly increase a person’s risk of developing mania.

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