Marks Psychiatry

I sometimes hear people ask “one minute I feel down, the next minute I’m really happy, am I manic depressive?”

Bipolar disorder or manic depression is a mood disorder whereby a person has discreet episodes of depression or mania. The index episode is a term used to define the first episode. If a person’s index episode is depression, they may not be diagnosed with bipolar disorder until they have a manic episode. That is, this person may be diagnosed as having depression for years until they have a manic episode at which time their diagnosis will change to bipolar disorder. The person who has mania as their index episode will start with a diagnosis of bipolar disorder.

Everyone is different, but a typical course of the illness is such that a person may have 1-2 episodes of mania and/or depression in a year or every few years. Rapid cycling bipolar disorder is defined by having four or more episodes in a year.

So back to the question - people with bipolar disorder don’t switch between depression and mania within the course of a day. In fact, depression requires symptoms lasting two weeks to be considered a depressive episode. The situation of extreme moods that flip back and forth over the course of a day would be considered emotional lability or emotional volatility that may be present in a person with anxiety or a mood disorder (such as depression or bipolar disorder). But it can also be a part of someone’s personality. For example, people with histrionic personality traits can have dramatic or “over the top” responses that are intense reactions to life issues that are not necessarily a mental disorder that requires medication treatment.

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Hoodia is a cactus-type plant from Africa that has many uses, however the native populations of South Africa have used it for indigestion or infection.  The plant Hoodia gordonii has been recognized as an appetite suppressant since the late 1970’s in Africa, but in the US there have been no definitive studies establishing it as a safe and effective appetite suppressant.

Despite this, media hype about the drug began around 2004 when 60 minutes aired a special on it’s effectiveness and since then others have followed suit such as the Today Show and Oprah catapulting it’s popularity.  To protect consumers, Hoodia exporters must be issued a CITES (the Convention on International Trade in Endangered Species of Wild Fauna and Flora) certificate by the office of Western Cape Nature in order for Hoodia to be legally exported abroad from Africa.   It is illegal to export Hoodia without this certification.

Why is a psychiatrist talking about Hoodia?  Having treated patients who took Hoodia (at their own initiative), I’ve seen how it has benefited most and also had some negative effects.  Most established appetite suppressants available in the US are stimulants and stimulants as a side effect can lessen one’s desire to eat.  It’s not clear what the active ingredient (P57) does, but I wouldn’t be surprised if it’s not a naturally occuring stimulant.  As such, it can also have the unwanted affects of agitation and anxiety.  If you already have anxiety, this could really worsen your condition.

Some people have dealt with this by taking less than the recommended dose.  The pills are usually capsules and can’t be split, but rather than taking it three times a day, some people have taken it once a day at the time of their worst cravings.  I have heard some people say Hoodia “takes the edge off” their cravings giving them enough contol to choose not to eat junk or munch unneccessarily.

We know there is no magic pill to control weight, as controlling your eating requires behavioral change.  So for some who recongize that long term control of eating is a lifetime, lifetstyle adjustment, Hoodia can be something that gets them started in the right direction long enough to get used to a new way of eating and using food.

Of course, as with any drug (and herbal remedies are drugs too, just naturally occuring ones), a person considering starting it should check with their health care provider prior to taking it.

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Medication discontinuation syndrome can happen when a person stops their medication abruptly. In general, medication should be tapered off slowly with medical supervision. But since we don’t know precisely how slow is slow enough for each individual, sometimes tapering off the medication can still result in some withdrawal symptoms.

Usual withdrawal symptoms are things like fatigue, irritability, diarrhea, headache, anxiety, or feeling like you have the flu. These symptoms typically last a few to several days.

There have been some who have experienced electric shock sensations when stopping Effexor and some other serotonin agents such as Cymbalta, Paxil, etc. This is very unusual, but I’ve heard patients describe it as a “brain shock” that was worsened with movement. In the literature, reports of these symptoms last up to 5 days.

The origin of these sensations is not entirely clear, but thought to be a form of paresthesia (which is the sensation of feeling tingling or creeping on the skin). Paresthesias result from our nerves being activated in a particular area when there is no apparent trigger for the activation – for example, feeling a pinprick on your skin when you haven’t been pricked by a pin.

The electric shocks have been helped by adding back the medication that was discontinued and tapering it more slowly or adding another long acting serotonin agent such as Prozac.

Therefore, stopping medication abruptly is usually not a good idea, especially if you have been taking a particular agent for a long time. It’s best to discuss a tapering schedule with your doctor so that you can have the smoothest transition possible.

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Sleep latency is the amount of time it takes to fall asleep. Normal is considered to be 15-25 minutes (some say 30minutes). I’ve had many people tell me with disappointment that it takes them 30 minutes to fall asleep and how they know people who can fall asleep instantaneously. They are surprised to hear that 30 minutes falls into the normal range.

In fact, a sleep latency of less than 5 minutes is considered to be a sign of sleep deprivation. So, if you can go into a dark room and fall asleep within 5 minutes – this isn’t necessarily a good thing and could mean you need more sleep.

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We used to believe that we were born with all of the new brain cells we would have for life. Once we reached adulthood, we can’t learn any more new tricks. Actually it’s not quite that way, but in general neural stem cells (undifferentiated brain cells, like fetal brain cells) were thought to only exist in fetal or neonatal brain. This is why brain injury to an adult has such a devastating affect.

But, new research conducted by Fred Gage PhD of the Salk Institute shows that neural stem cells exist in the adult brain and they can multiply, differentiate and join the rest of the mature brain cells. This process, called neurogenesis (think nerve beginning or nerve birth) can happen throughout our lives.

Aging slows neurogenesis, but Dr. Gage has also found that physical activity enhances the process. Chronic stress suppresses neurogenesis temporarily, possibly for months.

These findings have tremendous implications for finding ways to promote growth of damaged brain and spinal cord cells.

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Two studies published in the New England Journal of Medicine in June 2007 reported on the risks of birth defects when women took selective serotonin-reuptake inhibitors (SSRIs) during pregnancy (sources: Louik, C et. al NEJM Volume 356:2675-2683 June 28, 2007 Number 26 and Alwan S. et al. NEJM Volume 356:2684-2692 June 28, 2007 Number 26). Both articles conclude that SSRIs taken during the first trimester of pregnancy increase the risk of certain birth defects, but the increased risk was considered to be small. Given that untreated depression carries its own risks to the unborn baby, the researchers were said to have considered these finding reassuring in terms of weighing the risks and benefits of treating depressed women during pregnancy.

Further analysis of their data showed that women with a body mass index of 30 and greater showed an even further increase in risk defects. For example, obesity plus SSRI use resulted in 3.5 times greater chance of certain heart defects and 5.9 greater chance of certain cranial defects. These numbers were in comparison to non-obese women taking SSRIs.

We don’t know why having more body fat makes a difference, but we do know SSRIs are absorbed more quickly in fat. Thus, it would stand to reason that perhaps more drug is absorbed and/or retained and this may amplify the effects of the drugs.

Women taking antidepressants and considering getting pregnant should consult with their doctor about whether to continue on the medication during pregnancy.

Your body mass index is calculated based on you height and weight. Want to know yours? Get you BMI

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Some researchers still question whether problematic Internet use should be considered a disease. An argument against this is that the internet can be a means to satisfy other compulsive behaviors such as gambling, shopping, pornography use, etc. So it’s a medium of exchange to fuel other addictions and is not the source of the addiction. That is, if a person has a shopping compulsion and spends hours shopping on the Internet, they are “addicted” to shopping and not the Internet. Others will say that the Internet itself provides its own level of rewarding experience such that those addicted to the Internet use the internet simply for the experience of being online.

So, what’s wrong with enjoying being online? After all, there is a vast amount of information available over the Internet and it is easy to spend loads of time reading and surfing. How is this different from watching television? Although theoretically, the Internet could be seen as a better use of time than television because it can be a research tool providing useful information, it is the interactive nature of the Internet and the sheer volume of information available that makes it more dangerous to some than sitting in front of the television.

Unfortunately, we haven’t definitively established how much is too much. In a review article on problematic Internet use (source: Liu T, Potenza MN, CNS Spectr. Vol 12, No. 6, 2007), the author cites several studies where they used time as a measure of social and occupational impairment. In one study those considered to have an Internet addiction spent 38.5 hours/wk on the Internet for non-work related activities compared to 4.9 hours/wk for the non-problematic user.

How does one find 38 extra hours in the week to spend on the internet?

So how do you know if you spend too much time on the internet? Diagnostic criteria aside, I think the most practical way is to examine how much of an impact it has on your personal and work life. Are you less efficient at work, missing deadlines, being warned not to surf, being distracted in meetings because you’re thinking of what you’re going to surf next? Are you spending less time with friends, losing sleep because you’re up late on the Internet? Is your spouse or significant other threatening to throw away your Blackberry? Are you getting more headaches, neck pain or finger cramps because of too much time at your keyboard?

As for treatment, the Center for Internet Addiction Recovery is a web-based treatment that some have found to be very helpful (despite that it uses the Internet to treat an Internet problem). There are also some more traditional treatment centers that use an addiction model and 12 step recovery program. Some research has suggested antidepressants may be helpful.

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