Sunday, December 16, 2012

It's time...

Mental disorders are characterized by abnormal thoughts, emotions and behaviors.

Last year 36,000 people died from drug overdoses associated with obsessive thoughts and impulsive behaviors.

Last year 36,000 people died from suicide associated with depression and other emotional disorders.

Last year about 20,000 people died from gunshot wounds associated with emotional disorders and impulsive behaviors.

That's 100,000 people who died from treatable and preventable causes. It's time to talk about gun control laws and mental health for everyone. Sandy Hook is in my prayers. Who will it be the next time?

Sunday, September 9, 2012

Common Drug Interactions You Don't Know About

Just a quick blog about some common drug interactions you probably don't think about.

Caffeine and Psuedoephedrine: With hay-fever season here in California, short term nasal decongestants are a way of life at this time of the year. Mixed with lots of caffeine from gallons of ice tea with the hot weather, it's easy to become wired and not even recognize it. Caffeine and sudafed potentiate each other. If you do need to use nasal decongestants, use for the short term and limit your caffeine so you can sleep and not become some wired maniac.

Melatonin with Tramadol or Antidepressants: I see this all the time; people taking over the counter melatonin for sleep with their antidepressants or Ultram. These drugs mixed together in any combination can cause a life threatening illness called serotonin syndrome. It is a very common reason why I don't see people responding to their antidepressants as they should. All antidepressants by themselves help sleep. If you are not getting relief, discuss this with your doctor before you begin self medicating.

Steroids (Prednisone, Birth Control, Testosterone): These medications should be generally taken in the morning. I see people who have various immunological diseases on these medications complaining of insomnia. I usually see this in patients who take these medications at night. All of these drugs are known to cause insomnia. In fact high doses of all these drugs can cause mania and psychosis. Keep your doses for the morning hours.

Dementia medications (Aricept) with bladder medications (Vesicare): I see this commonly as a prescribing error by most primary care physicians. The two drugs essentially negate each other. Dementia medications increase acetylcholine in the central and peripheral nervous system. Bladder agents work by blocking this chemical in the same central and peripheral nervous system. I suggest you decide which is the issue causing the most loss of function and start there first, dementia or incontinence. Incontinence medications when used by themselves can cause a drug induced dementia, and might be worth stopping in elderly patients to see if their mental status improves before adding extra medications.

NSAIDS and Antidepressants: All nonsteroidals such as aspirin and ibuprofen thin the blood. So do antidepressants. In fact I frequently tell surgeons in my pre-op evaluations that antidepressants should be stopped 5 days before surgery if they are worried about a bleeding risk. Recently a patient of mine who was on an antidepressant had a complicated outcome with her liposuction because she forgot to mention this to her surgeon. I have many career actresses and models as patients where I advise using Tylenol for pain while on their antidepressants to minimize bruising.

I always tell my patients to inform me about medication changes including OTC's and supplements. It is one of the reasons I advocate using less medications overall. People are so worried about psychiatrists over medicating them. Be careful not to over medicate yourself.

Sunday, September 2, 2012

Less is MORE

Last week at the end of our session my patient told me, "I'm glad I found you". He had earlier seen an "addiction medicine" doctor who detoxed him off of opiates, i.e., 20+ Norco's per day. This doctor used a Suboxone taper with Tramadol and detoxed him over 5 days. The Suboxone was appropriate;  the Tramadol was not. My patient then stated that for 4 to 5 months he did not feel well. He couldn't sleep, he kept having racing thoughts, and he felt quite dazed. He was probably in a manic delirium exacerbated by his "successful" detox. My patient thought that he was still having drug withdrawal symptoms. I told him, "No, although your detox was successful this most likely triggered a bipolar mood cycle". It is not necessary to wait a year of sobriety to make this diagnosis. In fact my patient was so impaired during this time he almost lost his job.

I told my patient that this "addiction specialist" he saw was not trained to recognize why he was abusing prescription drugs in the first place. His attempt at self-medicating his unrecognized bipolar disorder was the problem. An internist or any other physician who does detox but is not a trained psychiatrist is going to drop the ball.  WHY?  It is a rare person who uses drugs in a vacuum. Usually there is some underlying issue that leads to the abuse or dependency. I applaud doctors who detox patients successfully. I can tolerate physicians who miss identifying Major Depression, Anxiety, Bipolar and ADHD disorders. But when they start taking the initiative to treat these disorders, I get mad as hell because it is dangerous! 

An addiction doctor I know put a patient on Lithium after his "successful detoxification". To make a long story short, he eventually came under my care after relapse. Lithium is a serious drug that has serious side effects. I discussed this with my patient and decided to discontinue Lithium. I evaluated him later and noticed continued hyperactivity and poor attention. After starting him on Stattera (Amoxetine) his ADHD is much better. We went from "bipolar disorder" to ADHD where my patient is now happy, functional and thriving.

The moral of the story? See a psychiatrist who can perform your detox AND who will not miss a serious underlying diagnosis that would prevent your optimal recovery and health. All psychiatrists who are recently trained can perform detox and treat psychiatric disorders. More so if they are board certified. Psychiatrists are the only medical doctors who are trained and certified in the biopsychosocial approach which aims at treating the whole person and not just parts like detox, withdrawal symptoms and maintenance. Psychosomatic medicine subspecialists like myself, practice this orientation for all types of diseases including drug abuse and dependence. The moral of the story? See a psychiatrist who can perform your detox AND who will not miss a serious underlying diagnosis that would prevent your optimal recovery and health.

The intersection of all 3 circles is health and well being.

Seriously?!?  Make it easy on yourself. Start with a psychiatrist and get it all done at one time. Why see several providers? As a board certified, subspecialized psychiatrist all of this is pretty easy for me to do. Less is MORE.

Sunday, July 22, 2012

Paranoid Schizophrenia in Aurora, Colorado

I am sad thinking about the Colorado shootings. Victims and survivors. It makes me think about my college days. I can't imagine dying in my 20's. When I was in school, the only time I really went out was to see a movie. I couldn't afford much else. When I was in med school, 2 of my classmates 1 in my first year and 1 in my third year had psychotic breaks. Both were struggling during exams and both became very isolated. One of these classmates I knew well. I even escorted him to the dean's office when he had come to my apartment obviously acting odd. As a psychiatrist I now know both of these men suffered from paranoid schizophrenia. Thinking back I remember how two bright young men seemed isolated at first, then talking very little, then what appeared as an odd way of listening to things that weren't there. We call this in psychiatry responding to internal stimuli, another way of saying "listening to auditory hallucinations". Both men were in their early 20's. Both men had no prior psychiatric history. I don't know their family histories except to say they were from families who were very proud that their sons were going to be doctors. There was probably no legal history. You really can't get into med school if you have one.

Paranoid Schizophrenia is a disease that strikes young people and usually becomes apparent after some initial stressor. It is characterized by delusions, particularly paranoid delusions which are fixed false beliefs that would not make sense to you or me. This is a thought disorder that then includes changes in emotions and behaviors. The affect or emotional expression becomes blunt, flat or inappropriate. For James Holmes the Colorado shooter, the affect was blunted and is now described as inappropriate (his grin).

Mr Holmes does appear to have symptoms consistent with Schizophrenia. I don't know the particulars, I have made no examination. Drug abuse although a possible issue and co-occurance, does not present in this fashion. There are no strange behaviors after intoxication wears off. In fact, Mr. Holmes seemed alert with a clear sensorium during the shootings. Having seen many such patients, the description of events can be interpreted as a psychotic episode. The treatment is actually fairly simple. Depending on the severity, the prognosis is good with medication and psychotherapy that emphasizes treatment compliance.

I am angry thinking about the Colorado shootings. 1 in 4 Americans, right now suffers from mental illness. Yet people continue to minimize mental health issues. I hear statements like, "oh, he'll grow out of it, it's just a phase" or "it's normal to feel like this, it's a part of life". I am tired of psychiatrists and mental health professionals being vilified and scapegoated because of people's refusal to understand their own suffering. Insurance companies don't want to pay for treatment, stereotypes about medications and treatment abound, etc., etc., etc. Even other physicians I know don't understand the value of treatment. Once I see their kids for management and they thrive; all of the sudden I'll get a ton of patient referrals from them. WAKE UP ONE AND ALL. IF THERE HAS BEEN A CHANGE IN HOW YOU OR SOMEONE ELSE IS BEHAVING, THINKING OR FEELING FOR MORE THAN 1 MONTH, GET HELP. PLEASE. PLEASE. PLEASE. JUST ASKING A PROFESSIONAL "IS EVERYTHING OK?" CAN SAVE A LIFE. MAYBE YOURS.

I can't imagine dying in my 20's.

Sunday, June 10, 2012

Can't Sleep? 10 No Medication Tips!

...OK, so there are actually 11 Tips!

Sleep difficulties are the most common complaints that I encounter in my practice. Often the reasons for poor sleep include anxiety disorders, mood disorders and a myriad of medical disorders. Although treatment often requires medications, treatment plans always include learning how to sleep correctly. We call this sleep hygiene and it sort of means the same as brushing your teeth correctly as in oral hygiene.

Try these 10 tips below and see if you get immediate relief from your sleep disorder:

1. No caffeine 10 hours before you go to bed. It actually takes that long for caffeine to metabolize and be completely out of your brain. Even if you think caffeine doesn't affect you, it does disturb all the biological processes that your brain performs during sleep including your REM or dream sleep.

2. Same goes for alcohol: because alcohol is a vasodilator and disinhibits brain control centers, sleep can be difficult. It usually takes 2-3 hours to metabolize 1 glass of wine out of brain tissues.

3. Get a good pillow Neck tension can disrupt sleep and cause restlessness. Pillows are now made for side, back and face down sleepers. The same concept goes for getting rid of and replacing that 20 yr old bed with that huge sag in the middle.

4. Unplug the TV in the bedroom for 7 days; yes unplug. When I did this I was surprised how many times I tried to turn on the TV forgetting that I unplugged it. For most of us, TV is a bad habit that keeps us from going to bed on time. Sleeping with the TV on actually keeps some unconscious centers of the brain hyper alert preventing good sleep.

5. Exercise. Even exercise late at night does not disrupt sleeping, in fact you sleep better. This is probably the best thing you can do to sleep well. Walks outside in the morning are the best, see below

6. Bright daylight particularly in the blue or green spectrum inhibits melatonin production during the day. Complete darkness at night allows full release of brain melatonin for sleep. The pineal gland located behind eye retinal nerve cells regulates how this gland responds and produces melatonin. If you're taking a 5 to 10 minute walk in the morning daylight, you're setting up your melatonin production to be good that same night; with exercise you've got 2 birds with one stone.

7. Get on a sleep schedule routine. Set your alarm clock for the same time every morning. GET OUT OF BED when you turn off the alarm. Stay awake all day no napping, even if you didn't sleep the night before. GO TO BED 8 hours before your alarm goes off. After about 7-10 days of this routine your circadian rhythm will be set (your internal biological clock).

8. No heavy meals before sleep and conversely don't go to bed hungry. Heavy meals pull blood flow from the brain and disrupt all the important functions the brain accomplishes during sleep. Your brain is a highly active organ during sleep and sleep is an evolutionary process to accomplish these tasks. Not eating enough also robs your brain of needed nutrients for biologic sleep functions.

9. No liquids 1 hour before bed and also void before going to bed. Waking up to pee in the middle of the night disrupts sleep. Trying to fall back to sleep delays your sleep cycle and ruins your sleep for the next night.

10. No internet, Facebook, or other social media devices when you get into bed. Try instead, reading or laying in the dark and allowing your conscious mind to relax. Think about all the good stuff that happened during the day and actively suppress the negative. Reliving the things you can't change sets you up for anxiety and depression.

11. Keep a note pad next to your bed. That way if any to do things come to mind, write them down in the dark and let your mind go and relax. I can't believe how many of my patients keep themselves awake trying to remember things at night. Also this is a great way to learn how to remember your dreams by scrawling out in the dark anything that seemed vivid. You'll find as you remember more, you won't be able to wait to go to bed!

Any other ideas you can think of? Let me know and sweet dreams. Seek a professional psychiatrist if you have more concerns about your sleep disorder.

Tuesday, May 29, 2012

Stressed out?

Yesterday while out with friends, I was asked what was the most common disorder that I treat. Without thinking twice I answered anxiety disorders. Yes, most people suffer with anxiety (including myself) that for the most part, is normal. Anxieties that interfere with your day to day activities or impair your ability to function should be evaluated. I find that if these conditions continue, patients often end up self medicating with either prescription drugs or illicit drugs to get relief. The problem with self medicating is that it always worsens the condition in the end.


Anxiety Disorders include the following conditions:

During my evaluations I am careful to rule out any other causes for anxiety symptoms such as endocrine, vascular or acute drug withdrawal syndromes. I also have to rule out other psychiatric diseases such as depression, somatoform disorders and personality disorders. This is no small task but is very doable after the first or second session. Often I have to obtain labs and clarify health history from a primary care physician. Actually, a lot of my referrals come from primary care physicians who have already ruled out the medical causes for presenting anxious symptoms.

Medications used for the treatment of anxiety disorders usually includes antidepressants. Let me repeat, THE TREATMENT FOR ANXIETY IS AN ANTIDEPRESSANT. Benzodiazepines are helpful but they are not the first line drugs of choice. I usually use these for a short period of time (less than a month) or until I have an antidepressant working. Because these drugs rapidly calm anxiety, they often psychologically reinforce and cause more anxiety in the long run. I prefer using SNRI antidepressants but also routinely use SSRI's. Often alpha or beta blockers can be helpful, especially for acutely anxious situations.

After I have obtained control and resolution of most anxious symptoms, I then focus on coping skills. My preference is CBT (cognitive behavioral therapy). Addressing irrational fears and developing strategies to reduce fear in real time is curative. Once successful strategies are developed and can be automatically used, I can taper most of my patients off medications. Conflict resolution of past traumas rather than dwelling on them or being victimized by them is my treatment goal orientation.

Patients are then given assignments to be social and practice their skill set. Social phobia? Anonymous meetings present great opportunities here. OCD? Talking out loud your anxiety with a confidant is better than hiding it in some ritualistic behavior. Panic Disorder? No, I don't push you out of a plane parachuted but you can gradually be challenged with a progressive set of social exercises.

Addressing the biopsychosocial aspect really works with anxiety disorders. If you are suffering personally or professionally, treatment is easy and provides a tremendous amount of relief in a few weeks. There really is no need to keep worrying after all, don't you think?

Monday, February 27, 2012

Understanding Anorexia - How to deal with this Eating Disorder

Understanding Anorexia is very important in managing this disease. Without the proper knowledge about it, it won’t be taken seriously as a life threatening medical condition. The incidence of anorexia has become alarming. We often hear this disorder affects those in the entertainment and modeling industries where many women think when they’re skinny, they’re beautiful. In fact, there are already celebrities who have died from anorexia. Yes, it’s not wrong to look beautiful but beauty and health are synonymous. Anorexia is not healthy. You are not beautiful if you’re not mentally and physically healthy, plain and simple. You should face and not take your health for granted.

Anorexia often first appears among teenagers. Understanding anorexia nervosa is the first step in order to deal with it properly. If you suspect that you are suffering from this eating disorder or someone whom you care is, here are some tips on how to deal with anorexia nervosa:

Do your Homework. Research about Anorexia
Search online for articles written by people who had this eating disorder and check on the bad effects it had to their bodies. This way you’ll get a better view of anorexia. Stay away from people who are practicing improper eating habits or websites that promote anorexia so you won’t be influenced into doing the same thing. You may even try to start blog writing about your condition to share your experience and help other people who are struggling with anorexia.

Understanding Anorexia as a disorder of Thoughts, Emotions and Behaviors
 You should learn to acknowledge that the problem with anorexia is medical, physical and mental dysfunction. The most difficult part in suffering with an eating disorder is admitting you have a problem. Most people with anorexia are fascinated in becoming thin and not taking into consideration their health. Try to ask a trusted person that you know to give an honest opinion about your current weight or your physical appearance as a whole. Upon knowing the reality, this can be the starting point to your healing and recovery.

Make your Day fun and exciting
When you’re socially engaged, this will distract your mind from thinking of being fat. Try to avoid being alone so you’ll not feel sad and lonely. Isolating allows you to engage in harmful behaviors. Start exercising and socializing instead of starving yourself.

Set an Appointment with a Board Certified Psychiatrist
It would be a wise decision to pick up the phone and call a professional health care provider if you think you are suffering from anorexia. Ask for your family and/or friend’s support in getting treatment for this eating disorder. If you know someone who has anorexia, offer to accompany them on their next visit to the doctor so you can give them your moral support. Knowing that you’ll get the full support of your love ones is very important in dealing with this disorder. To prevent serious consequences it is advisable to address this disorder as early as possible.

Anorexia Nervosa is a mental health issue and eating disorder where a person is obsessed in losing weight through not eating. This disease will definitely affect the health of the person suffering from anorexia. It may lead to malnutrition and can be deadly if not treated right away. You should discover ways on how to deal with this eating disorder. Treatment includes medical management, medications, nutritional support and psychotherapy to get rid of it for good. It may not be an easy task but when it is detected early, it can save you from suffering and permanent complications.

Understanding Anorexia is important. Take control of your life if you want to stop anorexia nervosa. It can be very challenging but control of your life instead of your food is healthy and life saving.

Monday, February 13, 2012

Mental Health Issues in the Black American Community

Whitney Houston’s “I’m Every Woman” was my banner song during the last year of my psychiatric residency training. She gave me a sound track that became part of my identity. Watching the Grammy Awards Night was tremendously painful; we lost an American Treasure…a Black American Treasure

As a Black American myself, we should learn and recognize that taking care of ourselves is very important. It is clear that Whitney Houston suffered from mental health issues that sadly most people ignore.

Why? Because…Mental health treatment is a taboo subject to Black Americans because of fear and misunderstanding. No one would like to admit that their family member or family is seeking psychiatric treatment(s).

Instead of seeking professional mental healthcare, Black Americans often rely on religious institutions, family members, or self diagnosis. This prevents the community as a whole from accessing available programs and treatments.

I am not saying that it is wrong to seek spiritual help, but when mental health issues are involved, this should be in conjunction with psychiatric and psychosomatic medications to recover from the problem. It is not a sin to use drugs, to feel suicidal, to not sleep, to not take care of your family, and to behave improperly. These are mental issues that are highly treatable and can be rapidly treated and resolved. 

A recent published poll revealed Black Americans in response to emergency situations, call a family member first rather than 911. These kinds of health care decisions and fears of healthcare professionals keep us from being a vibrant and healthy community.

Gone is our collective history of sacrifice, adversity, and talent. We must learn how to take care of ourselves and not to just run to a preacher who might be less than helpful. We must use all available resources including mental health services, primary medical care, and social institutions like our churches and faith based groups. 

Culturally competent minority physicians can be hard to find, but we are here. Word of mouth and Google searches are a good start. Get help for your mental health issues if you need one and know that we can take care of our own.

Rest in peace…Whitney.