Saturday, September 27, 2014

If You Really Want to Get Better with Your Anxiety...

The treatment for all ANXIETY DISORDERS if you want the most rapid and complete outcome is medication; antidepressants to bring down the symptoms quickly and cognitive behavioral therapy to unlearn the anxiety you learned. I typically see people much better in 6 weeks or less. Everyone suffers from anxiety but if it is getting in the way of your life that's when it's time to get help. These are the most common disorders that I treat.

Talk therapy -- not medication -- best for social anxiety disorder, large study finds
Published: Saturday, September 27, 2014 - 05:51 in Psychology & Sociology
While antidepressants are the most commonly used treatment for social anxiety disorder, new research suggests that cognitive behavioral therapy (CBT) is more effective and, unlike medication, can have lasting effects long after treatment has stopped. Social anxiety disorder is a psychiatric condition characterized by intense fear and avoidance of social situations and affects up to 13 percent of Americans and Europeans. Most people never receive treatment for the disorder. For those who do, medication is the more accessible treatment because there is a shortage of trained psychotherapists.
The findings of the study, a network meta-analysis that collected and analyzed data from 101 clinical trials comparing multiple types of medication and talk therapy, are published online Sept. 26 in The Lancet Psychiatry.

"Social anxiety is more than just shyness," says study leader Evan Mayo-Wilson, D Phil, a research scientist in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. "People with this disorder can experience severe impairment, from shunning friendships to turning down promotions at work that would require increased social interaction. The good news from our study is that social anxiety is treatable. Now that we know what works best, we need to improve access to psychotherapy for those who are suffering."

The research was a collaboration between the Johns Hopkins Bloomberg School of Public Health, Oxford University and University College in London, where Mayo-Wilson formerly worked.
For the study, Mayo-Wilson and his colleagues analyzed data from 13,164 participants in 101 clinical trials. The participants all had severe and longstanding social anxiety. Approximately 9,000 received medication or a placebo pill, and more than 4,000 received a psychological intervention. Few of the trials looked at combining medication with talk therapy, and there was no evidence that combined therapy was better than talk therapy alone.

The data compared several different types of talk therapy and found individual CBT was the most effective. CBT is a form of treatment that focuses on relationships between thoughts, feelings and behaviors. It helps people challenge irrational fears and overcome their avoidance of social situations, Mayo-Wilson says.
For people who don't want talk therapy, or who lack access to CBT, the most commonly used antidepressants -- selective serotonin reuptake inhibitors (SSRIs) -- are effective, the researchers found. But they caution that medication can be associated with serious adverse events, that it doesn't work at all for many people, and that improvements in symptoms do not last after people stop taking the pills.

The researchers acknowledge that medication remains important but say it should be used as a second-line therapy for people who do not respond to or do not want psychological therapy. The group's analysis has already led to new treatment guidelines guidance in the U.K. and, Mayo-Wilson says, it could have a significant impact on policy making and the organization of care in the U.S.

Social anxiety disorder typically begins in adolescence or early adulthood, and it can severely impair a person's daily functioning by impeding the formation of relationships, by negatively affecting performance at work or school, and by reducing overall quality of life. Because it strikes people at critical times in their social and educational development, social anxiety disorder can have important and lasting consequences.

"Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce healthcare costs," Mayo-Wilson says. "The healthcare system does not treat mental health equitably, but meeting demand isn't simply a matter of getting insurers to pay for psychological services. We need to improve infrastructure to treat mental health problems as the evidence shows they should be treated. We need more programs to train clinicians, more experienced supervisors who can work with new practitioners, more offices, and more support staff."

Source: Johns Hopkins Bloomberg School of Public Health

Sunday, September 7, 2014

Tipsheet: Bipolar Depression Versus Unipolar Depression

Tipsheet: Bipolar Depression Versus Unipolar Depression
Published on Psychiatric Times  (
Tipsheet: Bipolar Depression Versus Unipolar Depression August 19, 2014

Milder forms of bipolar disorder are something that I see frequently in my office. Most of my patients become quite concerned and even alarmed when I discuss this diagnosis with them. Chronic recurrent depression is often bipolar II. As a board certified sub-specialized psychiatrist, I can tell if certain symptoms and history are important in making this diagnosis; see if any of these items sound familiar to you. Most of my patients think I'm talking about a disorder that involves crazy. Instead, it really is a disorder of mood variation which is important to diagnose. Diagnosis means a treatment plan which is very different from the treatment plan for major depressive disorder. Clarification of the diagnosis is treatment that allows my patients to become well, possibly for the first time in their lives.

Given the greater frequency of depression than manic episodes in bipolar disorder, what clues
indicate bipolar disorder rather than unipolar depression? The Tipsheet below lists factors that may
help identify bipolar depression.

■ Prepubertal onset of symptoms
■ Brief duration of depressed episodes
■ High frequency of depressed episodes
■ Seasonal pattern
■ Postpartum symptom onset
■ Multiple antidepressant failures
■ Nonresponse to antidepressant treatment
■ Rapid response to antidepressant treatment
■ Erratic response to antidepressant treatment
■ Dysphoric response to antidepressant treatment with agitation and insomnia
■ Family history of bipolar disorder
■ History of unstable interpersonal relationships
■ Frequent vocational problems
■ Frequent legal problems
■ Alcohol and drug use

■ Bipolar I disorder, with episodes of full-blown mania, is usually easier to diagnose than bipolar II disorder, with episodes of subtler hypomania
■ Recognizing that the primary mood state may be irritability rather than euphoria increases the likelihood of diagnosis
■ Focusing more on overactivity than mood change further improves diagnostic accuracy
■ Bipolar disorder is associated with a significantly elevated risk of suicide
■ Bipolar patients often use highly lethal means for suicide

■ Early age at disease onset
■ The high number of depressive episodes
■ History of antidepressant-induced mania
■ Traits of hostility and impulsivity

Further reading:
•Effective Personalized Strategies for Treating Bipolar Disorder," by Stephen V. Sobel, MD, from
which this Tipsheet was adapted.
•Successful Psychopharmacology: Evidence-Based Treatment Solutions for Achieving Remission, by
Stephen V. Sobel, MD (New York; WW Norton; 2012).

See also psychiatryuplugged: Bipolar Disorder, It's a Mood Thang

Sunday, July 20, 2014

Good Research on Marijuana Use, Don't BLUNT your Dopamine!

 by Marcia Malory report

Credit: Rice University

(Medical Xpress)—People who use marijuana heavily experience a blunted response to dopamine, according to researchers at Brookhaven National Laboratory, New York University Langone Medical Center and the National Institute on Alcohol Abuse and Alcoholism. When marijuana abusers took methylphenidate, a drug that stimulates dopamine production, they did not experience the cardiovascular, behavioral and brain changes usually associated with an increase in dopamine levels. The research appears in the Proceedings of the National Academy of Sciences.

 Scientists don't know much about how excessive use of marijuana affects the brain. Marijuana doesn't seem to affect the brain in the same way that other drugs of abuse do. Other drugs stimulate the release of , a neurotransmitter associated with feelings of pleasure, in a region of the forebrain known as the striatum. While some earlier studies have shown that marijuana does this as well, other studies have shown that marijuana does not have this effect. People who abuse alcohol, nicotine, cocaine, methamphetamine and heroin experience a decreased ability to produce dopamine. However, scientists have never found a link between marijuana use and reduced dopamine production.
Joanne Fowler of Brookhaven National Laboratory and her colleagues wanted to see if marijuana abusers have a different response to dopamine than other people do. To do this, they gave 24 marijuana abusers, who had been smoking a median of about five joints a day, five days a week for 10 years, the drug methylphenidate. This drug, also known as Ritalin, stimulates the production of dopamine. Fowler's team gave 24 control subjects methylphenidate as well.

When the researchers compared the two groups' reactions to methylphenidate, they found that members of the control group experienced greater increases in heart rate and than the marijuana abusers did. Members of the control group reported feeling more high, restless, anxious and affected by the drug than the marijuana abusers did.

PET scans showed that (Ritalin) caused changes in the striatums and the cerebellums of the controls. These changes were significantly smaller in the marijuana abusers.

The research suggests that people who use marijuana excessively have problems with the reward circuitry in their brains. Even when their brains produce large amounts of dopamine, marijuana abusers don't respond to it normally. Personality tests showed that the marijuana abusers in the study were more likely to experience negative emotions, including depression, anxiety and irritability, than the controls were. This is a sign that marijuana abusers find it harder to experience pleasure than most people do.

It's not clear whether excessive marijuana use damages the brain's reward circuitry, or whether people who already have damaged reward circuitry use to make themselves feel better.

More information: Decreased dopamine brain reactivity in marijuana abusers is associated with negative emotionality and addiction severity, PNAS,
Moves to legalize marijuana highlight the urgency to investigate effects of chronic marijuana in the human brain. Here, we challenged 48 participants (24 controls and 24 marijuana abusers) with methylphenidate (MP), a drug that elevates extracellular dopamine (DA) as a surrogate for probing the reactivity of the brain to DA stimulation. We compared the subjective, cardiovascular, and brain DA responses (measured with PET and [11C]raclopride) to MP between controls and marijuana abusers. Although baseline (placebo) measures of striatal DA D2 receptor availability did not differ between groups, the marijuana abusers showed markedly blunted responses when challenged with MP. Specifically, compared with controls, marijuana abusers had significantly attenuated behavioral ("self-reports" for high, drug effects, anxiety, and restlessness), cardiovascular (pulse rate and diastolic blood pressure), and brain DA [reduced decreases in distribution volumes (DVs) of [11C]raclopride, although normal reductions in striatal nondisplaceable binding potential (BPND)] responses to MP. In ventral striatum (key brain reward region), MP-induced reductions in DVs and BPND (reflecting DA increases) were inversely correlated with scores of negative emotionality, which were significantly higher for marijuana abusers than controls. In marijuana abusers, DA responses in ventral striatum were also inversely correlated with addiction severity and craving. The attenuated responses to MP, including reduced decreases in striatal DVs, are consistent with decreased brain reactivity to the DA stimulation in marijuana abusers that might contribute to their negative emotionality (increased stress reactivity and irritability) and addictive behaviors.

Journal reference: Proceedings of the National Academy of Sciences search and more info website

Saturday, January 4, 2014

Longer tapering more effective for prescription opioid addiction : Clinical Psychiatry News

Longer tapering more effective for prescription opioid addiction : Clinical Psychiatry News

Some real evidence to support slower tapers versus the rapid tapers that most of my patients expect. This strategy particularly is helpful for the psychological symptoms of withdrawal which is always longer than physical symptoms of detoxification.