spiritmender

[spiritmender]

5 Myths about Bipolar disorder, debunked by a psychiatrist

1. People with bipolar disorder have moods that fluctuate moment by moment, or within hours. As in, “my ex was SO bipolar!” 

(I’d love it if we just all agreed to never use the word “bipolar” as an adjective.)

FALSE

Bipolar disorder is a situation in which moods get “stuck�� in certain states, either depressed, manic (the opposite of depression) or mixed (a mix of depression and mania). In order to have been diagnosed with bipolar disorder, these mood states need to last on the order of days (at least 4 days for mania) and weeks (at least 2 weeks for depression.)

Although it is possible for someone who has bipolar disorder to also have emotional instability - meaning, widely fluctuating emotions moment by moment - this is possible in other issues as well, most notably Borderline Personality Disorder & substance dependence and withdrawal. It’s also a hallmark of the teenage years, a stage in brain development when our frontal lobes are not fully developed. So, adolescents can often have intense, widely fluctuating moods that change multiple times in a day that they then grow out of as they mature into their mid-20s. 

2. Bipolar medications are the most “hardcore” of all the psychiatric medications. 

FALSE

I’m not sure how we’re defining “hardcore” here when people use words like this, but I often hear people talk about the relative “strength” of medication and get questions like “well isn’t that medication ‘stronger’” than another medication. There are many different types of bipolar medications. If “hardcore” refers to frequency of side effects, then some, like lamictal, are more mild than even the SSRIs (like prozac, lexapro, zoloft), a mainstay of depression & anxiety treatment. 

One of the difficult things about bipolar disorder is that people may need to be on medications long-term, and many of the bipolar medications do have potential side effects in the long-term that need to be monitored. This might be how this myth developed. 

3. Bipolar medications make people feel like “zombies.” 

FALSE

If you feel like a “zombie” on any medication, that’s a side effect and should be addressed immediately. Our goal as psychiatrists is to never have anyone feel sedated or not like themselves. The point of being on medication is to be less controlled by the illness and feel MORE like yourself. I can’t tell you how many times I’ve put someone on the right medication for their condition and they return to tell me they finally feel like “me.” 

Some of the bipolar medications can cause sleepiness, in part because one of the phases of bipolar disorder, mania, is a high energy, low-to-no sleep state. To treat it we have to calm down someone’s system and help them sleep. Once mania resolves, we often have to make adjustments to the medications, because physiologically, a person is no longer ramped up, so the medication will now be overly sedating. Having a good relationship with your psychiatrist and frequent meetings is essential to avoiding the discomfort of being on the wrong medication or the wrong dose. 

4. You either HAVE bipolar disorder or you DON’T.

PARTIALLY TRUE

Although technically, you either meet criteria in the DSM-5 for bipolar disorder or you don’t, diagnosing bipolar disorder is challenging for many many reasons. 

To diagnose bipolar disorder you have to establish that there’s been a manic episode - 4-6 days of manic symptoms (for hypomania and bipolar II) or 7 or more days (or a hospitalization, for mania and bipolar I).

People often don’t have accurate recollections of manic states because they aren’t laying down good memories when their brain is functioning this way. Any answers about a possible manic episode given by a person about some past event are always suspect, so we have to take them with a grain of salt. Unless I see someone manic with my own eyes, or have good information from family/friends, or someone was hospitalized and diagnosed, etc., I often leave the diagnosis as an open question. They may actually have bipolar disorder, but unless I’m certain of it, I won’t give them the diagnosis. 

Now this is the controversial bit - there seems to be a spectrum of bipolar illness. Some people naturally fluctuate between depressed and manic states (people who end up receiving a diagnosis of bipolar disorder), but others have some biologic loading for these mood states that if they get pushed in certain ways, say by medication (i.e. steroids, or anti-depressants like prozac), drugs like marijuana, cocaine or methamphetamine, or by forced lack of sleep (say by jet lag, studying overnight, etc.), may find themselves in a brief manic state, that then resolves as soon as the situation does. For instance, stopping the medication, no longer being on drugs, or getting to sleep the next night after your test. You can’t be diagnosed with bipolar disorder given these circumstances because they don’t meet criteria, but it may mean that we have to lean in towards bipolar medications rather than traditional depression treatments to treat depression in these folks because it just seems like the depressed states are different and respond to different medications. Although some people in these groups will eventually progress to meet criteria for bipolar disorder, the majority will not.

So although they DON’T have bipolar disorder, it’s a little fuzzy, and we might approach depression treatment more like we do with bipolar depression.

5. Medication is the most important treatment for bipolar disorder.

FALSE

Medication is almost always an important component of treatment, but just as important is a regular sleep cycle that promotes good circadian rhythm and psychotherapy. Reducing & managing stress is essential. Regular sleep-wake times and catching any sleep disturbance before it begins to affect mood are great preventive steps that can reduce the overall reliance on medication.

Do you have additional questions about bipolar disorder? Other myths that need debunking? Let me know!

[spiritmender]

Making the Switch from Coffee to Tea - advice from a Tea Lover

A long-time patient asked me today if I had any advice about making the switch from coffee to tea, and I realized, wow I have a lot of passion on this topic, so here goes: 

Making the Switch from Coffee to Tea

First up: Why ever would you want to do this?

Good question, incredulous person! You’re rarely going to find me being dogmatic about anything, and this is no exception. Coffee has pros and cons, and whether it’s net positive or negative has everything to do with you - your own biology, taste buds and preferences. There are plenty of studies that toot coffee’s benefits - like reducing your risk of dying from any cause (A review on the topic is here - Je & Giovannucci 2014), so don’t make the switch because you believe tea is “better”. It’s different. It has different advantages and disadvantages. Tea also has plenty of documented health benefits like high levels of antioxidants, as well as anti-inflammatory, nerve cell building and anti-cancer properties (Hayat et. al 2015). 

So here’s why you might want to do so - 

1. You experience a fair amount of anxiety

2. You have sleep issues

3. You get irritable or jittery with coffee

4. You want to experience a wide new world!

What’s the difference between coffee and tea (besides taste)

1. Coffee has more caffeine per cup (63mg for espresso - 95-200mg for drip coffee) than even the most caffeinated tea (~40mg, but this ranges). This can lead to increased anxiety, sleep issues and jitteriness. 

2. Coffee can be a harsher experience of caffeine, even mg to mg than tea - this is because tea also contains other phytonutrients like l-theanine, a natural calming compound, that buffers the effects of the caffeine

So if you’ve decided you want to make the switch, or you’re just interested in a broader experience of tea drinking, read on.

A brief overview of Tea 

Tea is a broad category of beverages that involve steeping some herbal/plant/fruity component in water, usually hot water, but sometimes we cold steep tea. There are as many types of tea are there are types of plant-components you can toss into hot water - and that’s a boatload. Thousands.

However, when we say “Tea” and don’t specify, we mean the beverage produced by steeping the leaves of the Camellia sinensis plant (an evergreen shrub native to Asia). A wide array of teas are created just by different curing methods or growing regions. 

All teas made from C. sinensis contain caffeine, but the amount varies depending on preparation, especially oxidation level. In general, the darker, more oxidized teas (blacks, oolongs) have more caffeine than the lighter teas (green and white). In fact, white has the least caffeine of all the C. sinensis teas. 

Teas - the real stuff - made from Camellia sinensis include:

Black tea (the most oxidized tea leaves) - English Breakfast, Darjeeling, Earl Grey, Ceylon, etc. -most caffeine

(Pictured here: English Breakfast tea - a robust, dark, unflavored black tea & Aged Earl Grey, a black tea flavored with bergamot)

Oolong (slightly less oxidized than black teas)

Green tea - Bancha, Sencha, Gunpowder green, Genmaicha (brown rice and green tea), Jasmine tea (green tea plus jasmine flavoring/flowers), Matcha (specially made powdered form - this is the exception to the caffeine rule - it contains more than the average green tea because of the preparation), etc. These should generally be drunk just after steeping, and without milk (with the exception of matcha). Tea leaves should be removed from the brew after you’re done steeping, otherwise the brew can become bitter and unpleasant.

(Pictured here: Japanese ceremonial grade Matcha, a loose leaf Chinese green tea, Genmaicha, and a Tazo green tea that has been processed to become decaffeinated)

White tea (youngest, un-oxidized form of the C. sinensis leaves)  - least caffeine. Again, milk would just crush this delicate tea, so these are drunk unadulterated.

Yerba Mate - the caffeinated alternative to the C. sinensis teas

In addition to the caffeinated C. sinensis teas, there are also teas made from other plants that are also caffeinated, most notably Yerba Mate from South America. Yerba Mate, depending on how strongly you prepare it, has about the same amount of caffeine as in black tea - ~40mg per cup. It’s smoky, if you get the smoked variety, and usually smooth and drinkable. It can hold its own as a latte as well. Generally less bitter than C. sinensis teas and can hold up to a wide range of steeping times, although traditional tea shouldn’t really be bitter either unless you’ve just steeped them too long or gotten poor quality tea. 

Herbal Tea

Any other tea you buy, if herbal, is generally not caffeinated. This includes all the fancy Traditional Medicinal and Yogi Teas (that are not above-mentioned), many of the Celestial Seasoning teas, etc. These are generally better and better the longer you steep them.

So where do I start if I’m switching from coffee?

That depends, but generally speaking I’d say with

Black Teas

Yerba Mate 

Matcha

(I’m a fan obviously. Here we have pictured my go-to daily matcha, Do Matcha, as well as two ceremonial grade Japanese matchas)

They all have higher caffeine content, so they’ll be more comparable to your regular cup of coffee in that way, and all taste good with added milk (or milk substitute) if you’re a regular cappuccino or latte drinker. They also do not require the finesse of green and white teas in regards to water temperature and steeping times, so less places to go wrong. 

Important notes:

Get high quality tea. Just like how regular coffee drinkers don’t roll on into a donut shop and expect to get the same quality coffee as in the fanciest of individual cup drip coffee shops, all tea is NOT CREATED EQUAL! It makes a huge difference, so don’t skimp and get the cheapo teas. 

The temperature and length of time you steep tea is important. There’s even a whole wisdom around bubble size and boil temperature, and which are appropriate for which types of teas straight from ancient China. Check it out for fun if you like. Fish in Your Kettle: Chinese Water Temperature Method. 

If you’re considering black tea - try a flavored black tea if you’re not yet sold on the taste of tea. Earl Grey is a morning favorite for many, and is brilliant with milk. 

If you like iced teas, consider Yerba Mate, which actually brews cold in about 5 minutes. As in, just dump some room temperature water into a tea pot with Yerba Mate leaves in it, and five minutes later I’m not kidding, you have excellently brewed tea. Pour it over ice and you’re done. 

If you think you’d be drawn in by the ritual and find it a fun morning routine (like I do), consider whisking up some Matcha tea. It doesn’t need to steep, so you pour hot water on, whisk it for about 20 seconds until it foams, and you’re done. I like adding a touch of milk to my Matcha tea as well. It cuts some of the bitterness, especially if you didn’t splurge on the ceremonial grade matcha. (This is about the 10th time I’m raising the point of adding milk to your tea. Obviously I’m a fan of that preparation in addition to the unadulterated approaches). 

Also, you don’t need to buy the fancy whisk - for many months I just used my metal hand whisk - the one you would use for eggs. Once I realized that I loved matcha and was regularly drinking it, I made the purchase. 

(Pictured here: Traditional bamboo whisk for matcha tea ceremony from Japan. I use it every morning I make matcha. I also use a good ole cereal bowl rather than a mug as it works better with the whisk.)

Finally, if you’d rather just drink something that is naturally uncaffeinated, besides herbal teas you could consider:

I absolutely love chicory root (Cafix is a chicory root, malt and barley beverage). It’s a roasty, yummy hot beverage which, you guessed it, goes great with milk. I love drinking it at night when I’m in the mood for cozy. Rooibos is a favorite of some. I’ve never gotten as into it as most of the other hot beverages we’ve discussed here, but it is a legitimate neutral naturally caffeine free tea-alternative that makes its way into many herbal tea combinations when they want to richen up the flavor. It’s good by itself as well. 

I hope that helps some of you take some new adventures with tea! 

Hayat K, Iqbal H, Malik U, Bilal U, Mushtaq S. Tea and its consumption: benefits and risks. Crit Rev Food Sci Nutr. 2015;55(7):939-54.

Je Y, Giovannucci E. Coffee consumption and total mortality: a meta-analysis of twenty prospective cohort studies. Br J Nutr. 2014 Apr 14;111(7):1162-73.

[spiritmender]

The Eviction, or How We Ended Up in Miracle Mile

Dear patients,

This past two months have been uncomfortable knowing that things out of my control will end up affecting you. The situation began on the morning of May 1st, 2018. The person holding the master lease on our clinic space surprise-visited me to let me know she planned to use the space I was in for other purposes and needed us to move out.  

My clarifying questions - “Are you wanting more rent? How much more rent would you need?” Were met with shrugs and confusion. 

Her: More. A lot more. 

Me: Ok, how much?

Her: You need more space. It’s better for you to find another space.

Me: Ok, but if I wanted to stay, how much? 

Her: I don’t know. A lot more.

Me: How much is a lot?

Her: A lot more.

Me: Yea, how much more?

Her: I don’t know.

Me: Like, $500 more per month? $700? 

Her: I don’t know.

And so on. 

It became clear that she didn’t have a number, she just wanted the space cleared out. 

So I started looking for places.

I looked at every commercial space in a 10 mile radius of my former space. 

Some were exciting - a well-kept craftsman house in Hollywood advertised as commercial space. What? Amazing! The owner sounded excited to have me apply. 

And then, just before I was to submit the application, I took a look at the zoning. Residential with a hard R. Straight up. When I mentioned this to the owner her response was 

“I hope you didn’t tell the city. Just pretend you live here.” 

I visited old Hollywood Blvd landmarks - one place with the remnants of what could only have been a BDSM lair - sex swings now hanging innocently in a corner, faux stone archways painted into the doors. I visited sketchy vacant spaces on Cahuenga that were presumably previously held by failed production companies. A run down office space on Larchmont. Trendy, converted, high ceilinged, open-floor plan office spaces in mid-Wilshire (where would we see patients privately?). I looked at office shares in downtown & Beverly Hills. At some point a broker joined my crew and helped me finally see a space in Hancock Park I’d been eyeing.

It was larger than I had been looking for, but the floor-to-ceiling windows called to me. The property management folks assured me the space could be available by my deadline, July 1st. And so I played. Lease offers (LOIs) went back and forth. Finally we agreed on terms. Maybe this was it. My imagination was peaked - I could have my acupuncture space, my communal teaching/learning space. I had room for psychotherapy associates, and a few colleagues. We could build a community. Yes, this could work! So I played ball. I waited for the lease that my broker kept assuring me was coming. Days blend into a week. Meanwhile my eviction day is rapidly approaching. 

What is taking so long? “This is normal,” I’m told. But the days continue their rapid melt. The lease is coming. It’s coming, I’m told. 

And then 4 days before E-day, I receive it. Phew! Finally.

Except. It’s a 43 page long monster of legal mumbo jumbo.

It seems ok until I get to a few deal-breaker clauses that I was as clear as it was possible to be about in the original negotiation, and yet they are two dense pages of very very wrong. I think, maybe I can fix this, but I’m not a lawyer. I’m told by my broker to just have “my lawyer” look at it - perhaps he assumes I’m the sort of big fish who has a lawyer on retainer? I don’t, of course, so I make a few phone calls. They’re all out for the upcoming 4th of July week. And now I see the true timeline roll out before me. I’m fooling myself thinking I can get this squared away in a week or even two. I’ll be lucky at this rate to be moved in a full month after I need to be settled. Meanwhile I’m already having to move patients out of my mid-July time slots as they’ve now told me the construction on the space won’t be ready in time. Patients are frustrated, angry. I’m writing apology emails, and repeatedly explaining the circumstances to each patient I’m seeing.

Me: Yea, I don’t know yet where I’m going to be! I know! I’m out of this office tomorrow! Ha. :/

And then last night, the night before my move out date, I’m haggling with the sublease language, busting out Google, Esq and my LSAT-ese (I spent 10 years teaching the Law School Admissions Test, and somehow I think this makes me qualified to review a legal document) thinking, there must be something I can do to move this along! And I finally realize,

No. I’m done. I’m tired. This is out of my reach. 

So here I am. I’ve seen my last day of patients in my old space. I tear up a bit as I drive away for the last time. Los Feliz holds so much history for me at various stages of my life. But I’ve been noticing signs for awhile now that it was winding its way into my past. This is simply the most concrete and final of the messages - the door closing - even if I can’t help but feel like it clipped me on the way out to hurry me along. 

I have a mover scheduled to move my furniture tomorrow. Where to, I don’t know. I’m considering my own house at this stage as a way point until a new space is confirmed. I’ve reached out to an office from the first few days of the search - a Ketamine clinic in mid-city that welcomed me to their space if I wanted it, and even after I declined sent me kind emails saying they’d welcome me if I changed my mind. And this space is still available. And flexible. And welcoming, the importance of that I’m finding cannot be overstated.

It’s in a medical building across from a little community hospital in Miracle Mile. It’s not quite the vibe I thought I wanted, but it’s got a nice view, and nice people, and it’s a SPACE I can see my patients in. I’m thinking of taking it.

I wonder if you all, my patients, will be put off. I’ve built my practice in a converted house in a hip part of Los Feliz. Will you want to see me in a medical building in mid-city? But at this point, I think - 

this is where the Tao is leading me, so perhaps.. here I go.

[spiritmender]

A new series: Sleep, the natural way - A review of Magnesium

Who hasn’t had sleep issues at some point in our lives? But for some of us, sleep issues are so severe, or happen for so many days on end, that it begins to impact every aspect of our lives, from our work and relationships to our mood. 

Most, if not all mood issues - depression, anxiety and mania, have negative effects on our sleep. In fact, sleep dysfunction is actually part of the diagnosis of each of these disorders. Sleep and mood also clearly affect one another. It’s true that mood issues can lead to sleep issues, but also true that sleep issues can lead to depression, anxiety and more sleep issues. 

And yet, treatment is often elusive. Yes we have medications that can help people sleep, but there aren’t perfect. Issues like:

Dependence (needing every increasing doses) and addiction for Z-drugs like Ambien, Lunesta and Sonata & benzodiazepines like Xanax, Ativan, Valium and Klonipin.

Oversedation, morning groggyness with some of the antidepressant sleepers like trazodone and mirtazapine.

Urinary and cognitive side effects for the anti-cholinergic sleepers like Benadryl, Doxalymine and Doxepin (also an antidepressant sleeper).

Occur regularly and limit the use of sleeping medications for many people.

And none of these agents promotes a truly natural sleep rhythm. 

Don’t get me wrong, it’s better than not sleeping! And I do regularly prescribe sleeping medicine because sometimes you just need to sleep. But, there is a legitimate interest in natural interventions for insomnia as a result. 

Some of the most common natural interventions for sleep I see people independently trying over-the-counter are  magnesium, melatonin, valerian, kava kava, tryptophan and Gaba. 

So true to form, let’s take a trip through the evidence for each of these supplements and discuss if & in what cases we might consider using them. Today, Magnesium.

Magnesium

Magnesium is a salt, naturally occurring and a required part of our diet. You can find magnesium in beans, nuts, whole grains and green leafy vegetables. Magnesium serves a lot of functions in the body, from our cardiovascular system, to our immune and nervous systems and more. 

According to the National institutes of Health (NIH), the recommended dietary allowances (RDAs) for adult males is 400-420 mg; adult females is 310-320 mg; for pregnant females 350-360 mg daily; and for breastfeeding females, 310-320 mg. 

Magnesium and sleep

Magnesium is involved in complex biochemical processes that relate to sleep including the production of melatonin. Likewise, magnesium deficient conditions appear to be associated with poor sleep quality and an excess of wakefulness in animal models (Altura 1991, Chollet et. al 2001, Dralle & Bodeker 1980, Depoortere et. al 1993, Poenaru et. al 1984). However, as you can see, all the above references are quite old. I could not find much in the more recent sleep literature on magnesium except a few combination supplement trials (Magnesium PLUS melatonin and zinc in Rondanelli et. al 2011 & Magnesium PLUS Zyzphus & B6 among others in Scholey et. al 2017). It seems like we’ve mostly lost interest in studying magnesium as a supplement for sleep, but the hope persists in alternative medicine communities that magnesium supplementation could be helpful. I didn’t find any data that pointed to significant side effects or issues, but also could not find any solid, recent studies on humans - neither ones that showed it worked nor ones that didn’t.

So without clear evidence one way or the other, what do we do?

Ah, the perpetual question in integrative medicine. Here are my thoughts. There are some reasons to consider supplementing with magnesium for sleep issues, since some meager studies and some animal literature seems to show some benefit. But we should always keep in mind - what are the possible downsides?

Can you take too much? What side effects are possible? 

Yes you can take too much, but luckily Magnesium is a substance that can generally be easily flushed through your kidneys or washed out your system in your digestive tract (which is why it is used as a laxative) so overdose is not common in those with functioning kidneys who are taking a reasonable supplement dose (~350mg daily). So don’t take more than what is recommended. Even in normal doses, magnesium does regularly cause digestive issues like nausea and loose stool, so keep that in mind as well. It can be uncomfortable.

Should I try magnesium? In summary:

If you have chronic sleep issues, no kidney issues, and can tolerate some digestive upset if it occurs, magnesium supplementation at about ~350mg daily might be worth a try. Also, one study seemed to suggest that people experiencing the type of sleep issues that occur with age seemed to benefit from magnesium. As always, speak with your physician prior to trying any supplements to make sure there aren’t other serious issues that need to be addressed, or other reasons you shouldn’t be trying magnesium. 

Also, it isn’t a sedative, so don’t expect it to make you sleepy. The hope would be for it to help your sleep quality over time. If you don’t see any benefit after a few weeks, it’s best to just stop rather than take something you don’t know is helping.

As always, you should discuss any treatment with your health care provider prior to starting, and none of the statements on this site and are meant to constitute treatment recommendations. The information provided on this website is not intended to diagnose or treat any condition. It is for educational purposes only. Visiting this website does not constitute a doctor-patient relationship.  Information found on the internet cannot substitute for individualized evaluation and treatment by medical or mental health professionals.

You can find us in Los Angeles, and at HolisticPsychiatryMD.com

Altura B.M. Basic Biochemistry and Physiology of Magnesium: A Brief Review. Magnes. Trace Elem. 1991;10:167–171. [PubMed]

Chollet D., Franken P., Raffin Y., Henrotte J.G., Widmer J., Malafosse A., Tafti M. Magnesium Involvement in Sleep: Genetic and Nutritional Models. Behav. Genet. 2001;31:413–425. doi: 10.1023/A:1012790321071. [PubMed] [Cross Ref]

Dralle D., Bodeker R.H. Serum Magnesium Level and Sleep Behavior of Newborn Infants. Eur. J. Pediatr. 1980;134:239–243. doi: 10.1007/BF00441479. [PubMed] [Cross Ref]

Depoortere H., Francon D., Llopis J. Effects of a Magnesium-Deficient Diet on Sleep Organization in Rats. Neuropsychobiology. 1993;27:237–245. doi: 10.1159/000118988. [PubMed] [Cross Ref]

Poenaru S., Rouhani S., Durlach J., Aymard N., Belkahla F., Rayssiguier Y., Iovino M. Vigilance States and Cerebral Monoamine Metabolism in Experimental Magnesium Deficiency. Magnesium. 1984;3:145–151. [PubMed]

Rondanelli M, Opizzi A, Monteferrario F, Antoniello N, Manni R, Klersy C. The effect of melatonin, magnesium, and zinc on primary insomnia in long-term care facility residents in Italy: a double-blind, placebo-controlled clinical trial. J Am Geriatr Soc. 2011 Jan;59(1):82-90. doi: 10.1111/j.1532-5415.2010.03232.x. PubMed PMID: 21226679.

Rosanoff A, Dai Q, Shapses SA. Essential Nutrient Interactions: Does Low or Suboptimal Magnesium Status Interact with Vitamin D and/or Calcium Status? Adv Nutr. 2016 Jan 15;7(1):25-43. doi: 10.3945/an.115.008631. Print 2016 Jan. Review. PubMed PMID: 26773013; PubMed Central PMCID: PMC4717874.

Scholey A, Benson S, Gibbs A, Perry N, Sarris J, Murray G. Exploring the Effect of Lactium™ and Zizyphus Complex on Sleep Quality: A Double-Blind, Randomized Placebo-Controlled Trial. Nutrients. 2017 Feb 17;9(2). pii: E154. doi: 10.3390/nu9020154. PubMed PMID: 28218661; PubMed Central PMCID: PMC5331585.

[spiritmender]

Ready to try maca? Some therapeutic drink ideas.

In my previous post on maca, I reviewed why and how one might use maca, a Peruvian traditional medicinal herb heralded for its energy boosting and aphrodisiac qualities. Please do read through that post first so you can understand dosing, the safety profile, and what to expect from the experience.

Maca, the SpiritMender review 

Once you’ve decided whether you want to give maca a try, and you’re not pregnant, nursing, a child, or someone with a hormone sensitive cancer (breast, testicular, etc.), and you’ve discussed the use of maca with your health care provider and determined it’s safe to try, here are some ideas for including it into your daily routine.

The research suggests that daily maca use for 8-12 weeks may improve energy, libido and possibly mood, so one possibility is to get maca capsules, but if you already have maca powder lying around, or prefer having a morning drink to look forward to, consider getting a shaker bottle (one that has a flexible metal ball inside and the ability to seal it completely so you can shake the contents thoroughly). 

My favorite recipe so far has been the most simple. 

Recipe

SpiritMender’s original Simple Morning Hazelnut Cacao and Maca drink

The combination here of minimally processed cacao, full of antioxidants, maca powder, with its subtle maple-y aroma, and hint of hazelnut is a harmonious and tasty start to the day.

Ingredients

5-7oz hazelnut milk Update: I did this with almond milk & coconut milk and don’t recommend it, or for the same reason, with rice milk. They are too thin, and without even subtle flavoring, so the outcome is just not that appetizing. To illustrate, one serving of almond milk is around 40 calories, while one serving of hazelnut milk is 110. 

1 teaspoon cacao powder - cacao is the same substance as cocoa, just less processed so has more antioxidants and living enzymes which are thought to be more beneficial

1/4-1/2 teaspoon (1.25-2.5g) of maca powder

1/2-1 tablespoon flax seed oil (optional) for omega 3s - provides about 700mg

Combine all ingredients in shaker bottle, add shaker ball and shake for at least 30sec. Enjoy. 

If you’re looking for something a little more filling, consider:

SpiritMender’s Orange, cacao and mint maca smoothie

Juice from 1 orange, or 2-4 small mandarins/tangerines

2 teaspoons cacao powder - antioxidant

10-12 fresh mint leaves

10 raw almonds

7 ounces hazelnut, almond or your choice of milk

1 tablespoon flax seed oil - for omega 3s - provides about 700mg

1/2 banana - potassium, calories

1/4-1/2 tsp (1.25-2.5g) maca powder

Combine all ingredients in blender or food processor. Blend until smooth.

Let me know what you think!

You can find us in Los Angeles and at HolisticPsychiatryMD.com

As always, you should discuss any treatment with your health care provider prior to starting, and none of the statements on this site and are meant to constitute treatment recommendations. The information provided on this website is not intended to diagnose or treat any condition. It is for educational purposes only. Visiting this website does not constitute a doctor-patient relationship.  Information found on the internet cannot substitute for individualized evaluation and treatment by medical or mental health professionals.

[spiritmender]

Maca, an aphrodisiac, energy-booster that may also improve mood

I was at the local natural foods store the other day studying their fresh-made smoothie board for inspiration and found my attention drawn to a smoothie made with maca.

I had a vague recollection of maca as a supplement of some kind, but this field is large, and between Chinese herbs (numbering in the hundreds), modern pharmaceuticals (numbering in the hundreds), and the Western and Ayervedic herbs I have encountered over the years, there’s always something new to learn. 

So, I got to investigating. 

Maca is an herb native to Peru and well-regarded in Peruvian traditional medicine for its energy boosting and sexual enhancing properties. It’s considered an “adaptogen,” not unlike ashwagandha or rhodiola, meaning, a substance that’s thought to regulate and balance your system, improving resistance to stress. It has a few varietals, most commonly black and red maca, which have been studied separately and do appear to have some differing properties. 

First, maca appears to improve energy levels.

(Gonzales et. al 2016)

The research demonstrates this, but also in my own short trial of maca this was the most clear and notable effect. Most supplements are so subtle that it’s hard to tell if the effects are in your head, but maca created a tangible energized feeling that was almost uncomfortable at the dose I started with (see below under dosing). In addition, my exercise tolerance was increased. I didn’t see any mention of this in the literature, but I couldn’t find any studies that specifically looked at this.

Second, it appears to improve sexual functioning in both men and women.

Studies looked at sperm quality in men: black maca appears to have a beneficial effect, while red maca does not (Gonzales et. al 2009). It also appears to have libido enhancing properties for women, even with evidence for improving sexual issues caused by anti-depressant (Dording et. al 2015). I find it reassuring that despite these sexual enhancing properties, multiple studies have shown that maca does not appear to affect hormone levels in either men or women (Stojanovska et. al 2015, Gonzales et. al 2003). The mechanism of action is unknown, but maca is hypothesized to have testosterone-like properties, as one of the active components of maca may have a structure similar enough to testosterone that it triggers the testosterone receptor (Srikugan et. al 2011). 

Safety

Which leads me to my next point, maca has not been documented to have significant side effects or safety issues, according to the studies I found (Gonzales et. al 2016, Valerio & Gonzales 2005). Although this appears to be true across the board, my own trial with it left me feeling that it’s a fairly potent supplement and I’d recommend you try this only with the help of a knowledgeable provider. However, seeing as how it is over the counter, unregulated and few providers are all that knowledgeable on its safety profile, I’ll give you my two cents here: 

With a supplement like this, it is important to start at a lower dose and see how it specifically affects you, then increase slowly to the “therapeutic dose” if you can tolerate it (see dosing below). I did notice mild anxiety, and some sleep issues the first night I took it, and since there isn’t all the much data, it’s hard to know how it will interact with each individual’s medical or metabolic state. Do NOT use while pregnant or nursing, and do not give to children. I would definitely avoid it for anyone with any hormone sensitive tumor (certain breast cancers, testicular cancers, etc.) since it is too risky an unknown at this point.

Dosing

Finally, doses of 3g per day appear to be most beneficial per the research on the topic, in divided doses (1.5g twice daily). FYI, this is also the dosing that was tested for anti-depressant induced sexual dysfunction. One study tested 1.5g daily compared to 3g daily for female libido and found that 1.5g per day did not show significant effects, whereas 3g per day did (Dording et. al 2008). Most studies tested daily usage for 8-12 weeks. 

My input on this is: 

1) Most maca supplements I’ve seen seem to suggest a starting dose of 5g (1tsp) all at one time. This is a much higher dose than is needed and I do not recommend starting with it. I did, having not looked it up beforehand and that was the day I had anxiety, overly-energized feeling and sleep issues. I would start as low as 1/4 teaspoon (about 1.25g) once daily and see how it affects a person.

2) I am not really clear on why the studies dose maca twice daily. When I took it, I felt the effects for a good 8-12 hours at least, and you don’t need (and in fact should probably avoid) energizing during sleep. I would start with once daily dosing, then decide whether a second dose would be useful and not affect sleep. 

There were multiple options at my local Whole Foods including red maca, gelatinized maca (supposedly better absorbed), and maca in capsule form. I chose gelatinized powdered maca, although for many people, capsules may be easier.

Finally, it also seems to have some signal for improving depression and possibly anxiety 

(Brooks et. al 2008, Gonzales et. al 2016), but I could not find many studies on this topic.

I think it’s important to remember with most any herb that the research that has been done is usually pretty limited. Could you have a bad reaction even though that wasn’t documented in the studies up to this point? Sure. There are many unknowns. So you try herbs at your own risk. I recommend reading up as best you can, heeding the recommendations on dosing, and talk with your doctor if you’re uncertain. You may be on a medication or have a particular condition that makes it more risky to try them. I hope the information I provide is helpful in making your decision, but it’s simply informational and should not be taken as encouragement.

Are you interested in trying it? Stay tuned for my next post where I’ll include two recipes for therapeutic maca drinks.

 You can find us in Los Angeles and at HolisticPsychiatryMD.com

As always, you should discuss any treatment with your health care provider prior to starting, and none of the statements on this site and are meant to constitute treatment recommendations. The information provided on this website is not intended to diagnose or treat any condition. It is for educational purposes only. Visiting this website does not constitute a doctor-patient relationship.  Information found on the internet cannot substitute for individualized evaluation and treatment by medical or mental health professionals.

Brooks NA, Wilcox G, Walker KZ, Ashton JF, Cox MB, Stojanovska L. Menopause. 2008 Nov-Dec;15(6):1157-62. doi: 10.1097/gme.0b013e3181732953. Beneficial effects of Lepidium meyenii (Maca) on psychological symptoms and measures of sexual dysfunction in postmenopausal women are not related to estrogen or androgen content.

Dording CM, Fisher L, Papakostas G, Farabaugh A, Sonawalla S, Fava M,Mischoulon D. CNS Neurosci Ther. 2008 Fall;14(3):182-91. doi: 10.1111/j.1755-5949.2008.00052.x. A double-blind, randomized, pilot dose-finding study of maca root (L. meyenii) for the management of SSRI-induced sexual dysfunction.

Dording CM, Schettler PJ, Dalton ED, Parkin SR, Walker RS, Fehling. Evid Based Complement Alternat Med. 2015;2015:949036. doi: 10.1155/2015/949036. Epub 2015 Apr 14. A double-blind placebo-controlled trial of maca root as treatment for antidepressant-induced sexual dysfunction in women.

Gonzales GF, Córdova A, Vega K, Chung A, Villena A, Góñez C. J Endocrinol. 2003 Jan;176(1):163-8. Effect of Lepidium meyenii (Maca), a root with aphrodisiac and fertility-enhancing properties, on serum reproductive hormone levels in adult healthy men.

Gonzales GF, Gonzales C, Gonzales-Castañeda C. Forsch Komplementmed. 2009 Dec;16(6):373-80. doi: 10.1159/000264618. Epub 2009 Dec 16. Lepidium meyenii (Maca): a plant from the highlands of Peru--from tradition to science.

Gonzales-Arimborgo C, Yupanqui I, Montero E,Alarcón-Yaquetto DE(8)(9), Zevallos-Concha A, Caballero L, GascoM, Zhao J, Khan IA, Gonzales GF. Pharmaceuticals (Basel). 2016 Aug 18;9(3). pii: E49. doi: 10.3390/ph9030049. Acceptability, Safety, and Efficacy of Oral Administration of Extracts of Black or Red Maca (Lepidium meyenii) in Adult Human Subjects: A Randomized Double-Blind, Placebo-Controlled Study.

Srikugan L., Sankaralingam A., McGowan B. First case report of testosterone assay-interference in a female taking maca (Lepidium meyenii) BMJ Case Reports. 2011 doi: 10.1136/bcr.01.2011.3781.

Stojanovska L, Law C, Lai B, Chung T, Nelson K, Day S, Apostolopoulos V,Haines C. Climacteric. 2015 Feb;18(1):69-78. doi: 10.3109/13697137.2014.929649. Epub 2014 Aug 7. Maca reduces blood pressure and depression, in a pilot study in postmenopausal women.

Valerio LG Jr, Gonzales GF. Toxicol Rev. 2005;24(1):11-35. Toxicological aspects of the South American herbs cat's claw (Uncaria tomentosa) and Maca (Lepidium meyenii) : a critical synopsis.

[spiritmender]

Integrating CAM therapies with modern medicine: In pursuit of the best medicine, let’s take intuition, experience AND science.

I can remember a time when I believed that vaccinations were not necessary. 

The fuss about them felt like paternalistic browbeating by a biased medical community. 

This was a pretty common belief where I grew up. My family was no exception in their suspicions of modern medicine. This wariness was just how people in my community interacted with physicians. One of my fondest memories of this involves the time a family member refused to take prescribed ibuprofen as part of a carefully drawn post-surgery regimen, instead coming home with a vial from our local health food store. 

She proudly and unselfconsciously proclaimed to me that “the woman in the supplement aisle” had recommended emu oil instead. 

Yes. Emu oil. She would rather rub emu oil on her face than expose herself to a “chemical,” and rather take the advice of the woman in the supplement aisle than her own surgeon.

Fast forward a decade later, and now I am a physician. 

But, I remember what it was like to travel in those circles and not even realize I was part of a circle. 

I spent 5 years in the alternative medicine community in the time before medical school. I earned a Masters of Science in Oriental Medicine and practiced as a licensed acupuncturist during that time, working alongside homeopaths, chiropractors, herbalists, shamans, energy healers, sound healers, naturopaths and more. And I will say, from experience, that the anti-science viewpoint in the alternative medicine community is in most cases hard-earned. 

Many of my colleagues and all of my patients had seen physician after physician for complex medical issues and were either mistreated, misdiagnosed, or sent away without a diagnosis or explanation. 

This is absolutely happening, and it is common. Any physician worth their salt will tell you that modern medicine does not treat everything well, and most will agree that we simply do not know how to treat everything. There are abdominal pains of unknown origin that no number of laparoscopic surgeries, ultrasounds and MRIs will diagnose or solve. There is the elusive irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, but also some concrete and scientifically identifiable issues like some cancers that we simply do not know how to address. So yeah, a lot of people do not get their issues treated appropriately, and in some cases, the physician, after spending years in school to treat people, doesn’t know what to do when they don’t have a treatment. 

And through this opening complementary and alternative medicine (CAM) has in many cases rightfully and helpfully grown.

—————————————————————————————

Many CAM treatments come from wise and time-tested traditions, like Chinese medicine or Ayerveda. By the time we encounter them in this day and age, they are complete and fairly static systems. I can deepen my understanding of Chinese medicine for the rest of my life and still have more to learn, but the medicine itself isn’t changing much. 

Modern medicine is not only fairly new, its foundation is science which creates constant change and growth. What we learn in medical school is up to date only as of that moment. Research is constantly being done in order to verify old answers and ask new questions, and as a result, our knowledge base grows and changes. 

So the most valuable thing I learned in medical school wasn’t the medicine, it was Science. 

The individual pieces of information that we have gleaned from science - like the presence of mitochondria in our cells, or even the most up-to-date treatment guidelines as of today, April 22, 2017, for stroke is the product of scientific thinking and it evolves. The most valuable part of medical school was actually teaching me how to think critically and evaluate information so I can keep up with this evolution. I thought I already knew how to think critically - I spent a decade teaching prospective law students how to take the law school admissions test! But medical training takes this to a level I didn’t even know existed.

Here is part of what I learned. 

Reading headlines is easy. Figuring out how good the information that the headline is based on - that’s the hard part. 

I am not going to lie, it is usually a tedious process. How do I integrate my friend’s-cousin’s-daughter’s experience that one dose of prozac “ruined her brain” into all the other information available? For instance, what is my own experience with hundreds or thousands of patients? Even more importantly, what are the experiences of large numbers of patients across different parts of the country or world? There is a lot of bad information out there, and it is especially sneaky when that information is presented as Scientific Research. Who doesn’t want to just read a headline, trust that it’s “Science”, get the gist and move on? 

But no study is perfect. No conclusion is irrefutable. You can (irresponsibly) use Science to support any conclusion you like, but that doesn’t invalidate the idea that there is useful information embedded in research. 

It’s all in the intent of the reader. Are we reading critically, or to push an agenda?

The biggest difference between me as an acupuncturist and me 10 years later as a physician is this: I know the likelihood that something is going to work for my patients. I know the likelihood of side effects. I know what order to rank the recommendations I give my patients, and often those recommendations include CAM approaches like acupuncture, herbs, supplements or lifestyle approaches. But, I actually know who to recommend acupuncture to now. And how long to try it before giving up. And what conditions it is most likely to work for. Because there are actually a lot of studies on acupuncture. I didn’t know this before, and I certainly wouldn’t have known how to evaluate the studies back then if I did. It was actually a really challenging process learning how to read the research. I was frustrated and confused much of the time in those early days of medical school. But, I know these things about acupuncture now, rather than believing or thinking them, because I learned to critically read the research. I have something bigger than my own belief or experience to base my recommendations off of: the experience of thousands and sometimes hundreds of thousands of people in more controlled conditions than my clinic. 

Is it perfect? Far from it. Am I wrong sometimes? Definitely. But, I do give better care and get better results now. And ethically, it feels much better to me to have something besides belief - my belief, my circle’s belief, to offer my patients.

————————————————————————————-

So when a good friend from the old circle, who went on to study chiropractic medicine, shares that she is looking for research that supports the idea of not vaccinating your otherwise healthy children (“the more scientific the better”), I get twitchy. When her response to my comment “I don’t think there is any” is, “there is loads of data!” - adamant, self-assured and forceful, I get troubled. And when her proffered “proof” is one informal survey sponsored by an anti-vaccination group with a clear agenda, and a PDF document written by a licensed acupuncturist compiling a few anecdotal stories of horrible vaccine outcomes that were then cured with homeopathy, I get sick to my stomach. I am imagining the families in the South American country where she is practicing, taking the “data” offered by the foreign doctora as encouragement to not vaccinate their children and having them die or be maimed by otherwise preventable diseases. When she tells me “I too have read the research and we will need to agree to disagree,” I am at a loss.

How can you agree to disagree when you can’t agree upon what constitutes facts or how to formulate an argument?

I wanted to understand. I am open to the idea that I haven’t seen all the data, that data is necessarily flawed and that there are many many things we have not yet learned how to study or may never be able to study. I may be a physician, but I believe in Qi and research acupuncture! But the illogic of this conversation ABOUT SCIENCE is so confusing to me.

And then I remind myself. This isn’t a debate. The merits of data are not important here. My friend lives in a circle that she cannot see her way out of. She believes she sees a bigger picture, but she simply wasn’t trained to do so. Almost no one is.

This is not an ode to the supremacy of science. 

Science is not everything. It does not explain everything. Maybe you believe it should, or maybe you believe it never will. But, even as science is not everything, it does exist. It is part of our existence here. There is gravity. We don’t fly off the face of the planet. No one ever does. No exceptions. It is a foundation from which to build ideas, formulate opinions and care for people safely. This foundation is tested and re-tested. The truth does not change, but scientific thinking causes our understanding of it to change and grow.

I am reminded of my first oath as a physician. First do no harm. I hold every provider, alternative medicine practitioners included, to this tenet, but I remind myself they did not make this oath. I did. They were not given the tools to do so. But, if someone is practicing medicine and using Science to justify their beliefs, shouldn’t they? Is it ok that some people can call themselves “doctor” and treat people’s medical issues without understanding something so foundational?

As our culture for the moment is drifting away from facts, from science, from an idea of truth, I do not know if most people will even value the question. But, I hope we can bring a love for science back. Not to bludgeon people with. 

Science can bring a false sense of certainty, so we must always remember what we do not know. 

But, I wonder what we could all do with a healthy respect for the unknown (and perhaps unknowable) balanced with a recognition of what science has to offer. At the very least, there could be better medical care all around if modern scientific medicine felt a little less certain about facts, and alternative medicine a little more so.

[spiritmender]

A Psychiatrist’s take on “Crazy” in Orange is the New Black

“Crazy” appears to be a beloved Deus Ex Machina in television and films. Just imply someone has mental illness and a writer is free to create any ole improbable scenario that furthers the plot, and Poof! “Crazy” explains it.

Only, the unintended impact for this handy writer’s tool is to create further distrust, misunderstanding and stigma for conditions that nearly 20% of the population is dealing with at any given time.

Let’s take the example of Orange is the New Black, a show that gets a lot of things right, and this one thing, repeatedly and stunningly, very wrong.

The reality of film and TV is that medical details are often horribly wrong. Ok. It takes me, as a physician, out of the experience for moments at a time, but I suck this up. I realize that most people neither know nor care that falling in and out of a coma happens much less frequently than you might think for the number of times we see it on TV, or that CPR chest compressions are usually filmed so wrong its comedic. You don’t want to watch a medical show with a physician since you won’t get through it without copious scoffing and outbursts (as my husband can attest), but I can and do laugh and move on.

But getting mental illness so wrong has consequences. In Orange is the New Black, Suzanne Warren is the longest running and most notable character with mental illness on the show, although Lorna Moretti and Lolly Whitehall (a limited run character in seasons 3 and 4) are additional examples.

Suzanne, played by Uzo Aduba, is lovable and eccentric. Aduba plays the role as sympathetic, which is not an easy task for a character who is in one moment wise, the next moment obsessive, and the moment after that destroying ceiling tiles and physically assaulting other inmates. Except that this character is beyond fictional - she is all the stereotypes and none of the reality of mental illness. As I watch the show, I find myself wondering if I have just stepped into someone’s utterly ignorant mind’s eye about what mental illness is. The message Suzanne conveys about mental illness is that it’s erratic, violent, theatrical, and childish. The fact that she is shown as a sympathetic character is a very small bonus in what is overall a cluster of a character development.

But mental illness is rarely any of these things. I can’t even figure out what Suzanne is supposed to have. Is she developmentally disabled? That would explain the child-like qualities. Except so much of the rest of the character doesn’t fit. Is she autistic? That would explain why she is so easily overstimulated, but nothing else fits. Is she schizophrenic because she sometimes talks to people that aren’t there? Except that’s a ridiculously inaccurate stereotype of people with schizophrenia who really almost never do this, and the rest of her behavior doesn’t jive with this. I’ll spare you the rest of my internal dialogue, because even more troubling is how she is used as a plot point in the story of the 5th season.

Orange is the New Black: The Bizarre 5th Season Mental Illness Story Line

The 5th season mental illness story thread involves Lorna, whose character is more realistic as someone with mental illness, possibly delusional disorder, lashing out after someone calls her “crazy.” She takes it upon herself to play doctor of the rioting prison and begins withholding psychiatric medication on the belief that mental illness doesn’t actually exist. So she withholds Suzanne’s undisclosed medication from her, and we watch Suzanne rapidly deteriorate into the aforementioned violent, erratic, theatrical child. So another character decides Suzanne needs medication and grabs lithium - ah the maligned lithium - and gives her a dose of it to calm her down. Except Suzanne slips into a coma due to this one dose of lithium. A COMA, of course! So there’s a whole drama as they try to save Suzanne by wheeling her around the prison. They find an EpiPen, and stab her with it, and like in Pulp Fiction, she suddenly returns to life completely back to normal. (#*@%&(@#%

This story line is so nonsensical I find myself actually offended. Lithium is not a sedative, and even 1, 2 or 3 doses of it would not put someone into a coma. Seriously if any one on the writing team even took 30 seconds to google lithium, they would know this. But instead, the writers use lithium and poor confused Suzanne as a plot device and in so doing further stigmatize psychiatric medication (as if lithium needed any further stigma). 

The message is, lithium is dangerous, even a single dose could put you into a coma, and “crazy” people need to be sedated.

I know no one writing Orange is the New Black was thinking, “I don’t care about people with mental illness,” or “this is ignorant but I’m going to write it anyways.” I imagine it just seemed like an interesting story line, so why not? If the writers don’t know the difference, then most people won’t either, right? 

Except, do you know how hard it is for me to talk to a person about the possibility they might have bipolar disorder? 

It feels like a death sentence for many people. 

Do you know how many people balk immediately at the mention of lithium, 

even though it has advantages over other bipolar disorder medications, and manageable risks if well monitored? Well, why wouldn’t you if a single dose could put you into a coma? 

These ignorant portrayals of mental illness happening in highly popular shows further these stigmas and make societal acceptance, treatment and life in general harder for people with mental illness. 

Do we as a society want the 20% of people at any given time who are suffering from psychological symptoms to have even higher barriers to seeking care?

Mental illness is not synonymous with “crazy.” 

People can and do act “crazy” without any discernible form of mental illness. 

Mental illness is rarely violent, childish or theatric. 

And there are plenty of valid criticisms of psychiatric medications, but that a single dose of lithium might cause a life-threatening coma is not one of them. 

Can the entertainment industry please stop using mental illness as a catch all plot device? Please take a moment, just a single moment, to do an online search before you codify an ignorant stereotype into your writing. Or better yet, talk to an expert. I’m sure there are plenty of us who would gladly speak with you about what is within the realm of possibility and what is not. Hey, I would do it for free just to see better portrayals of people who live with mental illness. I think this could decrease the spoken and unspoken judgements so many people live with every day. It is widely thought that Will & Grace and Modern Family were able to bridge a divide with the American people to reduce stigma against homosexuality by portraying gay characters as actual human beings - you know, people with lives, jobs, friends, goals and dreams. There is power in stories.

So, next time you’re writing a mentally ill character, seriously, call me.

[spiritmender]

I’m all for bringing more love and kindness into our daily lives. Dogs have a special way of caring for us as we care for them, and can apparently help people be friendlier and more cooperative when part of a group. I say, let’s make our world more dog-friendly!

[spiritmender]

And again it’s borne out that non-surgical, minimally invasive methods of managing acute, subacute and chronic back pain are preferred. Exercise, mindfulness and acupuncture in addition to NSAIDs and duloxetine if needed are first and second line approaches. Adding the right kind of exercise to your self-care routine is essential if you suffer from chronic back pain. This is a central part of our method for addressing chronic pain without opiates.

[spiritmender]

The Many Sides of Me

I have had a hard time finding my voice lately. 

I know what Psychiatrist-me would say. I also know what Daughter-me, Wife-me, Friend-me or Colleague-me might say. And recently, who hasn’t had a bit of forbidden Political-me wanting to come out? But having all these compartments is confusing. Who am I to that colleague who is starting to become a friend? How much is wise for me to show? And how soon? Who is on display in my public persona? Is it only Psychiatrist-me? But you aren’t my patients. But some of you are, potentially. It would really be most prudent for me to keep it to the blandest part of me, pruning out anything that might be controversial or offensive or might reveal too much of my true feelings. But I do need to keep it interesting. 

So find a bland but interesting part of myself, Self! Get to it! 

And of course this drawing itself is way oversimplified, right? Because Friend-to-Margaret is different than Friend-to-childhood Friend who is different from Colleague-to-Jennifer who is also different from Colleague-to-Fred-whose-Partner-Sees-Me-As-A-Patient. And on and on. 

Agh!

Trying to show you a “bland but interesting” part of myself is likely why I’m stuck. Not only is the task itself a contradiction, it’s also just not in my nature to speak to you only from a small, safe part of myself because what do either you or I get from that? Do you need more small talk in your life? 

A common theme of the challenges of my patients in psychotherapy is related to this. Without vulnerability there is no true depth or connection. And without connection, our lives lack spunk and meaning. I could make the intricacies of psychiatric medications more funny and relatable and interesting than anyone else in the history of human existence ever has and it still wouldn’t be as touching or memorable as a personal story about my own private experience.

So what to do? As a psychotherapist, it helps for me to be a tabula rasa - a blank slate for my patients to see what they need or want. If my personality is too present in the room, it is thought that it might make it harder for patients to do the work they need to do. This situation seems like a contradiction - being a blank slate and also de-compartmentalizing myself - but I have an intuition that there is a way through. I think it might actually add value, meaning, spirit and connection to my doctor-patient relationships without threatening the process. 

I just don’t have it quite figured out yet. 

So I am stuck. 

But just like I do for my patients, and I hope you’ll do for yourselves, I decided to sit with this feeling for a bit. 

I will say with humility, 

I don’t know who to be for you! 

and

I feel trapped by the person I think I am supposed to be.

Even though I know I shouldn’t. 

(And I know how I should feel about “shoulds.”) 

And trust that eventually, as long as I’m listening for it, the way forward towards integrating my various selves will make sense. And through sharing my own struggle with you, perhaps those of you with similar challenges won’t feel quite so alone in the process. 

Here’s to finding a way to embrace those buried parts of ourselves. 

[spiritmender]

Food & Herb Therapy: Summertime Beverages to feed the soul

I had one of those weeks I’m sure most of you are familiar with. It was busy. We didn’t have much of a chance to plan our meals or grocery shop, so we ended up eating a whole lot of variations on dairy and starch. Cheese, milk, bread, pasta, pizza, cereal. Don’t get me wrong, I’m all for pizza and pasta at times as they can be some serious soul food, but by the end of the week my body was definitely trying to tell me something.

Unlike many holistic physicians, I’m not a purist about nutrition. I’m not going to tell you to go gluten free unless I believe you’re one of the few folks with actual gluten allergy. Nor am I going to tell you to cut out dairy, eat only organic, or subsist on raw or vegan. I won’t badger you if you decide for yourself one of these diets is best for you, except to ensure you’re not deficient in an essential vitamin or nutrient that may be absent from your diet or tweak some of the specifics of your diet to make it easier on your digestion. But I am a big believer in food as therapy, and especially that what we eat and how we eat is important, just not in the particular and sometimes rigid way that some espouse. 

For me, the principle I value above all else is following your body’s cues. 

Developing awareness of our mental and physical cues is a central tenet of my approach to wellness. And although I know some of us developed more awareness than others growing up, never fear, it can be learned! That will be an in depth post for another day.

For today, I wanted to call your attention to food therapy, and even more specifically, flavor therapy. 

I am a big fan of the magic of a home cooked meal, especially home cooked food using fresh ingredients. By creating concoctions at home, we have the power to manifest exactly what our body or mind is needing. 

And my body was saying, LIVE FOOD FULL OF MICRONUTRIENTS PLEASE. So after a thorough Farmer’s Market and natural food store shopping spree, I made my way home to enjoy the booty. 

I was feeling inspired and creative, and I had a few items in my fridge, mostly fresh herbs, on their last legs and needing to be used - the perfect conditions for flavor discoveries!

My first project was a smoothie. I am often tickled by the combination of savory and sweet and appreciate the unexpected, so this smoothie was a bold foray into the unknown. 

Mint, banana and cashew superfood smoothie

Combining the savory (mint and cashew) with bananas and yogurt create a nice, mild, balanced flavor profile that isn’t too sweet. It also has a healthy amount of good fats to keep you full longer and moisturize your skin, lips and hair from the inside, as well as potassium from the banana for exercise recovery, probiotics from the yogurt for a healthy gut, and superfood greens and protein from the spirulina. 

And let’s not forget the therapeutic properties of mint - a staple of both Western and Chinese pharmacopeias: Cooling, refreshing, antiviral and antioxidant. 

Combine all the following ingredients in a blender:

-A handful of cashews. I prefer raw and unsalted, but roasted is what we had.

-1 banana

-Half a small package of fresh (organic) mint. If not organic, make sure you rinse it thoroughly. (The photo shows thyme - another herb I have sitting in the fridge, but I do mean mint for this particular recipe)

-1 and a half tablespoons of spirulina powder

-1 teaspoon of coconut oil

-1 cup of organic, whole milk yogurt. If you go with greek yogurt, half the amount and add a half cup of water.

Blend. Add water, ice, or the milk of your choice (regular, almond, coconut, soy, etc.) to taste if you prefer a thinner smoothie. 

OPTIONAL: Can add 1 scoop of protein powder or meal replacement powder if you’re looking to increase the calories and macronutrients (protein) of the smoothie, although spirulina already has a significant amount of protein, as does the yogurt. I added the meal replacement powder solely for the uber active spouse.

Makes ~2 servings.

Savory Fresh Cucumber Sage Water

The second inspiration I had this afternoon was as a result of thirst, a sensation I seem to have a hard time shaking this summer given the heat. 

I have been so attracted to cucumbers over the past few days - another cooling food in Chinese medicine, excellent for the summertime heat. So even after eating an entire cucumber yesterday - quick pickled in a smattering of salt and sugar, I was drawn to more cucumber in a savory herb-spiked sparkling water. 

Although sage is not as often used as other herbs in our modern Western cuisines, it is a therapeutic powerhouse: antioxidant, brain booster (cognition, memory, depression), antibacterial (including the ones involved in dental cavities), and lowers lipids.

Medicinal Properties of Sage

I have a lot of spare fresh herbs lying about this week, so although I used sage today, you could just as easily try this with basil. I’d give the herbs a sniff alongside the cucumber before you mix them to see if they seem appetizing in combination to you. If so, give it a go!

Combine the following:

-Half a cucumber, peeled

-Half a small pack of sage leaves - again if it’s not organic, make sure to rinse it thoroughly

Blend. Add a touch of water to the mixture if it’s having trouble blending until the blender is able to transition all the ingredients into a liquid. 

Fill a glass with ice, then fill it half way with the cucumber sage mixture. Add sparkling water to fill the glass, then mix and enjoy. 

Makes ~2 servings

This is just a starting point. I hope you’ll make your own concoctions inspired by your ingredients, your instincts and directed by the aromas, flavors, and colors that appeal to you. The most important piece is the enjoyment you get from creating, discovering and imbibing some new and interesting flavor combinations. Happy concocting!

[spiritmender]

A personal interlude. “Stuff” in the City.

I woke up this morning to discover that my bike was stolen. Out of my garage. It was an old bike - maybe 10 years old. But I liked it. And it was perfect for the city. It worked well and wasn’t too flashy so as to invite thieves - or so I thought. I had left it in my carport unlocked for 3 years in the Bay area with nary an issue.

And then I move to Los Angeles. 

We discussed the move long before we made the leap. We wanted to be part of a city again. The Bay area was beautiful, but it had the feel of one large suburb when you weren’t living inside San Francisco proper. With Los Angeles we longed for the art, the creativity, the vibe, the inspiration. But we also talked about the grit and the risks - was it the best place to raise a child? 

But all said and done, we decided to move and were immediately glad we had. The art, the creativity, the vibe, the inspiration were all there in spades. We wandered our old, lovely LA neighborhood in the evenings and were awed by the architecture. We stopped by local hole-in-the-wall food places and cherished the food. 

And then, driving home from our first outing to the beach, waiting to pull into our own driveway, a neighbor just up and backs into my car. Let me take a moment to paint a picture for you - We are passed each other, facing opposite directions on the street, and he decides to reverse down the street (?!) and hits my car. It’s an oversized monster pickup truck and he manages to do a fair amount of damage. The guy is nice and apologetic, but tells me he doesn’t have his insurance card on him, so provides me with his other information, and now, nearly 3 weeks later, continues to dodge me about his insurance information. This weighs on me, and it’s my first brush with the dark side of the city. 

(That’s not my car.)

I try to care for my stuff. My car may be old (about 20 years), but it had no dings and is well maintained. For the first week after the slow-moving-reversed-down-the-street-into-me car accident happened, I felt reluctant to leave the home. Suddenly my neighborhood didn’t feel like a safe place. I realized intellectually how silly this feeling was, but there’s a truism in it. Los Angeles drivers are erratic and foolhardy. That bubble around you we call our personal space doesn’t exist for cars in Los Angeles. 

A few days after this, my in-laws manage to break our stroller, and then my car’s starter goes out and needs to be repaired, and we’ve hardly been here 4 weeks. Meanwhile that neighbor still hasn’t gotten me his insurance information, so my car is still jacked with no timeline for repair. 

It feels like my cherished stuff is under assault. 

So the air feels heavy when I realize the bike is gone this morning. Again? I feel a twinge in my chest for the attachment I felt for that bike and the hassle of trying to find a new old bike. I have a moment of wondering if I should tell my neighbors in the building, ostensibly to warn them, but probably more so just for the emotional support. Should I call the police? But my next thought is, seriously, no one is going to care. It’s a 10 year old bike and you really should have been smarter and locked it up. If you mention it, you’ll get one of those “well-of-course-that-happened” looks. 

(Me riding the bike that was stolen - sketch on paper, credit Joseph Jimenez, http://blackbeltdiaries.wixsite.com/themodernninja) 

I realize I feel stupid and violated. Someone came onto private property and took something of mine, and I really should have known better. I imagine them riding my bike around. It’s a girl bike - you know, with the cross bar slanted down at a sharp angle. Did the thief give it to their girlfriend? Was it a female who stole my bike? Did they not realize that it was a girl-bike in the dark when they stole it? 

And then I try to regroup. This is a pattern, and a pattern has meaning. 

I’m attached to stuff. I rarely buy new stuff, and when I do I carefully think it through, research it till I’m blue in the face, and plan to keep it until it keels over. I like to keep it nice, and keep it protected. But when we moved to this area, I had to forgo one of my biggest stuff-cherishing instincts, which was buying a home. And in trying to come to peace with that, we have been talking a lot in recent months, even before this all happened, about the trapping of “stuff.” It serves you, but also weighs you down. And moving is a huge process of culling your stuff. What you get rid of and how (donate it? give it away to friends? yard sale it? Craigslist or ebay it?) sets the stage for the next chapter of your life. 

Who knows why my stuff is under assault. A materialist would say it’s just a simple function of moving to a city. But I wonder about the benefits of loosening my stranglehold on stuff. Letting it come and go from my life a little more freely. Trusting in the ebb and flow. We’ve all heard the expression “When a door closes a window opens.” The vacancy of the old leaves room for the new. And I don’t just mean a new bike. I mean whatever that space ends up ushering in. Or as one of my favorite parable goes, a Chinese one by Liu An, aka Huai-nan-tse (I paraphrase):

“An old man lived with his son in a small village. His only possession of value was a horse. One day the horse ran away. 

The village people said, ‘that’s bad!’ 

The old man said, ‘we’ll see.’ 

Next day the horse returned bringing a herd of wild horses. 

The village people said ‘that’s good!’ 

The old man said, ‘we’ll see.’ 

The next week the man’s son was breaking in one of the wild horses and fell off and broke his leg. 

The village people said ‘that’s bad!’ 

And the old man said, ‘we’ll see.’ 

The following week the king’s army came through and took every able bodied man to fight in a war where few returned. The son could not go because he had broken his leg.”

So I say, let’s see what the next chapter holds. 

[spiritmender]

Remember my post on Vitamin D for depression? Here’s some evidence about reducing the risk of cancer. Researchers out of UCSD found that having a level  greater than 40ng/ml may reduce a woman’s risk of cancer by 67% as compared to someone with a “low” level, defined as less than 20ng/ml.  

[spiritmender]

Vitamin D and depression

In our next installment on evidence-based complementary treatments for depression I thought we’d look at Vitamin D and its role in the development and treatment of depression.

Vitamins are essential nutrients the body needs to perform certain functions. Vitamin D, as its name suggests, is one of these essential nutrients, important in the absorption of minerals like calcium, magnesium, iron, phosphate and zinc. It is for this reason that physicians know Vitamin D as being essential to bone health, with low levels of Vitamin D being associated with skeletal diseases like osteoporosis and rickets.  

But there is emerging research suggesting that Vitamin D has far ranging effects on not just the skeletal system, but also on immune function, cardiovascular disease, mood and the development of cancer. 

But first, where does Vitamin D come from? And why would you be low in it? 

Vitamin D comes from sun exposure and food sources. However, Vitamin D does not occur naturally in most of the foods we eat with the exception of fish so some foods, primarily dairy products, are fortified with added Vitamin D. (Foods high in Vitamin D) 

So what about sun exposure? Our ability to produce Vitamin D from the sun is affected by many variables including the angle of the sunlight, the amount of pigmentation in our skin, and the amount of time our skin is actually exposed to light. Many of us live in colder climates with less direct sunlight most of the year and/or work indoors for most of the daylight hours. Some of us have darker skin which is naturally more resistant to the sun, or use sunscreen extensively, which is important in the prevention of skin cancer, but also blocks the rays necessary for the manufacture of Vitamin D in our skin. As a result, our skin may not spend enough time interacting with sunlight to actually produce sufficient levels of Vitamin D, especially at certain times of the year (Winter).  

So what does this have to do with mood? 

Lower vitamin D levels seems to be associated with a higher likelihood of being depressed (Hoogendijk et. al 2008, Ganji et. al 2010, Lee et. al 2011, Milaneschi et. al 2013, Polak et. al 2014), and a higher risk of developing depression (Milaneschi et. al 2010). Research has also shown that supplementing with Vitamin D in those with low levels can improve the symptoms of depression (Spedding 2014). 

Just as importantly, the minimum effective level of Vitamin D in your blood to affect your health seems to be different depending on whether you’re targeting the treatment of rickets or osteoporosis (skeletal disease) versus other diseases. I bring this up because that minimum cut-off on your lab report that leads to a red flag for your doctor is often calibrated to the skeletal disease level. Since that level is lower than the minimum effective levels for premature mortality, diabetes, cardiovascular disease, infections, cancers and mood, your level may not raise any red flags for your doctor, and yet could still be lower than some of the research suggests would be best for your mood. A 2013 review by Spedding et. al summarized this information as the following:

Minimum cut-off levels of Vitamin D for:

Rickets - 25nmol/L

Osteoporosis and fractures - 50 nmol/L (20 ng/ml)

Premature mortality - 75 nmol/L

Depression - 75 nmol/L (30 ng/ml)

Diabetes/Cardiovascular disease - 80 nmol/L

Falls and respiratory infections - 95 nmol/L

Cancer - 100 nmol/L

Vitamin D Toxicity

You can have too much of a good thing. Excessively high levels of Vitamin D can cause toxicity which includes fatigue, weakness, and decreased appetite among other symptoms.

Toxically high levels start at 184 nmol/L

Also, pay attention to the UNITS your lab report is in. To further confuse things, the units used by your lab may be ng/ml not nmol/L. Here is a conversion calculator. 

So what should I DO about this?

First, you should always involve your doctor and carefully listen to their advice about the approach that is right for you. If you are unable to get enough Vitamin D from the sun or dietary sources, and your doctor determines that supplementation of Vitamin D is indicated for you, most studies used between 800 and 5000 I.U.s per day of Vitamin D (Spedding 2014). The preferred form of Vitamin D is cholecalciferol (Vitamin D3) which more efficiently raises Vitamin D levels than ergocalciferol (Vitamin D2) (UpToDate accessed March 21, 2016). 

To Summarize Vitamin D and Depression:

1. Low vitamin D levels and depression are associated with each other and supplementation in those with low levels (<50 nmol/L) can improve depression.

2. Optimum Vitamin D level for the targeting of depression has been suggested to be greater than 75 nmol/L. Conversion calculator here if your lab uses ng/ml. 

3. Your vitamin D level as measured by your doctor may not raise a red flag depending on what minimum value was set by the lab. However, many labs set the minimum value at 50 nmol/L. 

4. Supplementation with Vitamin D should be done only with the recommendation of your doctor. It is generally better to get your nutrients from foods if at all possible. Generally, doses between 800 and 5000 I.U.s per day have been studied in those people with Vitamin D deficiency, and cholecalciferol (Vitamin D3) is the preferred formulation. 

5. It is possible to become toxic (have an excessively high) level of Vitamin D with supplementation. Please do not supplement Vitamin D without the guidance of your doctor. You should be monitored by a licensed medical professional. 

As always, you should discuss any treatment with your health care provider prior to starting, and none of the statements on this site and are meant to constitute treatment recommendations. The information provided on this website is not intended to diagnose or treat any condition. It is for educational purposes only. Visiting this website does not constitute a doctor-patient relationship.  Information found on the internet cannot substitute for individualized evaluation and treatment by medical or mental health professionals.

Ganji, V.; Milone, C.; Cody, M.M.; McCarty, F.; Wang, Y.T. Serum vitamin D concentrations are related to depression in young adult US population: The Third National Health and Nutrition Examination Survey. Int. Arch. Med. 2010, 3, 29.

Hoogendijk, W.J.; Lips, P.; Dik, M.G.; Deeg, D.J.; Beekman, A.T.F.; Penninx, B.W.J.H. Depression is associated with decreased 25-hydroxyvitamin D and increased parathyroid hormone levels in older adults. Arch. Gen. Psychiatry 2008, 65, 508–512.

Lee, D.M.; Tajar, A.; O’Neill, T.W.; O’Connor, D.B.; Bartfai, G.; Boonen, S.; Bouillon, R.; Casanueva, F.F.; Finn, J.D.; Forti, G.; et al. Lower vitamin D levels are associated with depression among community-dwelling European men. J. Psychopharmacol. 2011, 25, 1320–1328.

Maddock, J.; Berry, D.J.; Geoffroy, M.-C.; Power, C.; Hyppönen, E. Vitamin D and common mental disorders in mid-life: Cross-sectional and prospective findings. Clin. Nutr. 2013, 32, 758–764.

Milaneschi, Y.; Hoogendijk, W.; Lips, P.; Heijboer, A.C.; Schoevers, R.; van Hemert, A.M.; Beekman, A.T.; Smit, J.H.; Penninx, B.W. The association between low vitamin D and depressive disorders. Mol. Psychiatry 2013, 19, 444–451.

Milaneschi, Y., Shardell, M., Corsi, A. M., Vazzana, R., Bandinelli, S., Guralnik, J. M., & Ferrucci, L. (2010). Serum 25-Hydroxyvitamin D and Depressive Symptoms in Older Women and Men. The Journal of Clinical Endocrinology and Metabolism, 95(7), 3225–3233. doi:10.1210/jc.2010-0347 (level of 50 as cut off, higher risk of developing depression and more likely to have higher depression scores - older population)

Polak, M. A., Houghton, L. A., Reeder, A. I., Harper, M. J., & Conner, T. S. (2014). Serum 25-Hydroxyvitamin D Concentrations and Depressive Symptoms among Young Adult Men and Women. Nutrients, 6(11), 4720–4730. doi:10.3390/nu611472 (level of 50 as cut off, higher association of depressive symptoms in young people)

Spedding, S. (2014). Vitamin D and Depression: A Systematic Review and Meta-Analysis Comparing Studies with and without Biological Flaws. Nutrients, 6(4), 1501–1518. doi:10.3390/nu6041501 (controlling for studies with biological flaws, supplementation did improve depressive symptoms)

Spedding, S., Vanlint, S., Morris, H., & Scragg, R. (2013). Does Vitamin D Sufficiency Equate to a Single Serum 25-Hydroxyvitamin D Level or Are Different Levels Required for Non-Skeletal Diseases? Nutrients, 5(12), 5127–5139. doi:10.3390/nu5125127 (different levels for different diseases - variably 75nmol/L and 95nmol/L (30 and 38ng/ml) depression)

UpToDate online resource for medical professionals. Vitamin D deficiency in adults: Definition, Clinical Manifestations and Treatment. http://www.uptodate.com.laneproxy.stanford.edu/contents/vitamin-d-deficiency-in-adults-definition-clinical-manifestations-and-treatment?source=machineLearning&search=vitamin+d&selectedTitle=1%7E150§ionRank=1&anchor=H7#H7

Additional resources:

Vieth, R., Kimball, S., Hu, A., & Walfish, P. G. (2004). Randomized comparison of the effects of the vitamin D3 adequate intake versus 100 mcg (4000 IU) per day on biochemical responses and the wellbeing of patients. Nutrition Journal, 3, 8. doi:10.1186/1475-2891-3-8

Chei CL, Raman P, Yin ZX, Shi XM, Zeng Y, Matchar DB. Vitamin D levels and cognition in elderly adults in China. J Am Geriatr Soc. 2014 Nov;62(11):2125-9. doi: 10.1111/jgs.13082. Epub 2014 Oct 3. (Greater odds of cognitive impairment - average level 32 vs 46)

[spiritmender]

Sleep Deprivation Therapy in Depression - Immediate effects, but can it be lasting?

I started looking more closely at this therapy as a result of a dear patient I have been seeing in clinic who has been persistently, painfully depressed. Like many people suffering from depression, he has been severely depressed for many years, to the point of feeling life isn’t worth living anymore. He’s on multiple medications for depression without much effect, they’ve been shuffled around to every which medication combination, and he’s even seeing a therapist weekly. But despite all this, and now adding acupuncture, he continues to live his life in mental pain, barely existing. I gave him some information on electro-convulsive therapy (ECT), since this is the classic situation in which we begin to think about ECT, and when someone is suffering this much it would be unconscionable not to offer therapies with the highest level of evidence. But, as I imagine many people can relate, he was less than thrilled with the idea. One Flew Over the Cuckoo’s Nest has understandably embedded itself in our collective unconscious about ECT and the ills of psychiatric paternalism, and who doesn’t get the shivers thinking of having electrodes strapped to their head?

But we use ECT because it works for people for whom nothing else has worked. We frequently describe ECT as a “reset button.” Sort of like when you call tech support about your computer freezing and they ask “did you turn the computer off and on?” And you say, duh of course I did. Because, you know that sometimes resetting a complex system works.

So I started thinking outside the box and remembered a study I had read somewhere about the idea of sleep deprivation therapy. Sleep deprivation could also be thought of as a reset button of sorts, rebooting the body’s circadian system which in turn is related to mood as well as the other fundamental rhythm based processes of the body (temperature, acid-base balance, etc.) It is a rarely used treatment for reasons I will get into below, but falls into that desirable category of treatments that has few long-term side effects we know of and the potential for immediate effects. 

So I delved into the research and here’s what I found. The information here is meant to be for educational purposes. I intentionally leave out step-by-step how-tos on the procedure because it really should only be done with the help of your doctor. But I am happy to point your doctor to the articles that outline the protocols if they don’t already have this information. 

So here goes!

Sleep deprivation therapy, 

the decreasing or forgoing of nighttime sleep for the treatment of depression has been around at least 45 years. 

`

What is “sleep deprivation” exactly? Most studies evaluate either total sleep deprivation, keeping a person up the entire night (at least 36h total) until the next evening or “partial” sleep deprivation, which is usually done by allowing sleep for the first half of the night, but then waking and keeping someone up halfway through their sleep. When we look at the research, it is clear that sleep deprivation therapy can rapidly reduce symptoms of depression, with at least 60% of participants achieving a response within hours of the treatment. 

That’s huge (!) considering that our first line treatments (anti-depressants and psychotherapy) often require weeks to take effect, with, in many cases, a lower number of people responding. It also seems consistently effective, and many studies have reproduced its effects. So what’s the catch?

Sadly, the effects are not lasting. Up to 80% of people who achieve some improvement in their mood relapse to depression after a full night’s sleep. Even those that maintain some improvements after sleep do show a worsening in mood over the next few nights. 

Disappointing, right? 

Here is the silver lining. Researchers are studying how to maintain the antidepressant response with some promising results. 

1. Combining sleep deprivation with certain medications: Medications that have shown promise in maintaining the response from sleep deprivation therapy are antidepressants (specifically SSRIs and TCAs) and lithium. 

2. Light therapy or sleep phase advancement therapy: Various approaches to introducing bright light during sleep deprivation or step-wise altering of the sleep cycle can in some cases maintain the positive effects of sleep deprivation therapy. There is research on this and your doctor can provide you with detailed instructions if they believe this is a good approach for you.  

Here’s what you should know:

1. This, like all treatments, should only be performed under the guidance of a licensed medical professional. They can help you determine if this treatment might be right for you, guide you through the risks and possible benefits, and devise a plan to evaluate and maintain any improvements. 

2. It works best for those who are actually depressed. Non-depressed folk and those with obsessive compulsive disorder or panic disorder can actually have their mood worsened by sleep deprivation.

2. Depression has many different causes. Sleep deprivation seems to work best in those people who have a primary depression, not a reactive depression (low mood caused by a specific ongoing circumstance, for instance a divorce). 

3. The likelihood of seeing improvement in mood with sleep deprivation seems to be related to your susceptibility to developing the opposite of depression - mania. Those with bipolar disorder (people who cycle between depression and mania) show greater rates of response to sleep deprivation therapy for depression than those with other causes of depression. Another group of people who seem to respond better to sleep deprivation are those depressed folk who experience fluctuations in their mood across the day with consistently improved mood in the evenings. 

These people should NOT consider sleep deprivation therapy:

1. Those who do not have depression.

2. People with epilepsy. Sleep deprivation can lower the seizure threshold and make you at higher risk for a seizure.

3. Those with psychotic symptoms. These symptoms include hearing voices, feeling paranoid, feeling you have special powers or others are controlling your thoughts or actions, having difficulty with logical thought (thought disorder) and other symptoms. Sometimes it’s hard to know if you are having these symptoms - another reason you should always seek the guidance of a licensed medical professional for the treatment of mood.

4. Pregnant women - Sleep deprivation is a stressor on the body and this type of stressor is not a good idea for pregnant folk, even those who want to avoid medications. Also, significant sleep disturbance in later stages of pregnancy have been shown to increase the likelihood of post-partum blues.

5. Those with other medical conditions that could be worsened by the stressor of sleep deprivation. For example, those with cardiovascular disease. A medical examination and close guidance by a licensed medical professional is essential.

And of course, there are risks associated with this type of therapy:

1. Sleep deprivation is a stressor on the body. Anyone with medical conditions that can be worsened by stress should be cautious or avoid this therapy.

2. It can induce a switch into mania or hypomania for those with bipolar disorder. The risk seems to be low, 5% and 6% respectively. This risk is decreased if you are on mood stabilizing medications but increased if you are on antidepressants (to 10-15%). 

So the SpiritMender conclusion:

*Cue trumpet music* In researching it for you all, I have discovered that sleep deprivation is not a first line therapy for a reason. It takes a week to do the full protocol, and then still requires some type of medication therapy. Also, let’s face it, depriving oneself of sleep is not fun. So I can imagine offering this only to someone who was persistently depressed despite all my usual interventions (medications, psychotherapy, acupuncture, lifestyle changes, sleep improvements, exercise, herbs, supplements) and super committed to avoiding electro-convulsive therapy (ECT) or transmagnetic cranial stimulation (TMS). 

As always, you should discuss any treatment with your health care provider prior to starting, and none of the statements on this site and are meant to constitute treatment recommendations. The information provided on this website is not intended to diagnose or treat any condition. It is for educational purposes only. Visiting this website does not constitute a doctor-patient relationship.  Information found on the internet cannot substitute for individualized evaluation and treatment by medical or mental health professionals.

Dallaspezia S, Benedetti F. Sleep deprivation therapy for depression. Curr Top Behav Neurosci. 2015;25:483-502.

[spiritmender]

Omega-3s for Depression

In our first installment of Evidence-Based Treatments for Depression, I thought we could look at the evidence for Omega-3s, a fatty acid available from dietary sources, especially fish, organ meats and eggs. 

So here goes Spiritmender's Dorked Out Chemistry Laden explanation of Omega-3s for depression.

ALL FATS ARE NOT CREATED EQUAL:

Basically, we humans need fat, but not all fats are the same. One way to divide them is into saturated, unsaturated and trans fats based on chemical structure.

Unsaturated fats seem to be healthier for our bodies than saturated fats - hence all the talk about eating more "good" fats like those from avocados and nuts (unsaturated) and less "bad" fats like those from butter and meat (saturated).

SIDE BAR - Incidentally, this property of fats - being unsaturated or not - is exactly the reason that vegetable fats tend to be liquids at room temperature whereas animal fats tend to be solids. Vegetable fats have more of these double bonds (unsaturated) which introduce kinks into the molecules making it harder for them to settle together into a solid. 

UNSATURATED FATS - specifically, the Omega fats:

Omega-3s and Omega-6s are two of the important unsaturated fats. Omega-3s come primarily from fish and Omega-6s from poultry, nuts and most vegetable oils. They are related compounds and are gobbled up fairly interchangeably by our bodies, however how our body responds to these two types of fats is a little different. 

Omega 3s and Omega 6s: It's all in the ratio

We know we should be eating more unsaturated fats, but more recently we've started realizing that the RATIO we eat of these two fats is important for health.

Because Omega-6s and Omega-3s look so similar to our bodies, they compete with many of the same enzymes, however our diets have shifted in recent years to include a whole lot more Omega-6 fats than we used to eat (Applied Research retrieved 2014).

An optimal ratio of Omega-3s to Omega-6s is 1:1, or even up to 1:4, however most modern diets are closer to 1:15 (Simonopoulus 2003).

More Omega-6s --> More inflammation

Modern diets lean heavily on Omega-6 fatty acids which changes the ratio of Omega-3s to Omega-6s, and this is thought to be associated with various diseases, specifically causing the body to be more prone to clotting (prothrombotic), inflammation, and constriction, and is associated with arthritis and cancer (Simopoulus 2003). The thought is that by supplementing Omega-3s, one helps to shift this ratio back.

Omega-3s: DHA and EPA

Finally, Omega-3s themselves can actually be divided into two important types. There is actually preliminary evidence that the type of Omega-3 you ingest can also have different effects on the body. The two types of Omega-3 fats important for our purposes are:

1. DHA - Docosahexaenoic acid

and

2. EPA - Eicosapentaenoic acid

DHA is especially prevalent in the brain and central nervous system. It is also essential for vision (Abedi 2014, Li and Hu 2009). DHA appears to directly affect neurotransmitter synthesis and uptake of serotonin, an essential neurotransmitter for mood (Li and Hu 2009), and perhaps it is this function that contributes to some of its effects on depression. 

EPA, on the other hand, appears to have some evidence for importance in the treatment of depression. A recent meta-analysis found that studies using >50% formulations of EPA were more often effective for depression than formulations using >50% DHA. Also, formulations of 100% EPA were effective for depression whereas formulations of 100% DHA were sometimes not effective (Martins 2009). 

Given the research, the American Psychiatric Association recommends 1g per day of a combination of DHA and EPA Omega-3 fatty acids for the treatment of affective disorders (bipolar and depression). 

PROS: May help with depression without known side-effects. 

CONS: Financial - supplements cost money. Often more out-of-pocket than medications if you have insurance. Also, with supplements one always has to be aware of quality control issues. 

Spiritmender interpretation:

Take a close look at your dietary sources of unsaturated fats. Consider increasing your ingestion of fish (2x per week is recommended). If you are considering supplementation for the purposes of depression, consider 1g per day of Omega-3s with >60% EPA to DHA ratio as an add-on to whatever treatment is recommended by your health care provider. 

(As always, you should discuss any supplementation with your health care provider prior to starting, and none of the statements on this site and are meant to constitute treatment recommendations. The information provided on this website is not intended to diagnose or treat any condition. Visiting this website does not constitute a doctor-patient relationship.  Information found on the internet cannot substitute for individualized evaluation and treatment by medical or mental health professionals.)

References:

Abedi E, Sahari MA. Long-chain polyunsaturated fatty acid sources and evaluation of their nutritional and functional properties. Food Sci Nutr. 2014 Sep;2(5):443-63. doi: 10.1002/fsn3.121. Epub 2014 Jun 29. 

Li, D., and X. Hu. 2009. Fish and its multiple human health effects in times of threat to sustainability and affordability: are there alternatives? APJCN 218:553–563.

Martins JG. EPA but not DHA appears to be responsible for the efficacy of omega-3 long chain polyunsaturated fatty acid supplementation in depression: evidence from a meta-analysis of randomized controlled trials. J Am Coll Nutr. 2009 Oct;28(5):525-42.

Mischoulon D, Nierenberg AA, Schettler PJ, Kinkead BL, Fehling K, Martinson MA, Rapaport MH. A double-blind, randomized controlled clinical trial comparing eicosapentaenoic acid versus docosahexaenoic acid for depression. J Clin Psychiatry. 2014 Sep 16. 

Russell FD, Bürgin-Maunder CS. Distinguishing health benefits of eicosapentaenoic and docosahexaenoic acids. Mar Drugs. 2012 Nov 13;10(11):2535-59. doi: 10.3390/md10112535.

Simopoulos AP. Importance of the ratio of omega-6/omega-3 essential fatty acids: evolutionary aspects. World Rev Nutr Diet. 2003;92:1-22. Review. 

Weiser MJ, Wynalda K, Salem N Jr, Butt CM. Dietary DHA during development affects depression-like behaviors and biomarkers that emerge after puberty in adolescent rats. J Lipid Res. 2014 Nov 19.  

http://appliedresearch.cancer.gov/diet/foodsources/fatty_acids/table2.html,retrieved November 24, 2014.

http://www.currentpsychiatry.com/home/article/omega-3-fatty-acids-for-psychiatric-illness/21b3766b86f37caa92fb4aec3f6cc4e9.html, retrieved December 27, 2014.