Category: Mental Health


I love mnemonics and acronyms; they make it easy to remember useful information.  We tend to use them frequently in medicine (ie, RICE: rest, ice, compression, elevation) and in mental health (ie, screening for alcohol dependence, CAGE: cut down, annoyed, guilty, eye opener).  I was reminded of a particularly useful one this week: HALT.  While HALT is primarily used for individuals in recovery for substance abuse issues, I find it useful to apply to any automatic, problematic behaviors in which people engage (including emotional eating).

HALT refers to the possible responses to the question “Why am I doing this? How am I really feeling? Am I really…?”

  • H- Hungry
  • A- Angry
  • L- Lonely
  • T- Tired

By asking oneself these questions, it enables the individual to be more mindful of the situation and more accurately meet his or her needs at that moment instead of engaging in emotion-led, automatic behaviors.  So the next time you find yourself grabbing for a cookie or glass of wine, try asking yourself if you need to HALT and be certain of your motivations at that moment.

“I forgot to take my medication for a few days and I thought I was going crazy…I thought I had the flu- given the headaches, diarrhea, nausea, vomiting, chills, dizziness and fatigue.  I have had insomnia, agitation, difficulty concentrating, vivid dreams, feeling like I just not myself, irritability and even suicidal thoughts. What the heck is going on?!?”

SSRI discontinuation Syndrome (or SSRI Withdrawal syndrome) is a condition that can occur following the interruption, dose reduction, or discontinuation of Selective Serotonin Re-uptake Inhibitors (SSRIs) or Serotonin-Norepinephrine (SNRIs) antidepressant medications. The symptoms often begin between 24 hours to 10 days after reduction in dosage or complete discontinuation, depending on the elimination half-life of the drug and the patient’s metabolism. While some of the prescribing labels of some SSRIs note the possibility of “intolerable” discontinuation reactions they are not commonly discussed and are sometimes mistaken by patients and physicians as worsening of psychiatric symptoms, or worse, dismissed as being imagined.  Unfortunately, some patients have extreme difficulty discontinuing use of SSRI drugs.  Discontinuation Syndrome tends to occur more frequently with antidepressants having a shorter half-life (Luvox, Paxil, Effexor, Cymbalta) than with longer-acting (Prozac).  The exact mechanism of SSRI Discontinuation Syndrome is unknown and is likely due to a variety of factors.

Symptoms that can occur in this discontinuation syndrome can include:

  • Dizziness
  • Vertigo
  • Lightheadedness
  • Difficulty walking
  • Nausea/vomiting
  • Fatigue
  • Headaches
  • Insomnia
  • Shock-like sensations “Brain Zaps”
  • Paraesthesia (skin crawling, burning or prickling)
  • Visual disturbances
  • Diarrhea
  • Muscle pain
  • Chills
  • Agitation
  • Irritability
  • Impaired concentration
  • Vivid dreams
  • Depersonalization – sense of unreality and loss of self
  • Suicidal thoughts

These symptoms last anywhere from one to seven weeks and vary in intensity from mild-moderate to extremely distressing for some individuals.  Studies now indicate that 35-78% of individuals who are on SSRIs or SNRIs for five weeks or longer, who then abruptly stop these medications or decrease their dose too dramatically, will develop one of more of these discontinuation symptoms.

To avoid these symptoms: Do not stop your antidepressant abruptly.  Take your medication regularly: in some of the shorter half-life medications, symptoms may occur in sensitive individuals who are a few hours late in taking their medications.  Talk with your provider about what to do if you miss one or more dose of your medication.  If you are experiencing any of these symptoms, discuss them with your provider as soon as possible.  SSRIs and SNRIs can be useful tools in the treatment of depression and anxiety; however, they must be adjusted and titrated with care and caution.  These discontinuation symptoms can frequently be minimized or avoided with proper planning and judicious titration and should not be taken as an absolute reason not to try such medications if deemed appropriate.

While many pharmacological treatments for depression and anxiety “work” by raising Serotonin level, too much Serotonin can be a potentially “bad thing.”  Serotonin syndrome can be a rare potential side-effect of taking SSRI’s/SNRI’s/MAOI’s antidepressants. Serotonin Syndrome is a potentially life-threatening drug reaction that can occur when levels of the neurotransmitter Serotonin become too high in the brain and body. This condition generally occurs when individuals are taking multiple drugs at the same time that act independently to raise Serotonin levels.  While some of these drugs are obvious (antidepressants), many are not, such as certain medications for migraines or pain.

Symptoms can occur within minutes to hours, and may include:

  • Agitation or restlessness
  • Diarrhea
  • Fast heart beat
  • Hallucinations
  • Increased body temperature
  • Loss of coordination
  • Nausea
  • Overactive reflexes
  • Rapid changes in blood pressure
  • Vomiting

Serotonin syndrome is more likely to occur when you first start or increase the medicine.  For example, you can develop this syndrome if you take migraine medicines called triptans together with antidepressants called selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SSNRIs), or even Herbal/OTC treatments. Popular SSRI’s include Celexa, Zoloft, Prozac, Zoloft, Paxil, and Lexapro. SNRI’s include Cymbalta, Pristiq, and Effexor. Herbal treatments for depression: St. John’s Wort (Hypericum), 5-HT, and SAMe.  Brand names of triptans include Imitrex, Zomig, Frova, Maxalt, Axert, Amerge, and Relpax.  Ultram has also been thought to interact and potentially cause this reaction as well. Older antidepressants called monoamine oxidase inhibitors (MAOIs) can also cause serotonin syndrome with the medicines describe above, as well as meperidine (Demerol, a painkiller) or dextromethorphan (cough medicine). Drugs of abuse, such as ecstasy and LSD have also been associated with serotonin syndrome.

What to do if you suspect you may be experiencing symptoms of Serotonin Syndrome?   Call your doctor.  Do not stop your medications abruptly unless directed to do so by your physician.  Although not a common occurrence, it can be dangerous and is considered a medical emergency.  Always let all of your health care providers know all of your medications so they can monitor for potential interactions.

May is Mental Health Month. Established by Congress in 1949, this designation was made to help illustrate the importance of mental health issues to the overall health and well-being of American citizens.  While mental health care has changed dramatically since 1949, one thing still remains: the perceived stigma regarding mental health conditions.

Despite the availability of relatively safe and efficacious treatments for these disorders, many individuals fail to seek treatment for their mental health conditions.  Inadequate treatment of mental health conditions remain a significant public health concern: costing millions of dollars in lost productivity, absenteeism, and health care costs.   Existing barriers to receiving adequate mental health treatment include the availability of appropriately trained mental health providers, affordable treatment options, and perceived stigma.  Perceived stigma is the belief that people will devalue and discriminate against individuals who use mental health services and/or have a mental illness.

Perceived stigma can cause a variety of problems for individuals experiencing mental health conditions, including:

  • a delay or failure to seek appropriate treatment
  • premature discontinuation of treatment
  • rejection or ridicule by family and friends
  • discrimination at work, school, or church
  • inadequate health insurance coverage of mental health conditions
  • feelings of anger, frustration, shame, or low self-esteem
  • encountering harassment or violence

Mental illness was commonly thought of as a personal character weakness; we now know that mental health disorders have a biological basis and can be treated like any other medical condition.  Yet as recently as 2008, an APA survey revealed that more than 50% of Americans saw stigma and potential negative perceptions as barriers that would prevent them from seeking treatment.  While an estimated 75 millions Americans experience a mental health disorder in any given year, only one in four will receive treatment. Current lifetime prevalence rates for any mental disorder (including substance abuse) indicate that 57.4 percent of all Americans will personally experience mental illness at some time in their life.

Historically, the traditional medical model has separated mental and physical health; only recently is science “catching up” and revealing the multitude of “mind and body” connections.  We now know that our physical health is directly impacted by our emotional health; and that suffering from a mental condition can be a devastating and debilitating as any physical condition can be.

Despite the progress that has been made in correcting and removing many of the misconceptions surrounding mental health conditions, we still have a long way to go to defeat many of the biases, fears, and misinformation that people continue to have about mental health and the subsequent stigma these attitudes can create. By talking about mental health, we can raise awareness and dispel the stereotypes that exist about individuals with mental health conditions.

What can you do to fight the stigma?

  • Seek treatment– If you suffer from a mental health condition, don’t let fear keep you from getting relief by seeking appropriate diagnosis and treatment.  Safe and effective treatments are available.
  • Don’t define yourself by your disorder–  You are not “Depressed”, you are a person with depression.
  • Utilize available resources– seek out support and assistance groups such as Celebrate Recovery and NAMI. If you can not afford your medications, inquire about patient assistance programs.
  • Speak out and speak up– Your story may encourage someone else to seek the treatment they have needed but didn’t have the courage to ask for.
  • Don’t allow your mental health condition to cause you to feel shame or self-doubt– Mental health conditions are real medical conditions; they are not character-weaknesses or punishments.  By coming to terms with your own illness, you show others that their judgements are based on a lack of understanding rather than reality.  If you are having problems with negative self-esteem or shame, seek appropriate counseling to come to terms with these feelings.

Here is an expanded, integrative approach to sleep hygiene, which is not meant to be applied mechanically, but implemented as a part of a personalized, soothing evening ritual.

  • Be mindful of the basic rhythm of daily life by establishing a regular bed and rising time, obtaining exposure to early morning light and evening dim light, and maintaining regular times for meals and exercise. You should avoid napping if you have insomnia.
  • Manage caffeine, nicotine, alcohol and other drugs. Caffeinated foods and drinks can affect some people up to 12 hours later. Even if you do not think caffeine affects you, it may be interfering with the quality of your sleep.
  • Although regular and adequate cardiovascular exercise promotes healthy sleep, it should be avoided at least 3–4 hours prior to bed because it raises your core body temperature, which can interfere with sleep.
  • Avoid high glycemic and harder to digest foods as bedtime snacks. As an alternative, consider complex carbohydrates (e.g., whole grains, lentils, beans) that may help transport tryptophan, a precursor to melatonin, across the blood-brain barrier.
  • Create a healthy sleep environment by keeping the bedroom cool (about 68° F), completely dark, quiet, and psychologically safe.
  • Avoid clock watching at night since it draws you back to waking consciousness. Ideally, position the clock away from the bed or use a non-illuminated battery operated clock to avoid light and subtle EMF radiation.
  • Manage hyper-arousal and anxiety with cognitive behavioral therapy (CBT) and body-mind techniques. CBT, which is more effective than hypnotics over the long term, addresses sleep-related dysfunctional thoughts and beliefs that trigger arousal. For some, self-help workbooks may prove helpful. CBT is best coupled with body-mind techniques such as mindfulness meditation, progressive muscular relaxation, breathing exercises and guided imagery.
  • Manage bed and bedroom stimulation, which can condition these areas for wakefulness, by using the bed only for sleep and sex. Minimize wakeful time spent there by going to bed only when sleepy and getting out of bed with extended period (15–20 minutes or more) of nighttime wakefulness until becoming sleepy again.
  • Ask your clinician about using a botanical supplement, such as valerian or hops, for sleep for a short term. Melatonin is useful when there is advancing age and/or circadian irregularities. Always use supplements with other sleep hygiene recommendations. Be aware that botanicals are drugs and may have drug-drug interactions with other medications.  Please consult with your physician before starting any supplements.
  • Understand that letting go and surrender are key in sleep onset. In the end, we cannot finagle sleep. We can set the stage and be receptive to it, but we cannot intentionally “go to sleep”.  Efforts to do so typically backfire.

Tips courtesy of the Arizona Center for Integrative Medicine

No! Saliva tests to measure the levels of Serotonin, estrogen, progesterone, melatonin, testosterone, or DHEA are almost never legitimate, are expensive, and do not provide any clinically meaningful information to health care practitioners.  These tests are usually marketed with various supplements to control imbalances of these hormones; a serious conflict of interest.  Some well-intentioned patients have purchased and completed such tests thinking that it might provide their healthcare provider with “important information.”

Saliva testing is not a reliable method of assessing levels of any hormone except Cortisol (which must be done under very specific conditions and only for certain conditions). There is no physiologic reason to measure most salivary hormone levels and no generally published ranges of normal levels of hormones measured in saliva. Hormones are typically measured in blood, which makes physiologic sense; some hormones and their metabolites can usefully be measured in urine, but are not currently a part of any protocol for evaluation or diagnosis of any mental health condition.  Moreover, even if the test results are technically accurate, I’m aware of no science that links salivary hormone assays to non-optimal levels of hormones or neurotransmitters. Nor, even if the tests were entirely legitimate, is there any evidence that the proposed treatments will “optimize” neurotransmitter or hormone levels.

If you are concerned that you may have a mood disorder such as depression or anxiety, concerned about reasons for insomnia, or concerned that you may be approaching menopause, please contact your doctor and have that discussion with him or her. Depression, Anxiety, Insomnia, and all other psychiatric conditions are diagnosed through a “Psychiatric Diagnostic Interview” based on standardized guidelines as put forth by the American Psychiatric Association in the DSM-IV TR (Diagnostic Statistical Manual, 4th Edition, Text Revision).  While certain blood tests may be useful in evaluating for medical conditions that may play a part in certain mental health conditions, such as thyroid conditions, saliva test are not.  Your resources would be better spent investing in yourself through health eating and exercise; you already have all the “important information” any clinician might need: your story.

A new study published in The British Journal of Psychiatry makes a strong case that processed junk food can trigger or contribute to depression, while eating whole and healthy food seems protective.  Here are some tips for food-based approach to mood disorders.

Reduce processed and refined carbohydrates and eat more whole grains, fruits, and vegetables. These healthy carbohydrates are important for reducing anxiety, as they increase serotonin levels in the brain, which allows one to feel calmer. Examples include:

  • Apples, pears, blueberries, and strawberries.
  • Brown rice, oats, whole wheat pasta, and beans
  • Broccoli, cauliflower, spinach, and cabbage

Don’t skip meals. As blood sugar levels fall, stress hormones are released to make emergency fuel for the body. This can lead to jitteriness, irritability, and feeling anxious. It is very important to maintain a stable blood sugar by eating a combination of lean protein, healthy fats, and complex carbohydrates every three to four hours. Some examples include:

  • A slice of whole grain bread with peanut butter.
  • Low-fat yogurt with sliced apple and 1 Tbsp of walnuts
  • Whole grain pita bread with hummus and carrot sticks
  • Fish with brown rice and steamed veggies

Increase your intake of omega-3 fatty acids, which are important for mental health.

  • Add fish 2 times per week to your diet and nuts and seeds everyday

Avoid caffeine. This alkaloid, found in coffee, tea, chocolate, many sodas and even certain medications, produces an effect similar to the stress response in our bodies. As little as two servings per day can cause jitteriness and worsen anxiety.

  • Substitute decaf for caffeinated coffee or tea.
  • Choose herbal teas that don’t contain any caffeine.
  • Drink water and/or flavored water to stay hydrated.

Reduce your alcohol intake. While small amounts of alcohol can be good for your heart, too much can aggravate depression and also deplete your body of important vitamins and minerals.

Ensure adequate magnesium intake. Studies suggest that low magnesium can trigger anxiety and depressive symptoms.

  • Almonds, cashews, and other nuts are a great source of magnesium.
  • Green vegetables, such as soybeans and spinach, are also good sources of magnesium.

Ask your clinician if should have your vitamin B12 and vitamin D levels checked. Deficiencies in these vitamins can increase the risk of depression and you might need to take a supplement. Otherwise:

  • Get 10 minutes of sun 2–3 times per week, exposing 25% of your skin without sunscreen to increase vitamin D levels.

(Tips courtesy of the Arizona Center for Integrative Medicine)

While the many mental (and even physical) health benefits of friendship  have been well established, I was struck by the similarity in benefits that GNO’s share with traditional group therapy.  I was asked about the topic by Malena Lott for an article she wrote for the Oklahoma Gazette.  Turns out, these Ladies-only events may actually be good for you as well as a fun break from everyday life.

In both situations, there can exist:

  • an opportunity to belong and to confide in others
  • an atmosphere that is both accepting and non-judgmental
  • a forum for sharing–for giving and receiving support and empathy
  • participating in and benefiting from group problem solving/collective reasoning
  • reassurance to the individual that she is not “the only one” who is experiencing the trials of everyday life
  • an occasion to be one’s “true self”: without having to maintain any pretense for fear of judgement or recrimination
  • a means to maintain a sense of connectedness with others
  • the possibility to “let loose”–to relax in the absence of day to day responsibilities

While a Girl’s Night Out is certainly not an appropriate substitute for Group Therapy (which is performed by trained and licensed specialists to address such complex issues as depression, addiction, abuse, and more), it can provide an opportunity for many women to reap some of the same therapeutic benefits as can be experienced in the group therapy setting. Women naturally communicate for the purpose of socialization to achieve closeness and intimacy; having a Girl’s Night Out utilizes our natural tendencies to connect with and support others through female friendships by providing a dedicated forum in which to do so. Girls’ Night Out can provide a wonderful opportunity to maintain and develop female friendships that can improve one’s overall happiness.