Serotonin Syndrome: Too much of a good thing?

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.

Be Here Now: Mindfulness Meditation

Mindfulness meditation is a term that is used to describe the cultivation of “non-judgemental, moment-to-moment awareness” of events in our daily life.  Through the purposeful exercise of bringing our awareness to the present moment, we can learn to be “more present” in our day to day lives and less distracted by ruminations of the past or anxieties about the future.  Such a practice can lead to a greater richness and fullness in relationships with spouses & children, help with problems with over-eating, as well as help coping with chronic stress, pain, or illness.  While it is based in Buddhist mediative discipline, Mindfulness Mediation is not a religious meditation; although, being “mindful” and “present” is emphasized by most religious and spiritual traditions.  Mindfulness meditation is not for the purpose of relaxation, although you may feel more relaxed, but rather an exercise in bringing our awareness to the present moment, “the only moment in which we are really alive”.  Most any activity can be done “mindfully” by experiencing the activity with all of our senses.

Mindful breathing is foundational to many mindfulness exercises and is a great place from which to begin a mindful meditation practice.  Mindful breathing does not require a large commitment of time, any special equipment, or location.  Our “breath” intersects both the voluntary and involuntary nervous systems.  Because of this, mindful breathing offers a wonderful opportunity to experience mind-body connectedness.  You may have noticed that when you are very upset or agitated, your breath becomes shallow and rapid.  This shallow breathing further exacerbates feelings of anxiety and creates a negative feedback loop.  Conversely, when we focus our attention on the breath and allow it to “be” without forcing it to be any particular way, our breathing calms down and with it, our mind calms down as well.  Our mind receives the message, “Everything is okay, no need to worry”, which helps us to feel at ease.

Here is a brief, introductory mindful breathing exercise:

Assume a comfortable position, either seated or lying down.  Allow your awareness to center on one area of the breath: such as the flow of air at the nostrils or rise and fall of the abdomen, but away from the mind and “thinking”.  Allow your body to breathe in and out exactly as it wants to.  You may notice the flow of the air in and out, the onset of the breath, the inflection point just before you begin to exhale, and the length of the pause before your next breath begins. Be aware that with every breath you are nourishing every cell in your body. Continue to follow the breath in and out of our body.  When your thinking pulls you away, as it will certainly do, notice the thoughts without judgement and gently bring your focus back to your breath.  Continue your practice for a comfortable period of time; perhaps starting with five to ten minutes.

Guided mindful mediations are a great way to experience Mindfulness Meditation and are readily available from various sources.  I have enjoyed the CD “Mindfulness for Beginners” by Jon Kabat-Zinn (available on iTunes or through Amazon.com).  I also highly recommend “A Mindfulness-Based Stress Reduction Workbook” by Bob Stahl, PhD and Elisha Goldstein, PhD. for more complete instruction in the art of mindfulness meditation.

An Integrative Approach to Sleep

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

Dietary Tips for Better Mental Health

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)

Girl’s Night Out as a form of therapy?

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.