SSRI Discontinuation Syndrome

“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.

Mental Health: Fight the Stigma!

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.

Do I need to get a test to measure my Serotonin levels?

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, 4^th 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.

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)

5 Misconceptions About Therapy

I was inspired by Therese Borchard’s post today, “9 Rules for Survivng Therapy” to include some common misconceptions that I have encountered regarding therapy.

1. Therapy is good for everyone:  Although Socrates said, “The unexamined life is not worth living”, it doesn’t follow that every person is ready to go through therapy at any given time.  Issues with psychological or internal resistance can be uncomfortable at best, and requires that the individual be stable and secure enough in one’s ego to tolerate such conflict.
2. All therapy is the same:  There are many different types and styles of therapy (psychoanalysis, psychodynamic, Gestalt, Interpersonal, Cognitive Behavioral, Supportive). Most therapist practice a few different types of therapy, but generally have one therapeutic approach that is their primary focus. Not all therapists and therapies may be the right fit for all patients.
3. My therapist is my friend:  This is a difficult one for many people. The therapeutic relationship is by nature supportive, non-judgement, and personal.  While the therapeutic relationship may feel “friendly” it is a one-sided relationship (whereas friendships are inherently two-sided).  Excepting certain revelations for specific therapeutic intent, the therapist doesn’t reveal much to the patient. This allows for therapeutic process of “transference” to occur (where the patient projects their own ideas and feelings about other people onto the therapist).
4. Therapy should feel good:  Another common misconception is that therapy should leave the patient “feeling good” after each session, much the way a visit to a “spa” would feel.  The reality is that, while most individuals eventually feel better, therapy is hard work.  Most people will feel worse, perhaps disheartened, as issues are brought up and discussed; but eventually may feel relief as issues are resolved.
5. Therapy should be easy:  While therapy may seem simple, it is very hard work and can emotionally draining.  It takes a great deal of courage for any person to face their “demons” and come to terms with the things in their life that may be keeping them “stuck”.

The SAD time of year

It’s that time of year, when the days get shorter and the amount of sunlight we are exposed to decreases dramatically. In some individuals who are predisposed to Seasonal Affective Disorder (SAD) this corresponds to an increase in depressive symptoms. While the cause of this disorder is not fully understood, many believe that changes in our neurochemicals may be responsible: specifically changes in Melatonin levels. Melatonin is a chemical that is produced during the hours of darkness; it is involved with regulation of sleep, temperature, and release of other hormones. It is thought that individuals with SAD produce an excess of Melatonin that leads to depressive symptoms.

Symptoms of SAD can sometimes mimic hibernation: tendency to sleep more, eat more (especially cravings for high carbohydrate items), weight gain, irritability, fatigue, social withdrawal and isolation (in addition to other signs of depression: sadness, hopelessness, anxiety, loss of interest and pleasure, and difficulty concentrating and focusing. SAD is more than the “winter blues” and requires a full diagnosis of Major Depression with the seasonal specifier for timing.

If you suspect that you might have SAD or Seasonal Depression, please see your doctor for full evaluation and discussion of treatment options. Many treatments are available and may include Light Therapy, medications, and psychotherapy. Light Therapy (with a specialized lamps using 10,000 Lux bulbs) should be initiated in early November and continued on a daily basis, for 30 minutes daily, until March or otherwise instructed by your healthcare professional. It’s not too late to address the cycle of moodiness and loss of motivation that may occur this time each year.

Should Christians Take Antidepressant Medications?

The decision to seek treatment for any condition can be a difficult one.  The decision to seek treatment for depression and anxiety can be made significantly more difficult by current social stigmas and also by one’s interpretation of religious beliefs.  This question represents so many other questions that can become barriers to treatment: If I seek treatment, does it mean I don’t have enough faith in God’s healing power?  If I seek treatment, does it mean that there is something really wrong with me?  If I seek treatment and someone finds out, will they judge me in a negative manor?  I have lost count of how many believers have delayed or avoided treatment for these very reasons; not to mention how many stop treatment prematurely so they can “get back to thinking that there’s nothing wrong” with themselves.  These same people generally would not hesitate to seek treatment for high blood pressure or diabetes.

 

My response is this: Our bodies are temples that we are entrusted with caring for.  We are an incredible collection of cells, nerves, chemicals, and more that are continually changing in response to biologic, psychological, and social factors.  Sometimes our chemistry can become unbalanced necessitating the use of antidepressant medication to correct states of depression and anxiety when they cause dysfunction in our lives.  Depression and anxiety are not punishment; they are real medical conditions that can respond to specific treatments.  To not take the steps needed to maintain our bodies would be far more wrong and damaging; sometimes this might mean taking medications in addition to doing therapy and other activities.  Have faith that the God of the Universe is not limited in His capacity to heal: that healing may very well be accomplished through any variety of treatment modalities including medications. Find a physician, who understands your beliefs and listens to you, but don’t avoid or delay getting the help you need.

Hope… for the economy & in depression

I had the pleasure of watching Dave Ramsey’s Town Hall for Hope last night. I like Dave Ramsey’s approach to money and I often recommend his “Financial Peace” program to my patients who are struggling with financial difficulties. I appreciate his take on the family’s budget as being just that: the outline of the family’s priorities as determined by the entire family together. His focus on personal responsibility resonates with me as well. I thought his presentation was uplifting and encouraging as he reiterated his common sense financial fundamentals to allay the “spirit of fear” that has come over most of America. If you missed it, I would encourage you to check out his website: www.townhallforhope.com .

Mr. Ramsey concluded his presentation with three action steps to combat “fear, panic, and hysteria.” They are: “take action, don’t participate in loser talk, and be giving”. I was struck by the need to apply these same principles in all areas of our life where we experience hopelessness: concern about a down-turned economy, dealing with difficult life situations, and most certainly, dealing with depression. Hopelessness can be one of the most challenging aspects of depression due to its invasive and destructive nature.

Let’s look at each step of the action plan as it pertains to mental health:

Take Action: “Get up, take action, get moving.” My treatment plans almost always include a recommendation for exercise. This type of “action” gets people off the couch and “out of their heads” at least for the moment. The mood enhancing effects of exercise have been well documented: improving levels of mood-enhancing neurotransmitters in the brain, boosting endorphins, releasing muscle tension, reducing stress –hormone cortisol levels, as well as improving sleep, confidence, and potentially reducing isolation. Exercise and music therapy remain some of the best non-pharmacologic steps individuals can take to improve their mental and physical health.

Don’t Participate in Loser Talk: This is one of the basic principles of Cognitive Behavioral Therapy. Specifically, don’t stay stuck in negative thinking. There really is power in positive thinking. Seek to identify and correct any distortions of thought that might be keeping you mired in negativity. Hopelessness is associated with many such “loser thoughts” that lead to poor self-esteem and creating a self-fulfilling negative spiral of thoughts and beliefs. Surround your self with optimistic and encouraging people and avoid those besieged with the “Spirit of Eeyore”.

Be Giving: Of all the recommendations I make to patients, giving can have the most profound effects on peoples’ lives. Giving is empowering. It improves self-esteem, imparts a sense of connectedness, and can foster an optimistic attitude. Altruism is one of the surest ways to restore hope as well as restoring an individual’s sense of purpose and meaning. Being a part of a cause larger than oneself and the feeling of making a difference in others’ lives are crucial for mental well-being. Giving, especially gifts of time and service, can grant a person perspective thus enabling him to look beyond his problems for a little while.

So no matter what obstacles or challenges you might be facing in your life, I join with Dave Ramsey in encouraging you to choose HOPE now.