About DoctorKatieMD

Katie is a Los Angeles psychiatrist providing weekly mental health news and advice on her website, Dr. Katie MD.

California Psychiatric Association Advocacy Day

This year, I had the distinct honor of being flown to Sacramento to participate in the California Psychiatric Association’s Advocacy Day. I went as a representative of Los Angeles psychiatrists and the Southern California Psychiatric Society (SCPS) with the goal to advocate for mental health.

In Sacramento, we were briefed on the bills that are currently being sponsored by the California Psychiatric Association (CPA). There are three main bills; two assembly bills (AB) sponsored by Assemblymember Susan Eggman and one senate bill (SB) sponsored by Senator Josh Newman.

According to the National Association of Counties, 64 percent of people in jail have a mental illness. Furthermore, 15 percent of male inmates and 31 percent of female inmates have what can be classified as a severe mental illness. AB 720 would allow for the involuntary medication of people in jail with a mental illness who are awaiting adjudication (i.e. sentencing). Of note, this law would only allow for involuntary treatment of people who are deemed to be dangerous to others, dangerous to themselves, or gravely disabled (as in not being able to care for their own food, clothing, or shelter usually due to a psychotic illness). This bill would not allow for involuntary medication of people with mild mental illness.

Already, law allows for inmates who have been sentenced to be medicated involuntarily; AB 720 would expand the scope of this law to include inmates who have yet to be sentenced. As a psychiatrist, it is clear to me that treating mental illness is of utmost importance. This bill has the potential to reduce harm to the inmate themselves, other inmates, and staff, and to reduce suffering by actively and effectively treating severe mental illness.

AB 1136 was the second bill on which we were briefed. This bill would mandate that the California Department of Public Health apply for federal funding under the 21st Century Cures Act for the creation of a web-based psychiatric bed registry. This registry would include inpatient psychiatric beds, crisis stabilization units, residential community mental health facilities, and residential substance use disorder treatment facilities. Currently, when patients come to an emergency department in an acute psychiatric crisis, social workers have to cold-call dozens of facilities to find out bed availability and if a particular patient would be appropriate. A bed registry that could be updated in real-time would greatly increase the efficiency of this process.

The third and final bill has to do with mental health parity. Mental health parity refers to the fight to end discrimination toward people with mental illness through ensuring equal access to treatment (i.e. the same types of benefits for mental illness as other medical illnesses). This takes the form of ensuring similar copays, similar numbers of doctor visits, and similar numbers of days in the hospital. SB 347 makes certain that regardless if the Affordable Care Act is repealed, the California Department of Insurance may continue to enforce mental health parity laws.

After being briefed on the three bills, I was paired with a senior psychiatrist (Dr. William Arroyo, president of CPA) and other resident-fellow members from the Los Angeles area. Together, we went to the State Capitol Building and met with Assemblyman Nazarian and Senator Bob Hertzberg’s Chief of Staff Diane Griffiths to discuss the importance of the three bills.

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Participating in CPA Advocacy day was an eye-opening experience on both the complicated nature of mental health policy in California and the relevance of the CPA and the SCPS in influencing that policy. I feel honored to be part of the wonderful team of psychiatrists who fight for mental health parity and increased access to care for all people.

If these topics interest you, I encourage you to reach out to your local California legislator to advocate for their support on these important topics.

 

Holiday Blues? Not so much. Trends in Psychopathology over the Holidays.

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The idea of “holiday blues” or “holiday stress” has been discussed extensively in popular culture and in the psychiatric literature. Interestingly, the majority of these articles presume its existence, yet do not cite data. Most of the literature comes from case studies or psychoanalytic teachings (as opposed to higher-quality research papers). As early as 1955, a psychiatrist described a “holiday syndrome” characterized by feelings of “helplessness, possessiveness, and increased irritability, nostalgic or bitter ruminations about the holiday experiences of youth, depressive affect, and a wish for magical resolution of problems.2 Not a small number of articles inundating my newsfeed are about how to “cope” with the added stress of holidays instead of how to enjoy a lovely season. Suggestions for how to manage this stressful time include living in the present (Oprah via HuffPo), making a budget and focusing on your breathing (US News), and just shaking it off (Today).

shake-off

You’d think that with all of this stress surrounding the holidays, psychopathology would increase. People would be visiting the psychiatric emergency room more frequently, people would be committing suicide, and there would be higher rates of depression, right? Wrong.

This is what we know from research: though your mood may worsen, overall utilization of psychiatric services goes down. There are fewer visits to the Psychiatric Emergency Room in the days and week before Christmas. The psychiatric wards are emptier, suicide rates go down, and people engage in less self-injurious behavior (i.e., cutting and face-picking).1

Theories abound as to this apparent discrepancy. Perhaps the hope inherent in the Christmas season leads to the belief that problems will be fixed.2 Perhaps increased contact with family members bolsters social support, which is protective against psychopathology.2 Or, perhaps there needs to be a greater distinction: demoralization, disappointment, and merely revisiting intrapsychic conflicts do not a disorder make.3

Maybe the idea of Christmas blues is merely that, “blues,” and most people cope appropriately.

My first impulse when researching holiday stress was to assume that people struggle and that there would be increased utilization of psychiatric services. I was pleasantly surprised to find that the majority of people tolerate the holiday season and many even fare better during the month of December than other months of the year. Older adults, those who are single or widowed, people who struggle with alcoholism, and those who have had traumatic past holiday experiences may be at increased risk of having a difficult time during the holidays. Furthermore, those who have a prior or current diagnosis of depression or other mental illness may experience shame when surrounded by [presumably happy] family members.4 If you’re a member of one of these groups, I encourage you to seek out appropriate supports in the form of family, friends, or a trusted therapist or psychiatrist. [You can also take a look at this infographic from Happify, which did actually have some great suggestions for coping with holiday stress.]

The take home? While the holidays might be tough for some, in general mental health pathology and utilization decrease. Though people may feel intermitently blue, let’s allow the hope of the season to seep into our psyche, and let’s enjoy the season as we continue to show each other love and compassion.

References:
1. The Christmas Effect
2. Holiday Blues as a Stress Reaction
3. What is it About the Holidays?
4. A Season of Hope

Contraceptives, Hormones, and… Depression?

For many years, researchers have been trying to clarify the association between estrogen, progesterone, and depression. We know that women are twice as likely as men to become depressed (likely due to hormones). We know that changes in the level of estradiol (a type of estrogen) are associated with depression. Furthermore, fluctuating hormones in the days before menstruation are believed to be the cause of premenstrual syndrome (PMS) and can even cause its angrier sister, premenstrual dysphoric disorder (PMDD).

Combined oral contraceptives include synthetic forms of both progesterone and estrogen. These hormones (given in specific doses and at certain times during a woman’s cycle) inhibit ovulation and prevent pregnancy. Interestingly, external progestins (more than endogenous progestins) seem to increase levels of monoamine oxidase, leading to more serotonin breakdown. Degrading more serotonin may lead to depression and irritability. [If you’ll remember from this article, one of the major classes of antidepressants blocks monoamine oxidase. External progestins seem to do the opposite.] 1

Looking back, I remember many of my friends taking birth control in college for the first time. Incidentally, many of these same friends also began to take antidepressants for mood changes or anxiety. After I started my first hormonal contraceptive, I too felt uncontrollably moody. I have always been prone to ups and downs, but certain types of contraceptives have made me feel as though I cannot regulate my feelings.

On to the data. Similar to the research on statins and SSRIs, Denmark has published another large study examining the rates of depression in women who use hormonal contraception. Over 1 million women from ages 15-34 were observed for 14 years. Women who had used antidepressants or who had been diagnosed with depression prior to study initiation were excluded. Both the first diagnosis of depression and the initiation of an antidepressant after starting hormonal contraceptives were tracked and were used to estimate the increased risk of depression with hormonal contraceptives.

The relative risks (RR) of first-use of antidepressants for users of hormonal contraceptives versus women not taking hormonal contraceptives are outlined below.

Combined oral contraceptives 1.2
Progestin-only pills 1.3
Vaginal ring (Nuva Ring) 1.6
Implant (Implanon) 2.1
Levonorgestrel IUD (Mirena) 1.4
Medroxyprogesterone depot (Depot-Provera) 2.7

RR can be understood as the number of “times” more likely you are to experience an effect. For example, an RR of 1.2 means that users of combined oral contraceptives are 20% more likely to use an antidepressant for the first time than women not taking combined oral contraceptives.

Clearly the use of hormonal contraceptives was associated with antidepressant use and also a diagnosis of depression. Interestingly, the relative risk decreased with age (i.e. adolescents had significantly higher relative risks: up to an RR of 3.2 for adolescent users of Mirena). For both age groups, the RR peaked at 6 months of hormonal contraceptive use.

This article should be taken with a grain of salt. Hormonal contraceptives play an incredibly important role in many women’s lives and have provided an independence that wasn’t present before. Women have more control over their health than ever and birth control plays a large role in this gain. Regardless, it is important to be aware of the possible side effects and to make informed decisions about your health care [and to seek help should you need it].

 

In Pop Culture: Is your birth controlling depressing the hell out of you?

References:

  1. External Progestins and MAO
  2. Association of Hormonal Contraception with Depression 

 

Sleep Basics: OTC Antihistamines

Many over-the-counter (OTC) medications used for insomnia have primary effects on the H1 receptor. At this receptor, these medications serve as an antagonist; hence the name antihistamine. The H1 receptor is primarily implicated in allergic reactions, so blockade of this receptor decreases the allergic response. Histamine receptors in the central nervous system also have a role in wakefulness; blocking them causes sedation. Studies report that nearly 25 percent of patients with sleep disturbances use OTC sleep aids such as antihistamines, and 5 percent use them at least several nights a week.

Routine use of OTC antihistamines such as diphenhydramine (Benadryl) and doxylamine (Unisom SleepTabs and Nyquil) for insomnia is controversial. I know that on inpatient psychiatric hospitals, these medications are frequently used for sleep because 1) they are relatively safe and 2) they are not addictive. However, the evidence supporting the use of these medications for long-term treatment of insomnia is lacking.  Additionally, many OTC antihistamines (especially Benadryl and doxylamine) have effects at cholinergic receptors leading to uncomfortable side effects such as dry mouth, blurred vision, constipation, urinary retention, and more importantly cognitive impairment and possibly delirium 1.

Recent literature has explored the long term implications of use of anticholinergics (one of the more common being OTC antihistamines). A large prospective cohort study demonstrated that greater cumulative use of anticholinergic medicine in people >65 is associated with an increased risk of dementia 2. To quote from the study:

Higher cumulative anticholinergic medication use is associated with an increased risk for dementia. Efforts to increase awareness among health professionals and older adults about this potential medication-related risk are important to minimize anticholinergic use over time 2.

 

In cases where use of a medication is controversial; its important to be an informed consumer. Benadryl or Doxylamine? What dose is effective? Is Tylenol PM different than Benadryl? Is Nyquil? Is it okay to take these medications if you’re >65?

With regard to insomnia, diphenhydramine has been studied more thoroughly and is noted with short-term use to lead to improvements on self-reported sleep efficiency and the Insomnia Severity Index, and a decrease in participant-reported number of awakenings 3. Unfortunately, most studies fail to observe significant changes on the polysomnogram for sleep-onset, sleep efficiency, and total sleep time 3. Thus, although you may feel like you’re sleeping better, the data doesn’t show this. Furthermore, long-term use of OTC antihistamines may be futile. In fact, studies demonstrate that diphenhydramine may lose its sleep-promoting effects after just 3 days. Furthermore, when dosed at 50mg versus 25mg (i.e. 2 Benadryl vs 1) participants had significant psychomotor impairment and a decreased level of wakefulness the next morning 3.

The studies on doxylamine are few and far between. Similar to diphenhydramine, studies show improvement with self-reported sleep but not with the polysomnogram 3. The main drawback to doxylamine? It has a longer half-life than Benadryl, and thus is likely to cause more morning impairment than a comparable dose of Benadryl.

Diphenhydramine Doxylamine
Brand Name Benadryl, ZZQuil, Tylenol PM, All Unisom products except SleepTabs Nyquil, Unisom Sleep Tabs
Half-Life 3-9 hours (usually reported as 8) 10 hours
Dosing 25-50mg 12.5-25mg

My recommendation? If you’re having insomnia and you want a quick fix, go with 25mg of diphenhydramine each night for a short period of time (I’d recommend no more than 1 week). If you’re over 65, be extremely judicious with your use of OTC antihistamines. Likely due to their anticholinergic effects, long-term use is associated with an increased risk of dementia. Short-term use is probably okay, but if you continue to have sleepdisturbances after 1 week of use, ask your doctor for a better, more evidence based, long term solution.

  1. New Developments in Insomnia
  2. Anticholinergics and Dementia
  3. H1 Blockers for Insomnia

Sleep Basics: Melatonin

Melatonin is a hormone produced by the pineal gland from the precursor, serotonin. During daylight hours, serotonin is stored and is unavailable for use. As darkness sets in, an enzyme is activated which converts serotonin to melatonin. Through its changing concentration (high at night and low during the day), melatonin plays a significant role in the human circadian rhythm.

After synthesis, melatonin is released into the blood stream and cerebrospinal fluid, where it acts on receptors found in many different targets in the human body including the suprachiasmatic nucleus (SCN) in the hypothalamus. In the SCN, melatonin inhibits the firing of certain neurons, which may contribute to it’s sleep-promoting effects.

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Melatonin is produced by the pineal gland (red) and acts on the suprachiasmatic nucleus (green). Image here.

A few things we know about melatonin:

  1. Melatonin secretion starts when human infants are 3-4 months of age. This is the same time infants begin sleeping through the night.
  2. Nocturnal melatonin production decreases over the human lifespan. Peak concentrations in 70 year olds are only 25% of the peak concentrations in younger adults and may contribute to sleep difficulties in older adults. (Fun fact: this decrease may be related to the calcification of the pineal gland with time. Calcification = decreased synthetic capability = less melatonin).
  3. Certain substances (i.e. caffeine and ethanol) can lead to decreases in melatonin concentrations. (Recommendations on caffeine and ethanol intake can be found here).
  4. Very dim light (i.e. 100-200 lux) such as that from the darkest of overcast days or from light-emitting devices (i.e. iPhones) can suppress melatonin production and can lead to feeling less sleepy before bed, increased time to fall asleep, and increased grogginess the next morning 1.

As an over-the-counter supplement, melatonin has an indication for treatment of age-associated insomnia (such as elderly people with decreased melatonin production), jet lag, and shift work. Its primary efficacy is for sleep-initiation and has not been show to have significant effects on sleep-maintenance or early morning awakening 2.

We know that melatonin receptors are highly sensitive to desensitization and that supraphysiologic doses of melatonin may lead to this. As such, optimal dosing of melatonin has not been clearly established. Anecdotally, I have had neurologists and psychiatrists recommend a starting dose of 3mg (such as from this preparation), however from my reading and literature review it seems that lower doses may be preferable. UpToDate, a widely trusted medical resource, recommends starting doses as low as 0.3mg, whereas the European Food Safety Authority recommends that “in order to obtain the claimed effect, 1 mg of melatonin should be consumed close to bedtime”3.

The take home? Melatonin is relativey safe, has few to no addictive properties, and has an indication for sleep-onset insomnia. If you have trouble falling asleep, it is reasonable to try a melatonin supplement with a starting dose of 1 mg. LabDoor provides rankings of the top 10 melatonin supplements, and as I have heard from other physicians, the Nature Made brand ranks near the top for product purity and ingredient safety. What do I take? I buy the 3mg Nature Made brand, break it in half, take it 30 minutes before bedtime, and it helps me fall asleep.

Sleep Basics: Sleep Hygiene

Studies estimate that around 30% of adults have experienced one or more symptoms of insomnia including difficulty falling asleep (sleep initiation), difficulty staying asleep (sleep maintenance), or waking up too early (early-morning awakening) 1. That means that almost 1 in 3 American adults experience trouble with sleep, an incredible number

This post will be the first in a series of posts on sleep. In addition to providing evidence-based recommendations for improving sleep hygiene, I’ll review the more common sleep supplements (i.e. melatonin and valerian root) and discuss the types of prescription sleep medications.

Now, on to behaviors that promote and enhance sleep, known as sleep hygiene.

  1. Maintain regular sleep-wake cycles. Going to sleep much earlier than usual causes greater sleep latency (longer time to fall asleep), whereas going to bed much later than usual causes increases wakefulness in the latter part of the night. Your body has a natural sleep-wake rhythm, try to stick to it as much as possible.
  2. Minimize light exposure during sleep. We know that tablets, iPhones, anything with a backlit screen, and sunshine actually decrease melatonin production (a hormone that promotes sleep) and can shift your sleep-wake cycle. Basically, light promotes wakefulness and blocks sleep. Minimize it by turning off your iPhones, reading a real paperback book (no backlit kindles for you), and buying those blackout curtains you’ve always wanted.
  3. Avoid naps unless you’re in a situation where sufficient sleep cannot be obtained. Naps decrease the quality and increase the latency of sleep. The only justification for napping is if you’re unable to obtain sufficient sleep (i.e. you’re a long-haul airline pilot or a medical resident working a 24-hour shift). In that case, naps have been show to help mitigate the impact of sleep deprivation on mental performance.
  4. Moderate caffeine intake. Most sleep hygiene recommendations encourage people to limit their caffeine use overall, especially in the late afternoon and evening. Although logically you would expect decreasing caffeine would improve sleep, a study demonstrated that 100mg of caffeine (~ 1 cup of coffee) administered at bedtime had minimal effects of sleep. The take home? Keep your caffeine at around 300mg a day, don’t drink it all at night, and you’re probably okay. (Fun facts: 1) Caffeine is a potent blocker of adenosine receptors. Adenosine is produced throughout the course of a day and promotes sleep; caffeine blocks this promoting wakefulness.  2) Caffeine’s half life is 5 hours, meaning that that cup of coffee you drank this morning won’t be completely out of your system for almost 20 hours.)
  5. Limit alcohol for up to 6 hours before you go to sleep. Alcohol helps you go to sleep faster, but it makes the sleep you actually get less restorative by decreasing the amount of time you spend in REM. This effect has shown to persist for alcohol ingestion as much as 6 hours prior. Not a fun recommendation, but if sleep is your priority, limit the alcohol.
  6. Exercise because it’s good for you, but not right before bed. Exercise completed in the afternoon and early evening may increase the depth of your sleep, however exercise right before bed has been shown to prolong sleep latency. Exercise in the morning has not been shown to have an impact on sleep parameters.
  7. Take a hot bath before bedtime. Aside from providing relaxation for the mind, taking a warm bath prior to sleep can increase the depth of sleep. The mechanism may be due to the relationship between core-body temperature and the circadian rhythm. It’s thought that a steeper downward slope in core body temperature (i.e. cooling off after a hot bath) may aid in sleep promotion.

I hope this was informative! More information on evidence-based sleep hygiene can be found here and the caffeine content in most drinks here).

Go Outside, It’s Good for You

Everyone knows that spending time outside is “good for you,” but how many of us know exactly how much time we need to spend outside, or what type of outside areas (beaches, forests, or parks) would achieve the most health benefits?

As urban areas attempt to incorporate more green space (think the High Line in New York City), public health experts are attempting to nail down the characteristics of these areas that have the most population-wide benefit.  A recent study published in Nature examined the relationship between the duration of exposure to green space and public health outcomes such as mental health, physical health, and social health.

The study found that with 30 minutes per week spent in a green area people had reduced rates of depression. This was dose-dependent up to 1 hour and 15 minutes (meaning that increased durations were associated with decreased depression). The mental health benefits were present regardless of the intensity of the green space (i.e. low versus high vegetation complexity). This article estimated there would be a 7% reduction in depression prevalence for the population if every person achieved this minimum time.

The point here is short and sweet; get outside and spend some time in a green space (however you define it). It’s good for you!

Eagle's Nest

Photo taken during a time spent outside hiking in Topanga Canyon to Eagle Rock. Link to trail here, highly recommended!


As an aside, I found the idea that vegetation complexity could influence the magnitude of mental health benefits pretty fascinating. Apparently, vegetation complexity may mediate this through increased feelings of restoration (i.e. higher levels of plant, butterfly, and bird species richness have been shown to enhance a person’s feeling of restoration 1) and by possible parasympathetic nervous system activation (which lowers your blood pressure and heart rate) which may decrease your experience of stress 2. Other fun facts, “more people tend to visit public green spaces with moderate levels of vegetation cover (rather than high or low), and vegetation is also likely to influence the perception of safety of an area.” That’s enough nerdiness for today, until next time!