Articles 2 | Menlo Park Psychiatry & Sleep Medicine

Agitated Depression and the High Functioning Bipolar Rockstar (of Silicon Valley)

Everyone reads the words “bipolar disorder,” and immediately thinks this cannot possibly be a “disorder” that they have. And indeed, this terminology is a bit clinical for most high functioning people who let nothing slow them down and have moved mountains to get to where they are today. Think of bipolar disorder, and one immediately thinks of mania – shopping sprees, flights to Vegas, talking fast, euphoria, grandiosity, and launching the next big “unicorn startup,” of Silicon Valley.

Because of this classic view of mania, and its requirement for the diagnosis of bipolar disorder (per the DSM, “handbook,” of psychiatry), many people simply write this off as impossible. And most of the time they are right. Bipolar disorder is rare, affecting about 1 to maybe, 2.4% of the population. The challenge comes for people that do not clearly fit the bill for having had a manic or hypomanic (less than manic) episode. These people are left with a wide array of symptoms that no one diagnosis can explain and no standard treatment or therapy can “fix.” They are left thinking it’s their personality, their childhood, trauma, a medical condition, or even a “spiritual crisis” that just cannot be shaken off.

I have worked with several patients who had gone to the end of the earth seeking a solution. Besides countless therapists and psychiatric interventions, people have sought out ketamine therapy, LSD micro-dosing, Wym Hof breathing, ice-cold showers, ketogenic diets, silent retreats, and float tanks, to find peace. Often, to no avail.

But what exactly is the problem to begin with?

In most cases, the classic triad of symptoms I have seen is a combination of what looks like ADHD, insomnia, and severe anxiety. I call this the “bipolar trifecta” of symptoms, that when seen together, raise the possibility of more than just classic “depression and anxiety.” This is important because the treatment and understanding of one’s life is very different through a bipolar versus a depression/anxiety lens. Many subtle, unrelated things start to make sense. When it all comes together, it can be meaningful, life-changing, and offer a tremendous amount of hope, through enhanced self-awareness.

“But I’ve never been manic.”

Indeed, this is when the diagnosis is often complicated. When mania is obvious, the diagnosis is easy. Classic mania will present most fundamentally with decreased sleep and increased energy. Additional symptoms may include elevated mood, productivity, speed of movement and thinking, as well as grandiosity. An easy way to conceptualize bipolar disorder is essentially as an energy problem – too little, then too much, for longer than just a day (technically at least 4 days in a row for hypomania). It is important to realize, that not all energy, on the upside, is good. Excess energy can look like ADHD, scattered thoughts, intense moods, a feeling of adrenaline, and the irritability that happens when one is driving 100 miles per hour on a highway where everyone else is driving 55.

Agitated depression, like it sounds, can often look like a combination of really intense anxiety, low mood, along with insomnia. In most cases, where the diagnosis between anxiety and bipolar disorder is unclear, it helps to look for such episodes, along with other soft signs:

Brilliance
Childhood
Intensity
Family, relationships, and feelings
Obsessiveness
Paradoxical Anxiety
Drugs
Sleep
Satisfaction

Brilliance

Scary symptoms aside, it’s important to recognize just how amazing people with this condition can be. Bipolar disorder is truly a blessing and a curse, and some of the most brilliant and accomplished people in history are suspected to have bipolar. From Beethoven to Robin Williams, the passion, intensity, and brilliance of bipolar disorder cannot be overstated. Their intensity allows them to be visionary, passionate, persuasive, and effective. People with bipolar disorder are like lasers. Unfocused, they will burn themselves and everyone around them. When focused correctly, they can accomplish anything and are a gift to the world.

Childhood

Bipolar (ish) people tend to have quirky childhoods and come from quirky parents. A family history of anything severe (i.e., suicide, hospitalizations, ECT, legal problems, domestic violence, drug, and alcohol dependence) always raises flags. Note that for most of history, psychiatric conditions were never diagnosed, so I always ask if someone in the family has been “intensely eccentric.” Children may have periods of obsessive behavior, intense interests, and equally intense moods. Early hyper-sexuality, substance use, and inconsistent ADHD are sometimes seen, often with strong academics. A history of significant mood symptoms as a teenager (after puberty) is often also a meaningful flag of bipolarity.

Intensity

I often use the analogy that stressors in life are like speed bumps on a road. “Normal” people will go over a bump, get knocked around a bit, and get back to driving on the same road within a few days or weeks, depending on what happened. The driver with bipolar disorder hits the bump, and takes off, airborne. Intensity. People with bipolar disorder do not get upset, they get depressed. They do not get angry, they feel blood-boiling rage. They do not get anxious, they feel panic. They are not suspicious, they are paranoid. They do not think of a good idea, they think of the best idea, and want to share it with the world.

The moment can feel critical and they cannot wait. They do not feel happy, they feel excited, euphoric bliss, and sometimes even cosmic nirvana. Intense, rapidly shifting moods can occur. But the key point here is the intensity. In any direction, good or bad, this intensity is often a lot more than average. Unfortunately, most people don’t know what “average” is.

Family, relationships, and feelings

When you feel a lot, the people close to you may hurt your feelings. Why? Because they matter, and they know which buttons to push. In these cases, the buttons are both sensitive, and the people, reactive. I will often tell my patients that their ears are too big – that they feel and sense a lot more than is usual, and it can be truly challenging to manage such intense inputs. Many people I have worked with report distant and damaged relationships, estrangement from parents and siblings, or being embroiled in intense years-long family disputes without any contact.

“Microtrauma” can also occur, though in fairness, this may be seen in non-bipolar spectrum patients as well. This is often the result of someone with very sensitive feelings dealing with a challenging situation for an extended period of time. While there is no clear “traumatic event,” the combination of exquisite sensitivity and prolonged duress can be unforgettable for years. A difficult high school experience for one person can sometimes be a cause of PTSD for another. Depending on the sensitivity and reactivity of an individual, their intensity can amplify relatively “common,” stressors into the stratosphere.

Obsessiveness

A lot of people I have worked with through the years go on “crusades.” They get an idea in their head and just cannot let it go. They lose sleep, fixate, obsess, problem-solve, and ruminate. They take action, which can often be highly effective, and yet seemingly excessive to many people around them. It’s basically intensity, or excess energy applied to a target for weeks at a time. This is how symphonies get written and startups get launched. But it’s also a source of relationship, professional, and legal problems. This happens when you just can’t stop or let something go. Don Quixote comes up, with the image of a man on a horse, attacking windmills, which he perceives to be ferocious enemies. Overly determined, sometimes rooted in reality, but clearly gone too far. Friends may have commented, “you’re just too much sometimes.”

Paradoxical Anxiety

People with bipolar disorder are paradoxes, partly because of intensity applied in so many directions, they may *sometimes look like they have every possible psychiatric diagnosis. Most significant is the paradox of anxiety and risk-taking. “Normal” anxious people tend to be risk-averse, calculated, and even overly thoughtful. Bipolar(ish) people have what looks like a weird combination of anxiety along with impulsive, risky, or adrenaline-seeking behavior. They are nervous, yet they speed. They are careful, yet they might go sky diving. They are hyper-calculated and yet they are novelty-seeking. This ultimate paradox, of thoughtfulness along with maverick behavior, allows them to have brilliant and novel insights, along with the obsessiveness to execute and deliver.

Out of character behavior is often a hallmark. It’s the feeling of surprise when you learn that conservative “Tim, from accounting,” has been sleeping with escorts in his time off. Or when the most cautious, calculated CEO is found stealing money from the company. Certainly, these behaviors can be sociopathy or criminal to varying degrees, but in the context of all of the above (and below), it might be something else more biological.

Drugs

Whether prescribed or recreational, most people with bipolar disorder tend to learn over time, “one pill makes you larger, and one pill makes you small.” Varying episodes of drug use, with “uppers” as well as “downers,” at times can make people look like they have been abusing just about everything. Alcohol is just too readily available and many patients use alcohol to slow down and get some sleep when they are going too fast. Cannabis use is seen extensively, with patients smoking several times per hour, to slow down the thoughts and reduce the irritability, so they can interface with the rest of the world. Unfortunately, most forms of self-medication are just too short-lived to be effective. Opiates and pain medications are abused as well to “slow down.” Sleeping pills help with sleep. Stimulants help with getting out of bed during a state of depression and are also used to focus the scattered thoughts during a manic period. I’m always watchful of someone who looks “okay,” but needs a bunch of caffeine to get through the day and a handful of sleeping pills to sleep. These things help, but all too briefly.

They offer quick fixes that last an hour, or at best a night, but do nothing to fix the underlying problem. It’s like putting a Band-Aid on a broken leg or makeup on a bruise. Things might look cosmetically better, but the underlying issue persists. It’s also a terrible idea to self-medicate without external supervision and guidance. Just as dangerous as a surgeon operating on his or herself.

Sleep

Sleep is never right in someone with bipolar disorder. Part of the bipolar trifecta is sleep and insomnia. Sleep is a vital sign in my work as both a psychiatrist and a sleep doctor. Most of medicine has things that they can check and measure – ECGs, cholesterol, blood pressure. In psychiatry, it’s all self-report, and there’s a lot of recency bias. Yes, the way you felt this past week or even today may convince you that this is how the past month has been. Sleep is perhaps the only objective metric in psychiatry and the most essential restorative tool for the brain, affecting everything from mood to memory. If in doubt, look at sleep.

You might wonder if you’ve been more snappy or irritable than usual and not trust the opinions of those around you. How much sleep you are getting is not a matter of opinion. It’s a data point you can watch closely on your own these days, with whichever gadget you chose. Any period of decreased sleep and increased energy or productivity, or inability to sleep when given the chance to, is concerning. More so when it goes on for four days or more.

Patients with bipolar disorder will often report a chronic history of light, thin, or easily disturbed sleep. Trouble falling or staying asleep, waking before the alarm, being easily awoken, and generally being unable to nap when given a chance to. There is also evidence that between mood episodes, or during low moods, they can experience hypersomnia, which is being really sleepy or needing to sleep more than usual. If you remember anything from this article, remember to look at sleep.

Satisfaction

Perhaps why people with bipolar disorder can be so accomplished is because they are never quite happy. The enemy of good is better. Even in between mood states, intensity persists on some level. Patients will report vacillating between over-excitement and boredom, with the accompanying meaninglessness. As the human mind is a meaning-making machine, we will often try to find outside reasons to explain this inner unrest. A consequence of this is having a non-linear life path. Numerous changes in life, career, relationships, and even personal style and preference. Sometimes it feels as if patients have lived three separate lives by the time they are 40. A drummer in one, a flight instructor in another, and now working as a real estate investor. Successful and “crushing it,” in each role, but quite a surprising assortment of talents.

Hope

Hope begins with understanding and awareness. At a minimum, the awareness of one’s own intensity and how it compares to that of others. Also an awareness of the numerous disguises that intensity can wear, from rage to obsession, to brilliance. I will often advise my patients to “check their own temperature” at any given time, to know how much, how long, and why the adrenaline has been surging through their body. Tracking moods can be useful, but confusing when moods shift rapidly in a day – sometimes these intra-day shifts, or “shiftability,” are worth tracking.

Sleep. Again, as an essential vital sign of mental well-being, any ongoing insomnia or period of insufficient sleep (despite having the opportunity to do so) is important and should not be written off as “normal” or buried with sleeping pills. Exercise, the intense kind, helps too. Thirty to forty minutes, three to five times per week, can help brain health, and improve sleep and mood, by “blowing off steam.” And lastly rhythmicity, in all aspects of life, cannot be understated. Regular bed and wake times, work schedules, medication schedules, and exercise schedules, all help create a stabilizing rhythm which can counteract the underlying waves.

Getting Treatment

If the symptoms are enough to cause difficulty in any aspect of life – personal, professional, legal, etc., do consider seeking help. In this regard, suspecting the diagnosis is more than just anxiety or depression is of paramount importance. Why? Because most medications that are used for depression and anxiety (the SSRI’s, selective serotonin reuptake inhibitors), can actually worsen agitation in bipolar disorder. It’s like pouring gasoline on a fire. But this too should be taken with a grain of salt, as indeed some cases of soft bipolar are indeed anxiety and depression, which will improve on an antidepressant, like an SSRI. If in doubt, it helps to remain vigilant, and make sure sleep and anxiety get better, not worse with antidepressant treatment.

Therapy can also be beneficial in managing mood swings and protecting and maintaining relationships at work and at home. Like medication, however, therapy too is more useful when there is an accurate diagnosis, which captures the myriad of diverse symptoms bipolar can present with. Past trauma, losses, and current life stressors can all become significantly amplified during periods of agitation, which would otherwise be at bay. It helps to know when symptoms are biological, or psychological, for ideal therapy work.

The Question of Intensity for People with Bipolar Spectrum Disorder

The aim of this article is not to suggest that everyone has bipolar disorder. But like most things in nature, this may exist on a spectrum, and present to varying degrees in various people. Appropriately, most things in psychiatry are not considered to be a “problem,” until they impact our daily lives and ability to function. This is worth bearing in mind as we test when something is beyond normal and problematic.

Road rage once a year is less concerning than when it happens with every drive to work. It is also worth noting that the above findings are observational, based on patterns of patient experience, and not yet backed by research. There are existing, validated scales that can be used to screen for bipolar disorder.

The Bipolar Spectrum Diagnostic Scale (BSDS) developed by Dr. Nassir Ghaemi and the Mood Disorder Questionnaire are two excellent resources to start putting the symptoms of bipolar together.

One issue with both of these questionnaires is that, while they cover essential symptoms for the diagnosis of bipolar, they may miss the finer symptoms that are far less pathological, but very common and often missed or never connected as a whole. To this end, we are developing a “Rockstar Bipolar Questionnaire,” to shed light on the softer nuances of this condition (reviewed above). We plan to validate the Rockstar questionnaire in our practice and hope to share the questionnaire and outcomes soon.

In looking at the softer signs of bipolar disorder, we can learn a lot about various other psychiatric conditions, and also increase awareness of what is normal, what is “too much,” and what makes some people brilliant Rockstars.

How Much Sleep Do Teens Need?

When you look at your teenager, try to soften the lens and view him/her as an oversized toddler. We say this because the developmental changes taking place in a teen’s brain and body as the result of puberty are equivalent to the changes that take place as infants transition into toddlerhood. With that perspective, it’s easier to understand why teenagers need more sleep than they did just a year or two younger.

So just how much sleep do teens need? On average, teenagers need between nine- and 10-hours of sleep per night (the average is about 9.25 hours), but that varies from kid to kid. Keep in mind that things such as involvement in sports, academic drive, or teens experiencing a higher-level of stress or anxiety may require even more sleep to feel and perform their best.

Photo by Giftpundits.com from Pexels

Help Your Teenager Establish Healthy Sleep Patterns

One of the best ways you can support your teenager is to help him/her establish healthy sleep patterns. A synchronized circadian rhythm has a myriad of health benefits, including getting better sleep, being more alert and attentive in school, supporting healthy metabolism, and minimizing depression, moodiness, or irritability.

Here are some of the things you can do:

Understand their internal sleep rhythm

If you have a teen who is early-to-bed and early-to-rise by nature, lucky you! Most teens experience a shift in their circadian rhythm when they hit puberty, and won’t be sleepy until about two hours later than their previously scheduled bedtime. This is good to note if you have younger children because syncing their sleep times to 7:30 or 8:30pm means they’ll be ready for bed by 9:30 or 10:30 pm when they enter their teens.

Since most junior high and high schools start between 7:30 and 8:30 in the morning, this natural shifting of a teen’s circadian rhythm leaves most teens sleep deprived – they simply aren’t able to get the adequate amount of sleep they need each night.

This explains why so many teens can sleep for up to 12 hours or more on the weekends; they’re not lazy – they’re simply making up for all that lost sleep during the week.

Create a teen-relevant “bedtime routine”

The bedtime routine you created to help your baby, then toddler, then child calm down, relax, and fall asleep probably faded or ceased entirely when your son or daughter hit about 9-, 10- or 11-years old.

Now, it’s time to re-establish some sort of routine to help him/her get into bed early enough to get at least 8 hours – optimally 9 hours – of sleep each night.

Examples include:

Ceasing all screen activity at least 30-minutes before lights out (more on this below)
Creating a more relaxed and sleep-friendly atmosphere in the home for the 30-minutes or so before bedtime
Drinking herbal tea or warm milk or some other non-caffeinated, soothing beverage that signals “wind downtime”
Installing dimmer switches in main living areas and bedrooms so lights can be dimmed before bed
Taking a shower or bath
Playing relaxing music (if they’re up for it – some teens balk at his one)
Giving them a foot, back, or shoulder rub on the couch

The first week or two is the most important because once the routine is established, it creates an automatic response in the body; the brain and body establish that Steps 1, 2, 3…etc., mean it’s time to go to sleep, making it easier for your child to relax and drift easier into sleep.

Establish set bedtime & wake time

Rule #1 of any “how to get healthy sleep” guidelines is to establish set sleeping and waking times. Again, this is trickier for teens on the weekend. However, if you’ve stuck with it and created a system for weekdays, your teen will more naturally adhere to the same patterns on weekend nights at home.

Turn off screens at least 30 minutes before bedtime

It’s scientifically proven that the blue light emitted from TV, computer, gadget, and phone screens disrupt the brain’s natural melatonin cycles. That makes it notably harder to fall asleep – and stay asleep.

Everyone in the family should turn screens off at least 30 minutes before bedtime, and then dim the lights to mimic the setting of the sun. These two simple steps allow your brain to create the biochemistry required to facilitate sound sleep.

Read this article (as a family!) from Harvard Health about the dark side of blue light.

Don’t allow phones, gadgets, or computers in the bedroom

There are multiple reasons that go far beyond healthy sleep for why phones and other computer-like gadgets have no place in teenagers’ bedrooms – especially during sleep times.

Want some proof? Check out, Teenagers’ Sleep Quality & Mental Health at Risk Over Late-Night Mobile Phone Use.

Good ol’ fashioned alarm clocks (with red light digital displays) work just fine. You can be the best model of this by creating a set “charging station” in a common area where everyone docs their phones/tablets at night. This prevents your teen from countless social media alerts and the temptation of the phone during sleep time.

Do you or someone in your family suffer from insomnia or anxiety? Contact the compassionate team at Menlo Park Psychiatry & Sleep Medicine at 650-326-5888. We’re dedicated to treating any issue as part of a whole, and for finding the most natural and healthy, long-term solution(s).

Night and Day: The Essential Role of Sleep Medicine

Dr. Dimitriu was published in Psychology Today on the topic of The Essential Role of Sleep Medicine.

Sleep is truly the other half of our waking lives, as well as an essential half of modern psychiatry. During sleep, our brains recharge the neurotransmitters that are so important to our mood and thinking—dopamine, norepinephrine, and serotonin, to name a few. Training in both psychiatry and sleep medicine has allowed me a unique perspective on these two highly related fields of medicine, which, unfortunately, tend to be practiced in isolation of each other. Through this unique perspective, I have seen some truly remarkable breakthroughs in difficult, treatment-resistant cases. A careful analysis and understanding of sleep and sleep architecture has made this possible. “If there is no gas in the tank, you can’t push the gas pedal,” is something I often say to my clients, because indeed, if you are not well-rested and recharged, not much will work.

Click HERE for the full article.

Shocking Sleep Statistics

Sleep is truly the other half of our waking lives as well as an essential half of modern psychiatry.

During sleep, our brains re-charge the neurotransmitters that are so important to our mood and thinking – dopamine, norepinephrine, and serotonin to name a few. “If there is no gas in the tank, you can’t push the gas pedal,” is something I often say to my clients, because indeed, if you are not well-rested, recharged, not much will work.

This article points to the alarming sleep epidemic that we have seen over the past several years, where indeed, most of us, may not be getting enough sleep. The good news is that it is indeed an alarming article. A 2015 study of preindustrial societies, living without light, heat, wifi, and Netflix, show that sleeping 5.7 to 7.1 hours per night may actually be quite “normal,” and natural. The long lines at Starbucks, and marked increase in stimulant prescriptions, do point out, we could all sleep a little more.

If you tell people they can sleep 7 hours, they tend to sleep 6. So be alarmed.

When Sleep Won’t Come…Do You Need Help?

By Dr. Alex Dimitriu, July 11, 2019

We all have occasional trouble sleeping. Anxiety, jet lag, something we ate, or any number of other things can have us tossing and turning restlessly now and then. Most of the time, these episodes of sleeplessness are of brief duration and with resolution of the root cause we once again sleep for seven to nine hours a night. But for millions of Americans, a night of restorative sleep is elusive and with prolonged difficulty sleeping they suffer both immediate impairment to daytime functioning and long-term risks to health and cognitive function. Read more

Smiling Depression: Masking the Pain

Smiling depression isn’t an oxymoron. It’s a serious atypical manifestation of depression in which the sufferer masks typical depressive symptoms like sadness and lethargy with the outward appearance of a happy, successful, productive life. While approximately 10 percent of the U.S. population suffers from depression, not all sufferers experience it in the same way. Typically, depression is associated with a deep sense of sadness, despair, and lethargy, a figurative and sometimes literal inability to get out of bed that depletes energy and impacts all aspects of life. In contrast, someone living with smiling depression feels the same sadness inside but is able to function normally and present a facade of contentment and happiness to the outside world. Read more

Overcoming Insomnia Without Drugs

By Dr. Alex Dimitriu, March 12, 2019

Sleep isn’t optional. It is one of our most basic physiological needs, right up there with air, water, food, and shelter. It isn’t heroic to go without sleep and it isn’t true that many people need only four or five hours a night. Most of us need seven to nine hours. Critical functions needed to maintain life and health occur while we sleep and insufficient sleep doesn’t just cause daytime fatigue, irritability, and sleepiness but is associated with a broad range of health risks including heart disease, obesity, diabetes, and a weakened immune system. Sleep is a natural function and critical to our health yet millions of people struggle to get to sleep, stay asleep, and get sufficient restful, restorative sleep. Read more

Sleep Restriction Therapy for Insomnia: Can Spending Less Time in Bed Help You Sleep More?

By Dr. Alex Dimitriu, March 12, 2019

Insomniacs know all about good sleep hygiene. They’ve lowered the temperature in the bedroom, hung room-darkening shades, eliminated nicotine, caffeine, and liquids before bedtime, taken warm baths, and banished electronic devices from the bedroom. Many have tried prescription sleeping pills but were groggy the next day. Natural relaxation and sleep remedies may have been calming and soothing but otherwise unhelpful as regular nights of restful, restorative sleep have remained elusive. Trouble falling asleep or long periods of wakefulness during the night or too-early awakening or combinations of all three persist for millions of people. These sufferers from chronic insomnia may be candidates for a seemingly contradictory therapy known as “sleep restriction.” Read more

Natural Sleep Remedies: Do They Work?

By Dr. Alex Dimitriu, February 21, 2019

We all have occasional trouble sleeping. Stress, anxiety, a change in routine, something we ate, …any number of things might be responsible for a night of restless tossing and turning. For most of us, bouts of insomnia are of short duration. But for many millions of people, sleepless nights are a regular occurrence, as are the daytime sleepiness, irritability, impaired job performance, accidents, and health risks that follow. In search of a good night’s sleep, many are tempted by the quick fix of sleeping pills but while they can be effective in the short term, they don’t offer a long-term solution.

Sleeping pills come with troublesome side effects and most people quickly build up a tolerance to them and must take higher and higher doses to achieve the same effect. No wonder many ask if natural, herb-based sleep remedies might be a better choice. They may be but your first order of business should be to develop better sleep habits and make lifestyle changes that are conducive to better sleep. If you still feel you need help, a natural sleep remedy might be useful, particularly in helping you relax at bedtime. Here are some suggestions that will help you achieve restful sleep. Read more

Coping with Agitated Depression and “Rockstar” Histories

Millions of people experience episodes of depression every year, making it one of our most common mental disorders. Although its symptoms may look similar, clinical depression differs in its intensity and duration from the ordinary sadness that we all experience from time to time. Sadness triggered by a loss, disappointment, or a major life change is typically short-lived, fading over time as we adjust to new situations. Clinical depression, also known as major depressive disorder, can be precipitated by a specific event but can also result from a change in brain chemistry that makes it difficult to maintain mood stability. Depression is a long-lasting, serious medical condition that must be diagnosed and treated by a medical professional. Read more

Reducing Anti-Anxiety Medications : Risks and Rewards

By Alex Dimitriu, MD, January 22, 2019

With anxiety disorders ranking as the most common mental illness in the United States – affecting 18% of the adult population every year – perhaps it’s not surprising that more than 1 in 10 Americans take antidepressants, the class of medications used most often to combat anxiety. Read more

Is There a Place for CBD in Treating Insomnia?

By: Alex Dimitriu, MD, January 6, 2019

With the rise in states legalizing the use of both medicinal and recreational marijuana, more attention is now being given to a component of the cannabis plant that’s been scrutinized for decades – CBD, or cannabidiol. But far from seeking a “high,” many of those giving fresh consideration to using CBD – available in supplement form and legal in all 50 states – are pursuing another elusive benefit: a good night’s sleep. Read more

Overcoming the Stigma of Psychiatric Medication

By Dr. Alex Dimitriu, 12/20/18

Even as the stigma associated with mental illness has – thankfully – dissipated over the last decade, millions of people still fail to get the help they need because the stigma around the medication that can alleviate their suffering endures. Fueled in part by celebrities talking about their struggles with depression, anxiety, and other conditions, openness about mental illness has become more acceptable. But even as people find understanding and support for their illness, they are also subject to a host of unhelpful and stigmatizing attitudes about medication, ranging from the implication that they’re just not trying hard enough to overcome their condition, to the recommendation that all they need is a certain diet, or exercise, or meditation, to the assumption that the cure for what ails them is as simple as taking a pill. Unfortunately, these attitudes are often internalized by the very people who could benefit from psychiatric medication and prevent them from seeking treatment.

The use of psychiatric medications, also known as psychotropics, has grown significantly in recent years. Various studies have estimated that 10% of American adults had taken an anti-depressant, anti-anxiety, or anti-psychotic drug in the previous thirty days and that as many as 17% filled a prescription for a psychiatric medication in the previous year. The growing usage of these drugs has led to widely shared and incorrect attitudes. At the same time, that many people see the use of psychiatric medication as a weakness or a failing on the part of the patient, others downplay the struggle of overcoming mental illness because ‘there’s a pill for that. It’s important to dispel misconceptions about mental illness and the best way to treat it.

Many years of research and clinical experience have proven that the best outcomes for those suffering from mental illness result from a comprehensive approach that combines a medically crafted and supervised regimen of psychiatric medication with psychotherapy. Medication and psychotherapy work together. By relieving severe symptoms, medication gives patients the clarity and stability that enable them to benefit from psychotherapy that can address emotional and behavioral issues and bring about the changes needed. Medication treats the physical aspects of mental illness, managing the levels of certain chemicals in the brain just as a statin manages levels of cholesterol in the blood. Taking medication for mental health is no different than taking it for physical health. With chemical imbalances in the brain under control, the patient is free to work on improving behavioral and emotional imbalances.

Common misconceptions that stigmatize psychiatric medication:

“Isn’t medication a crutch for people who are too weak to manage their problems?” A psychotropic medication relieves the symptoms of a medical disorder. It is no more an indication of weakness than taking medication for high blood pressure. Stigmatizing the taking of medication as a weakness implies that if the patient would just get it together and work harder, medication wouldn’t be necessary. This is akin to advising someone with high blood pressure to just relax. In fact, it takes strength to recognize that you have an illness that can be helped with medication and that you need to use every tool available to take care of yourself.

“Won’t a psychiatric medication change my personality, dull my senses, turn me into a zombie?” There is nothing more destructive to a person’s sense of self, to the unique characteristics that define a personality than a mental illness. Motivation, concentration, even the ability to get out of bed, are often gone. Medication can alleviate the symptoms of illness that sap energy and impair functioning and restore a sense of self. That said, some medications do have troublesome side effects, and the same drug can affect people differently. The medication that works for one person might not be tolerated well by another. That’s why we sometimes have to try several medications until we find the one that works.

“Is medication masking my problem rather than fixing it? Is it just a temporary solution, a quick fix?” Psychiatric medication is not a miracle cure. It doesn’t produce an instant change in mood. It takes a while for the drugs to build up in the system and causes a gradual change that alleviates symptoms enough to improve functioning and enable getting the therapy that will help over the longer term.

Psychiatric medication has helped countless people reclaim their lives. It is an important support for the journey to well-being, not an easy way out. And taking every step necessary to get well is nothing to be ashamed of. Bringing medication out of the shadows will overcome the stigma associated with it and encourage millions of people to get the help they need.

Alex Dimitriu, MD, is founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, CA. He is dual board-certified in psychiatry and sleep medicine.

Anxiety Disorders: When to Worry about Anxiety

By Dr. Alex Dimitriu, 12/13/18

We all worry. Occasional anxiety is part of everyday life –- an upcoming test, a job interview, a troubled relationship –- and anxiety may have a beneficial effect, helping us focus and problem-solve by studying for the test, preparing for the interview, or working on the relationship. But for millions of people, anxiety is excessive, disproportionate to the situation, generalized, and impossible to alleviate or control. Anxiety disorders are the most prevalent mental disorders and take an enormous toll. Read more

Combining Insomnia, Depression Treatment May Improve Outcome By Lynne Lamberg

In people with both depression and insomnia, determining which disorder surfaced first may be key to improving clinical care.

Studying the timing of emergence of symptoms in people with both depression and insomnia may help identify differences in patients’ clinical presentation and aid treatment decisions, according to experts at the joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Baltimore in June.

Insomnia is both a risk factor for depression and a symptom of depression, noted Rachel Manber, Ph.D., a professor of psychiatry and behavioral sciences at Stanford University School of Medicine.

Manber reported preliminary findings from the multisite Treatment of Insomnia and Depression (TRIAD) clinical trial, for which she is the principal investigator.

TRIAD, funded by the National Institute of Mental Health, seeks to determine whether combined treatment of major depressive disorder and insomnia improves depression outcome.

Started in 2008, TRIAD has enrolled about 150 participants, Manber told Psychiatric News. Recruitment recently concluded. Treatment will continue through the end of this year at Stanford, Duke University, and the University of Pittsburgh.

Participants receive 16 weeks of treatment with the antidepressants citalopram, sertraline, or desvenlafaxine. Choice of medication is based on the individual’s previous medication use, response, and tolerance. Participants also receive either cognitive-behavioral therapy for insomnia (CBTI) or desensitization psychotherapy for insomnia.

A pilot study, published by Manber and colleagues in the journal Sleep in April 2008, found that augmenting an antidepressant medication with brief, symptom-focused CBTI helped alleviate both depression and insomnia in individuals with both disorders.

About half the TRIAD participants reported at baseline that their insomnia started before their current depressive episode, Manber said. The remainder said their insomnia started at the same time as their depression or afterward. Members of both groups reported comparable severity of insomnia and depression.

In the first group, Manber said, insomnia may be independent of depression and require separate treatment.

If insomnia has emerged as a symptom of depression, she added, one might expect that treating the depression adequately will prompt the insomnia to resolve. While that often occurs, insomnia persists in some patients even after the depression remits. People who toss and turn often come to view the bed as a cue for poor sleep, she noted, and develop an insomnia disorder that needs additional sleep-focused treatment.

TRIAD participants who reported having insomnia before they experienced depression had higher scores on the Childhood Trauma Questionnaire, indicating childhood adversity such as sexual or other physical abuse. This surprising finding, Manber said, raises the possibility that events that disrupt sleep in childhood may foster both insomnia and depression later on.

In another report on TRIAD findings at the sleep meetings, Andrew Krystal, M.D., a professor of psychiatry and behavioral sciences at Duke University School of Medicine, analyzed participants’ responses to the Ford Insomnia in Response to Stress Test (FIRST).

The FIRST asks respondents about their likelihood of sleeping poorly after a bad day at work or an argument, before leaving on vacation, and in other situations. It assesses trait-like vulnerability to developing insomnia under stress.

“We were attempting to test a bias in the field that is not empirically based,” Krystal said, “that insomnia occurring in people with depression is driven by the depression and that there is a diminished etiologic role of factors that precipitate and/or perpetuate insomnia where depression or other conditions are not present.

“Our analysis appears to speak against that bias,” he said. It suggests that the same factors that seem to precipitate and/or perpetuate primary insomnia—which include dysfunctional beliefs and attitudes about sleep, worrying about sleep, stress, and anxiety—play a comparable role in insomnia that develops in people with depression.

The findings, he said, provide the first evidence that there is a trait vulnerability to developing insomnia under stress among at least some patients with major depression, similar to that in people with primary insomnia.