“A study done late last year delivered a black eye to ketamine, and as a result of the coverage, there was a wholesale acceptance by both potential patients and physicians that ketamine is an opioid,” says Adam Kaplin, Assistant Pofessor of Pychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. “This is most worrisome if people continue to think this way, particularly in the wake of the opioid epidemic; clinicians won’t refer patients for a treatment, despite that it has been shown to be incredibly effective for many patients with treatment-resistant depression.”
In late 2018, researchers at Stanford University and Palo Alto University showed that naltrexone—a drug used to reverse accidental opioid overdoses by binding to opioid receptors in the brain—also blocks the antidepressant effects of ketamine, which led them to propose that ketamine must also bind to the same opioid receptors and thus concluded that ketamine must be an opioid. Kaplin says that there’s plenty of contrary evidence demonstrating that ketamine sticks to an entirely different receptor on brain cells: NMDA receptors, which are involved in learning and memory.
These NMDA receptors are found together with the opioid receptors on brain cells, and Kaplin says it’s no surprise that their components can meddle with one another, like interference picked up on a phone call or on the radio. “This interference and cross-talk does not mean that ketamine is an opioid, and to wrongly label it as such could eventually keep patients from essential antidepressant medications that could make a huge difference in their quality of life,” says Kaplin.
In March of this year, the U.S. Food and Drug Administration approved ketamine as a nasal spray to treat depression, specifying that ketamine is to be administered under the watch of physicians in small doses and in a health care setting to minimize any chance of abuse. The drug works much faster than other traditional antidepressants on the market, sometimes even after one or two uses.
Kaplin and his team are in the process of setting up their own ketamine clinic at Johns Hopkins, which they anticipate will be opening within the next year.
As I think about what to write today, my thoughts are filled with a comment I received from a man who’d read last week’s blog, which you can read here. He wrote that he also suffers from bipolar 1 disorder and was upset and hurt by the description of the young man in the story who showed signs of violence. For him, a description like the one I wrote perpetuates stigma because it portrays someone suffering from a psychiatric disorder as a “dangerous” person.
Pause. Deep breath here. Not what I intended.
My concerned reader made the point that he takes medication to manage his symptoms and works hard to keep them from dominating his life. He emphasized that he had never thrown a lamp or a table (like the young man I’d described) … which is often the case. Most of the time, mood dysregulation is not accompanied by physical explosiveness or violence. He was right.
And he felt that last week’s blog misrepresented him and others like him.
It was heartbreaking to me that this reader felt hurt by my story. I never want to cause pain to anyone with my writing. But it can be hard to prevent. My readers come from a wide variety of backgrounds and experiences. My practice, on the other hand, consists primarily of the most ill, treatment-resistant patients for whom medications have failed.
So today, I want to go a little deeper and talk about stigma and the damage it causes.
And I want to explain why I write the accounts I do of severely ill patients and how they suffer.
The Pain and Marginalizing of Stigma
So what is stigma anyway?
We get the word “stigma” from the ancient Greeks, who used it to describe a mark made on the body that signaled to others to avoid or shun the bearer of the mark. And, we use it the same way today. Except in our present culture there’s no need for a mark on the body… with our words we make a mark on the soul.
Stigma creates shame, disgrace, humiliation…and the bad reputation that goes with certain things in our society. It’s associated with anything in someone’s life that labels them. A label that results in judging someone by the label rather than on their own merits.
Labels like this separate people from the group just as lepers were separated from the city in ancient times.
An example might be the experience of prison. When someone breaks the law and is sentenced to prison, that label hangs over them, as much within themselves as from the outside. This person might feel they’re “less than” others, that they deserve less respect. And they’ll almost certainly run into narrow minded people who will hold that fact from their past over them… impose upon them the pain and marginalizing of stigma to bring them shame and humiliation.
But the fact is, that some of those who spend time in prison continue a lawless lifestyle and others use the opportunity to improve their lives and accomplish great things. Still, it’s fair to say that improvement isn’t easily won. That person has to work very hard to rise above the experiences from his or her past.
Another example of stigma seems to accompany psychiatric disorders. There are those in our society who still associate the need for psychiatric treatment as a sign of weakness, “craziness,” and/or questionable character.
Working to Reduce Stigma and Increase Enlightenment
As we work to reduce stigma, and open conversations about brain disorders, behavior disorders, and the medications we use to manage them, we have to look honestly at individuals, and who they are. And we need to try to understand each other.
Because not all diabetics are alike. Not all the people with bipolar disorder are alike. Not all the people with PTSD are alike. Each one is an individual — with their own unique needs, symptoms, challenges, and vulnerabilities.
Most of us know someone who suffers from diabetes, either Type 1 or Type 2. There is some amount of stigma associated with diabetes. If you’re well informed about this condition, you know that while diet and exercise can help improve the condition for people with Type 2 diabetes, there is nothing someone with Type 1 can do to make this condition go away.
It’s pretty short-sighted of anyone who tells a person who suffers from this disease that they just need to stop being so sloppy about how they take care of themselves.
While it’s true that diet and exercise can improve their control of symptoms, it’s a disease that progresses and is not preventable.
Words can cut deeply … and we never really know the story that people keep hidden in their hearts.
In both cases, diet and exercise help in its management, but that’s true in a wide variety of illnesses. People with coronary artery disease, arthritis, hypertension, asthma, obesity, as well as depression, bipolar disorder, PTSD, and more…all can enjoy improved symptoms through diet and exercise. Improvement. Not cure.
The cruelty of stigma lies in the cutting words and attitudes the “unenlightened” use to build a box around an individual without knowing his story.
But what we DON’T want to do is marginalize individuals no matter what their experience is.
And just what do I mean by “marginalize” exactly? I mean that I don’t want anyone to feel shut out, alienated, trivialized, or ignored in any way by my words or actions. Whether you use all your strength to hold your symptoms under control or whether your medication helps you do that, your experience is important. You are important. And you matter.
When someone suffers from one of these disorders, but has no outward symptoms — because of medication or their own unique disease process — they can feel blocked out and unheard…misunderstood and not represented.
(By the same token, if you only know someone who takes medication that’s working, and never has any symptoms that show, it’s super easy to think that people with psych disorders should have their symptoms under control. Nothing should show.)
Maybe you know someone with kidney disease who looks and acts like anyone else. And maybe I know someone with kidney disease who is thin, pale, with only patches of hair. When I meet your friend I may believe there is no way your friend is ill. And you may believe that my friend has something much worse than kidney disease because she looks so terribly ill.
But in fact, they both have the same disease but it differs in severity.
Why Assume Everyone’s the SAME?
This is the case with disorders that are related to the brain. Why is a disorder more severe in one person than another? I don’t know. I may know some factors that could affect its severity, but I don’t know why one person has bipolar I disorder and another has bipolar II, or a third person has cyclothymic disorder.
None of these three got off scot-free. They all suffer.
And why does one person respond to medication and another doesn’t? If I knew the answer to that, I’d go on vacation more often! These are questions I’ve been studying to find answers to all the years I’ve been a psychiatrist.
For those who respond to medications, I’m very glad and thankful. For those who don’t, I search and read and research and seek hope for those patients. And when I write about people with severe cases of their illness, it’s to show others who suffer in this way that they aren’t forgotten. That there is no shame in their symptoms. Because in their case, the medicines aren’t working. And the symptoms run rampant.
It can be devastating.
Don’t Misinterpret Symptoms: Hollywood vs. Reality
And I want to add –quickly– that a table or chair that is flung out the window is not necessarily a sign of danger to others. It signals dysregulation, sure, and warrants a very careful assessment. Because often, even someone who is markedly dysregulated can draw the line between hurling an inanimate object and hurting another person.
Hollywood has a way of exploiting the human suffering of mental health problems, to intensify fear. That’s Hollywood. Get to know individuals and take note of how they differ from what you see on the big screen.
Coronary Artery Disease
One of my neighbors has coronary artery disease. He took medications, but eventually had to have open heart surgery. Does that mean that everyone with coronary artery disease needs open heart surgery?
No. In fact, I have a relative who has coronary artery disease, who manages to live a full life with medicines, diet, and exercise and has never needed surgery.
Words can be so hurtful even when they’re not intended to be. We’ve all done it. Without realizing someone’s personal story we tell the story of someone else that’s too close to their own…and it sounds to them like we’re judging them.
Pain and Marginalizing of Stigma… is Cruel
By the same token, when a treatment or clinic pops up that seems to promise a world of wonder to everyone, (which nothing can do, by the way), people can feel trivialized and ignored. Because they may not fit in that “slot” for a variety of reasons.
Let’s put up our antennas and notice when the pain and marginalizing of stigma has someone walled off from the world. Alone. Isolated.
Psychiatric disorders marginalize people, and we marginalize them, too. Every doc-in-a-box or one-size-fits-all protocol marginalizes your individual experience of suffering by suggesting there is a panacea.
Of course, there’s no universal cure, but there IS hope in a jar. Remember that story?
That was the story of ketamine treatment as a medicine prescribed “off label” because of its unique healing abilities in addition to the purpose it was FDA-approved for.
One Size Fits Some
ONE SIZE DOES NOT FIT ALL. Each patient needs to be custom treated for his own individual version of disorders. Each person also needs to be ACCEPTED and supported for who he is, and what he manages in life.
Let’s vanquish the pain and marginalizing of stigma. Let’s stop leaving people isolated in their suffering. And let’s look people in the eye and seek to understand their struggles.
If you don’t know what he manages, ask him. Let’s try harder to get to know each other, and respect each human for the life he or she manages.
And you know what? If you suffer greatly, or if your struggles are partially managed by medication, I want to hear from you. Not that I can solve your challenges, but you matter to me. And you matter to a lot more people than you may be aware. You are included here. And your experience can help someone else feel less alone in the world. Please share your comments below.
Ketamine has gotten a bad rap as an opioid when there’s plenty of evidence suggesting it isn’t one, Johns Hopkins experts say. They believe this reputation may hamper patients from getting necessary treatment for the kinds of depression that don’t respond to typical antidepressants.
In a new paper, the researchers clarify the mechanism behind ketamine’s mechanism of action in hopes of restoring the therapy’s standing among health care professionals and the public.
In March of this year, the U.S. Food and Drug Administration approved ketamine as a nasal spray to treat depression.
A study done late last year delivered a black eye to ketamine, and as a result of the coverage, there was a wholesale acceptance by both potential patients and physicians that ketamine is an opioid. This is most worrisome if people continue to think this way, particularly in the wake of the opioid epidemic; clinicians won’t refer patients for treatment, despite that it has been shown to be incredibly effective for many patients with treatment-resistant depression.”
Adam Kaplin, M.D., Ph.D., Assistant Professor of Psychiatry and Behavioral Sciences at The Johns Hopkins University School of Medicine
The researchers published their viewpoint and explanation of the alternative mechanism as a Letter to the Editor in the May 1 issue of The American Journal of Psychiatry.
Naltrexone — the drug used to reverse accidental opioid overdoses — binds to opioid receptors on the surface of brain cells and prevents opioids like morphine or heroin from sticking to them and acting on the brain, preventing the high.
In late 2018, researchers at Stanford University and Palo Alto University showed that naltrexone also blocks the antidepressant effects of ketamine, which led them to propose that ketamine must also bind to the same opioid receptors and thus concluded that ketamine must be an opioid. Kaplin says that there’s plenty of contrary evidence demonstrating that ketamine sticks to an entirely different receptor on brain cells: the NMDA receptors — involved in learning and memory — instead of the opioid receptors.
He proposes how this works:
Normally, NMDA receptors get turned on when the chemical messenger glutamate binds to them. Turning on the NMDA receptors turns off a master control switch in the cell called mTOR, which ultimately results in learning a behavior or forming a new memory.
Ketamine can also bind to the NMDA receptors, but it has the opposite effect of glutamate, in that it turns these receptors off. Turning off the NMDA receptors turns on the master control switch mTOR, which is required for ketamine’s antidepressant properties.
Separately, says Kaplin, opioid receptors are normally turned on at low-levels all the time, even without opioids to turn them on all the way. This low activity of the opioid receptors normally suppresses the level of another chemical messenger called cyclic AMP (cAMP). When the overdose drug naltrexone is administered, it sticks to the opioid receptors, turning them completely off, which releases the brakes on cAMP.
This increase in cAMP is what then interferes with the master switch mTOR, shutting it down. When ketamine is taken, it turns on the master switch mTOR to enable antidepressant effects, [emphasis mine] but if naltrexone is given on top of that, naltrexone obstructs and shuts off the mTOR again. It is through cAMP that naltrexone overrides and extinguishes the antidepressant effects of ketamine.
These NMDA receptors are found together with the opioid receptors on brain cells, and Kaplin says it’s no surprise that their components can meddle with one another, like interference picked up on a phone call or on the radio.
This interference and cross-talk does not mean that ketamine is an opioid, and to wrongly label it as such could eventually keep patients from essential antidepressant medications that could make a huge difference in their quality of life.”
Adam Kaplin, MD, Ph.D
The FDA specified that ketamine is to be administered under the watch of physicians in small doses and in a health care setting to minimize any chance of abuse. The drug works much faster than other traditional antidepressants on the market, sometimes even after one or two uses.
Kaplin and his team are in the process of setting up their own ketamine clinic at Johns Hopkins, which they anticipate will be opening within the next year.
Mike Wang was also an author on the paper.
Wang and Kaplin received grant funding from Janssen.
Kaplin is the co-founder of Reward Pathways and a consultant for Biogen, EMD Serono and Pear Therapeutics.
Wang, B. & Kaplin, A. (2019) Explaining Naltrexone’s Interference With Ketamine’s Antidepressant Effect. The American Journal of Psychiatry. doi.org/10.1176/appi.ajp.2019.19010044
“I don’t care what the &%@!* you think!! It’s all your fault!! I’m outta here!!!”
With that, Ben picked up the massive carved oak coffee table and threw it at the window. It hit the window and the wall with a thud, pushing the window frame in a contorted mangle of metal and glass out toward the garden, knocking a gash into the wall with the impact. Families that are suffering together with psychiatric disorders know this scene so well…
The table fell to the floor, unaffected by its collision, except for a few paint scrapes off the wall. The wall, however, didn’t do so well.
By then, Ben had already grabbed a china lamp and slung it toward another window. The shattering glass of the window and the shattering china in the lamp base formed a tinkling wind-chimes sort of symphony as they fell.
Ben beat his face with both fists, cursing his life.
Suffering Together
Little 6-year-old Sara shrank back into the shadows of the hallway. She knew not to cross her big brother at times like this. He was her hero and had been her best friend ever since she was born. He was kind, patient and included her even though he was 7 years older.
It scared her when he got like this, but she also instinctively knew he just couldn’t help it. She knew he’d probably cry again after this rage subsided, because he felt so helpless to control it and so sad about hurting the family.
She slipped back into her room and quietly closed the door to play with her dolls…and try to not hear what was happening.
Then her mom’s gentle voice sounded soothing and reassuring. She was helping him calm down, like she had so many times before. After 30 minutes or so (it was hard to tell time, but especially when every second seems like an eternity…) she heard Ben trying to talk through sobs… she knew what he was probably saying, and she wanted to go hug him. But she thought it was better to let mom do that right now. He might be embarrassed to know she heard all of that.
Each One Copes in His Own Way
Sara felt confident the “storm” had passed, but then the front door slammed so hard the house seemed to crack. She quietly opened her door to look and listen. Ben and Mom were talking in low tones in the living room…but she could see her older brother’s door was open.
Ohhhhh. I guess Ben’s episode made Gregory mad again. (Huge sigh) I wish everyone could just be happy. We must be the only family that goes through this..
Out of nowhere Scruffy, their mixed breed little dog, scooted between Sara’s legs and into her room for safety. She picked him up, and could feel him trembling…
Hugging Scruffy close to her, Sara withdrew back into her room and ever-so-quietly closed the door.
Quiet Distractions Provide Solace
She set up a tea party in her closet where it would be extra quiet… and brought in Baby Alive and Jenna to share it with her. hmmm….we need one more, she thought. She reached under her bed and pulled out Timothy, her cream-colored teddy bear…and took him into the “tea room” in her closet floor. With the light turned on, she pulled her closet door shut.
Shame Torments
Ben had stopped sobbing by now…and was looking at his feet. It’s never going to stop, he thought. What’s wrong with me?? I always ruin everything. I’m the black sheep of this family.
Why can’t I be like everyone else…? I’m so worthless, stupid, bad, and rotten to the core. I should never have been born…I’ll probably end up being a criminal…
“Whatcha thinking, Ben?” Ben’s mom waited patiently for Ben to gather his thoughts.
While Ben was searching for words, the front door opened.
Learning to Support Each Other In the Family
His dad was home from work. Ben tried to look pleasant.
“Hi Dad…”
“What’s going on…? Has something happened…?” Ben’s dad spotted the bashed windows and looked worried. Then his eyes fell on Ben’s swollen red face. Ben felt humiliated and didn’t know what to say.
“Hi Bill. How was your day?” Ben’s mom hated to bombard him with the latest family crisis when he’d just walked in from a stressful day. And she also hoped to give Ben a break from his dad’s scrutiny.
“It was fine, Lil. Is everything ok?”
The air in the room hung heavy with tension. But they were a family, and they needed to face times like these together, so Lily spoke up.
“Everything’s fine, honey. Ben had another episode today. It was terrible for him…well, for all of us. He’s feeling pretty discouraged right now. We were talking about what we could do to find a doctor that might help more than Dr. Mendolssohn has. Someone maybe who specializes in adolescent bipolar disorder?”
Ben focused on the pet hair on the rug. Bill nodded and stared at his feet, hands in his pockets. Lily stroked the sofa cushion. When a family is suffering together with psychiatric disorders…well, each one harbors his own secret pain.
A big part of that pain is helplessness.
Bill spoke first. “I noticed the car is gone…did Gregory leave?”
Ben sighed. Lily nodded.
“And Sara…?”
The NON-Squeaky Wheel Needs Attention, Too
Lily sprang up from the sofa and headed for Sara’s room. Her little girl had been so quiet…and with all the turmoil, she forgot to check on her. Guilt swelled up and threatened to choke her.
Tap, tap, tap. “Sara? May I come in please?” Lily tried to sound cheerful.
Tap-Tap-Tap. “Sara?”
Lily opened the door and didn’t see Sara.
“Sara??”
A tiny muffled voice squeaked, “yes, Mom?”
Lily got down on her knees and looked under the bed. Nothing.
She looked on the other side of Sara’s bed. Nothing but a couple stuffed animals.
“Sara? Where are you?”
The closet door opened. Sara’s hair was disheveled and the rims of her eyes were red. She’d been crying. Lily rushed over to her and swooped her up in a hug.
“Whatcha doing in your closet..?”
“Tea party…”
“Wanna help me cook supper?”
“Yeah!”
She swung Sara onto her hip and off they went to the kitchen, chattering about the tea party.
With Psychiatric Disorders, Symptoms Can Look Like Bad Behavior
Bill was sitting with Ben, helping him with his algebra homework. He knew a lecture about behavior wasn’t what Ben needed. He needed acceptance and support. Bill had made plenty of mistakes while he learned how to provide what his family needed in times like this.
So.
Another day. Once again they’d survived another major bump in the road. Tomorrow they’d call the insurance company about the damaged windows. But for now, they were thankful for peace.
He and Lily did their best to try to help Ben’s self-image remain strong…though they knew all too well that their best efforts might not be enough. They also tried to be sure Gregory had their time, support, and attention, too. It was easy in this household to be overlooked.
They were learning to avoid reacting with even more conflict or criticism. But rather to choose words and tone that soothed. Everyone needed it. And they believed their reactions were improving.
Family: Suffering Together with Psychiatric Disorders
Which brings up little Sara. They worked hard to try to protect her innocence and sweetness. But they couldn’t protect her from the frequent upheavals in her own home.
They also knew they had to be sure to communicate and make time for their relationship with each other. That was usually the first to be sacrificed.
Most of the time they were both stretched pretty thin.
No matter what the condition, and whether it’s you or someone else, a family with a psychiatric disorder suffers together, feels helpless together, gets frustrated together… no one escapes.
And while it’s easy to blame, that doesn’t accomplish much, does it? It just makes the wounds infect.
When it gets right down to it, there is likely some genetic connection that links you all to the disorder. In this family, Ben drew the short straw. And bears the stigma.
But just as Bill isn’t to blame for the high blood pressure he inherited from his grandmother, and Lily isn’t to blame for her kidney stones, Ben inherited the tendency to develop his condition before he was ever born.
To try to manage his blood pressure, Bill either jogs or takes a brisk walk every night after work while Lily cooks dinner. Lily is careful to stay hydrated to avoid more stones. Ben tries to get out and play football in the afternoons and they work together to see that he eats balanced meals and gets to bed early. And they all take medication for these health problems.
When The Brain is Disordered, It Can Be Hard to Maintain Order At All
Not just for the person with the condition, but everyone close to him, too.
So don’t be fooled. The family tries to maintain these routines, but that’s not as easy as it sounds. It takes a concerted effort, and they try to support each other and understand when things don’t go as planned. Because, when a family is suffering together with psychiatric disorders, everything is more complicated, it seems.
Families like this have plenty of bad days. More days than they care to admit actually… where all the opportunities to manage their collective health slip through their fingers.
But they do try. And when things fall apart, they help each other get up and try again. Or at least they try to. Sometimes everyone just gets sick and tired of it all. So they retreat into their corners to recover a bit, then come together and face their life together again. At least that’s their intention.
Life Is Challenging on Some Level for Us All
If you don’t have a person in your family who has a health condition, maybe things go smoothly for you…? But I bet they don’t go as smoothly as you wish. Nobody’s life is perfect.
Still, if you do have one or more family members who endure chronic illness, (the genetics often strike multiple times in a family) you probably feel like no one can imagine what it’s like. You likely feel isolated and alone. Maybe you feel embarrassed, because your life isn’t perfect. And you’re right to some degree. No one knows what it’s like to live your life. But you don’t know what it’s like to live someone else’s either.
I can say this however… that if your family suffers with a member who has a brain or behavior disorder, we know it impacts the whole family. And our hearts are with you.
Is Your Outpost Suffering Together with Psychiatric Disorders?
Family is our most important outpost of support. No matter what the challenges a family faces, they don’t manage them well all the time. In fact, it’s fair to say there are LOTS of times the whole family seems to implode.
Some families have financial struggles. Other families have marriage struggles. And still other families have health struggles. But whatever the challenges, pulling together is the best way for everyone to come out in the best shape possible.
But then, that’s life, isn’t it?
It’s for you we work at Innovative Psychiatry to find better solutions, more effective treatments, and the compassion and support you need. And we’ve found extraordinary results for families like yours with ketamine treatment. You may have a family member with bipolar disorder, major depression, or PTSD. If so, call us.
She just might be a candidate for IV ketamine treatment. That also goes for social anxiety, addictions…and of course suicidal thoughts. ALWAYS take suicidal thoughts seriously. And let us help.
But don’t forget to take note of other family members who may be suffering in addition. They may need treatment, too, so they have the energy to conquer the days, weeks, and months of stress at home.
There is help available for your family. To feel better, with restored hope, and more harmony.
Know someone who’s suicidal? Or…how about this? Do you know someone you think might be?
Is there someone in your life who’s always down, irritable, short-tempered… even jumpy, maybe? Maybe you wish they’d adjust their attitude, or take a chill pill. Sometimes, people can be like this and the problem is that they might be depressed. Or they may suffer from PTSD and even be suicidal. There are some researchers at Yale who are trying to identify biomarkers for PTSD and suicidal thinking. More about that in a moment, but first let’s talk about PTSD.
Some 8% of people will meet criteria for PTSD at some point in their lives. Those who have fought in active combat have roughly a 40% likelihood of receiving a PTSD diagnosis. But there are other life events that can also lead to PTSD such as sexual assault, domestic violence, cancer treatment, a child’s devastating illness, or a serious transportation accident, for example.
The DSM-5 sets the criteria for diagnosis of psychiatric disorders. It says there are several criteria required to diagnose someone with PTSD:
First, you must have been exposed to the threat of death or serious injury or sexual violence directly, or by witnessing it, or learning someone close to you experienced it. Or by indirect exposure as a first responder.
Second, you have to re-experience this traumatic event by reliving memories, or in nightmares, or maybe you suffer distress when you’re faced with a traumatic reminder of what happened.
Third, you likely make effort to avoid situations that would remind you of the traumatic event, or to think thoughts that pull you back into the painful memories of it.
Fourth, you have negative thoughts or feelings that resulted after the trauma. Like blaming yourself or others, shaming yourself, holding a negative attitude, and isolating yourself. You have lost interest in doing things you used to enjoy or getting out with friends. Does any of this sound familiar? Stay with me…because there’s hope coming…
Further, you find that you react to things that happen differently than you used to. Like you feel irritable and aggressive, or you may embrace high risk activities, or you may feel hyper-vigilant…always on edge for something to happen. Plus it’s hard to sleep or stay asleep, and it’s hard to concentrate. You’re likely to experience depression,anxiety, possibly substance abuse in an effort to avoid thinking about the traumatic experience.
Obstacles to Functioning
And all these things often result in problems with friends, with family, with your job, your education…and even with taking care of yourself and your own needs.
If you’re diagnosed with PTSD, these symptoms have lasted awhile and your doctor must know that you haven’t used other medications or illicit drugs that could have caused this.
PTSD isn’t just feeling bad about something that happened. It’s a reaction inside you to something terrifying that changes the way you think and feel and respond to life. It changes your body… and your environment. Because it changes the way your mind interprets what you see, smell, hear, taste, and feel.
How Fear is Connected to Suicidal Thinking
The Brain and Behavior Research Foundation recently offered a webinar about the work they’re funding with regard to PTSD, suicidality, and IV ketamine treatment. Lynnette A. Averill, Ph.D., Assistant Professor of Psychiatry at Yale University, explained the link between the fear and anxiety people with PTSD have and how it’s connected to suicidal thinking.
Three Regions of Your Brain are Key
So let’s talk about your brain, and how PTSD affects it. There are multiple parts of your brain that play a role in your experience as part of this disorder. And the trauma that caused this disorder triggered multiple changes in your brain. The prefrontal cortex, the amygdala, and the hippocampus are the primary areas involved, and what Dr. Averill’s team focused on.
The prefrontal cortex regulates our emotions and helps us make decisions related to them. The amygdala helps us with fear processing. And the hippocampus helps us interpret emotional context.
These three regions aren’t the only regions involved in PTSD, but they’re the most consistently significant.
The hippocampusloses volume when you’re traumatized. So as PTSD increases and its symptoms increase, too, the volume of the hippocampus decreases.
The prefrontal cortexthins in the presence of trauma. In fact, the more severely traumatized you are, the thinner the tissues in the prefrontal cortex. It makes the decision whether you’ll fight, run, or chill.
And the amygdala hyper-reacts. So it goes like this. Let’s say a T-Rex stomped down your street and through your yard. You look out the window and see his knees. Immediately, your amygdala sends out the alarm and calls upon adrenalin to scream, “FIGHT or FLIGHT!!”
PTSD Changes Brain Function
The job of the prefrontal cortex (PFC) is to call up the amygdala on speed dial…and tell him “Nothing’s wrong... It’s a hologram. Go back to your cable show… Everything’s ok.” And the amygdala settles back into his recliner.
Because PTSD doesn’t just change the way the brain areas look, it also changes the way they function…and so, in turn, the way YOU function.
Now here’s the thing. People who are suicidal have impaired executive function. This means that the organization, ability to focus and pay attention to others, as well as regulating emotion and disciplining yourself in a way that helps you meet goals…well, none of that is working well enough.
It means you’re likely scattered, and probably unpredictable. Maybe impulsive. The impairment of these abilities sets you at greater risk for making a tragic and impulsive final decision.
Is Suicide Rare?
Suicide is the 10th leading cause of death in the US across all age groups. To make that a little easier to grasp, think of it this way: 129 people take their own lives every single day in this country.
In 2016, suicide was the 2nd leading cause of death for people aged 10 to 24. More than leukemia, or fire, or overdose.
This is aside from the numbers for middle aged adults or the elderly. This includes children only 10 years old! And we need to better understand any biomarkers that can help us identify those who are at higher risk to even attempt suicide.
And it gets worse. Veterans are 1.5 to 2 times at higher risk for suicide. Sexual minorities are also at increased risk for suicidal thoughts and behaviors. The numbers include those individuals who suffer from bipolar disorder and have a 5 times greater risk for suicidal behaviors.
So this brings up this point. We need something to point to that’s common to all these conditions. Dr. Averill believes the link is synaptic growth.
Actually, it makes sense, doesn’t it? When synaptic growth stops, and synapses break down and thin out, you’re more likely to experience depression, anxiety, and PTSD along with other disorders that are stress-based. And when you treat this synaptic deficit, the symptoms of these disorders tend to dissipate.
Ketamine Treatment Restores Synaptic Growth and Just May Be a Biomarker for PTSD and Suicidal Thinking
The most effective treatment for these disorders is likely something that restores synaptic growth. Furthermore, that something needs to act rapidly, because there is the risk these patients may make suicidal attempts.
It just stands to reason, doesn’t it?
Well, it so happens that IV ketamine treatment does just that, and fast.
It switches on mRNA which turns on DNA to turboboost brain-derived-neurotrophic-factor (BDNF)to rapidly proliferate new synapse connections with their dendrites and dendritic spines all through the brain. It also slides the G proteins off their lipid rafts in the brain cell membranes, so they can productively go to work enhancing signaling along these new synapse connections. And within 24 hours you can feel amazingly better. Or it might take you a few days depending on your brain and genetic makeup.
But traditional antidepressants take weeks or even months… in many cases it can be three or four. And far too many people struggling with intrusive suicidal thoughts have ended their lives by then. That’s why it’s so extraordinary that ketamine is a RAAD (rapid-acting-antidepressant) rather than a SAAD (slow-acting-antidepressant).
Ketamine treatment is life-saving for a LARGE percentage of treatment-resistant cases. Ketamine doesn’t work for everyone, but we’re learning every day how to help more people benefit from it’s restorative actions.
At Innovative Psychiatry, we work with people who suffer from PTSD and with people who suffer from suicidal thoughts. We’ve been so gratified to watch them walk out of the office with a smile, and energy, and a joy for living.
If you suffer from PTSD, depression, bipolar depression, social anxiety, addiction, or other disorders that make life seem hopeless, or if you have thoughts about ending your life, call us. Let’s work together to help you find your joy, your hope, your fulfillment, and your relationships again.
We want you to see how appealing life can be.
To the emerging of your best self,
Lori Calabrese, M.D.
*****If you or someone you know is contemplating suicide, call the National Suicide Prevention Lifeline at 800-273-8255. There’s someone available to listen 24 hours every day.*****
SAN FRANCISCO – Serial ketamine infusions eliminated suicidal ideation in more than two-thirds of patients at a psychiatry office in Connecticut but at significantly higher doses than those recently approved for Janssen’s new esketamine nasal spray (Spravato). The patients were treated by Lori V. Calabrese, MD, at Innovative Psychiatry, her private outpatient practice in South Windsor. She presented her first 235 IV ketamine cases at the American Psychiatric Association annual meeting. It was likely the largest real-world series to date of ketamine infusions for treatment-resistant depression and suicidality.
The patients, 14-84 years old but mostly middle aged, received six infusions over 2-3 weeks, starting at 0.5 mg/kg over 40-50 minutes, then titrated upward for dissociative effect to a maximum of 1.7 mg/kg. Subjects filled out the nine-item Patient Health Questionnaire (PHQ-9) at baseline and before each in- fusion. Item nine – “thoughts that you would be better off dead or of hurting yourself in some way” – was used to gauge suicidality. That item has been validated as a predictor of suicide risk.
Among 144 patients (62%) who were markedly suicidal, ketamine infusions were tied to diminished ideation in 118 (82%) and eliminated ideation in 98 (68%). They were severely depressed at baseline; PHQ-9 scores fell in 127 (89%), and depression went into remission in 89 (62%). There were no suicide attempts, ED visits, or hospitalizations during treatment and at 4-week follow-up.
“Even if they had been suicidal for a long time, been hospitalized, and made suicide attempts, 68% had full remission of suicidality. This is a life-saving treatment, a breakthrough option for psychiatrists,” Dr. Calabrese said.
Lori Calabrese MD
The results are “fabulous,” said Jaskaran Singh, MD, who said he was clinical leader of the esketamine program at Janssen. “You prevented hospitalizations and saved lives,” Dr. Singh said. “This is a marvelous study that we should have done.”
Dr. Calabrese’s report, however, raises the question of whether the nasal spray will be potent enough to achieve the same results. She found that cessation of suicidal thoughts required an average dose of 0.75 mg/kg IV ketamine, which is higher than the 0.5 mg/kg used by many ketamine infusion programs in the United States. It’s also significantly higher than Spravato dosing. The spray was cleared by the Food and Drug Administration in March for use with an oral antidepressant for treatment-resistant depression.
Esketamine is approved in doses of 56 mg, which works out to almost 0.2 mg/ kg, and 84 mg, which works out to less than 0.4 mg/kg. Dosing is twice weekly at first, then weekly or biweekly for maintenance. When asked whether he thought those doses would be enough to prevent suicide, Dr. Singh said his company has finished two trials in suicidal patients and would present results later in 2019.
Dr. Singh
Dr. Calabrese, meanwhile, plans to incorporate intranasal esketamine into her practice, but will continue to offer ketamine infusions. “How can I not? I’ve seen how effective they are,” she said. Insurance companies have sometimes covered them for patients with a history of psychiatric ED visits and hospitalizations, on the grounds that infusions will prevent future admissions. But patients have to fight for coverage – and feel well enough to do so.
That’s the main reason Dr. Calabrese plans to start offering Spravato; coverage will likely be less of a hassle for patients once Janssen works out the insurance issues. Spravato has been reported to cost about $600-$900 per treatment session.
When someone commits suicide, you’ll sometimes hear people say, “It makes no sense! She had everything to live for…” Or, “What a selfish thing to do. What about all the people who loved him? What about his kids…his wife..?” But this sort of tragedy isn’t about selfishness. To grasp what happens with your suicidal loved one, we are beginning to understand that there is a biology of suicide, and it can play into whether or not someone takes her life. It also helps to know what can be done. Read one young woman’s story to see what I mean…
…Casey climbed the stairs and disappeared into the darkness of her room without flicking on the light. Somehow the darkness was more comfortable. More familiar. She dropped her keys on the hall tree and her purse and coat on the floor, then flopped onto the sofa.
Settling back, her neck resting on the back cushion, she stared blankly at the ceiling. Another day was behind her.
It was always a feat to survive another day of work. Miserable. Now that she had, her mind wandered to nothingness. The billowing relief that would come if she could just get off this ride…this miserable journey day in and day out… Casey lost herself in reverie thinking about what a relief that would be.
She couldn’t do it anymore. She just couldn’t. And…she wouldn’t.
No one in Casey’s life had any idea what she goes through. She seemed astute, responsible, reliable to those around her. Quiet. Sometimes a little short-tempered… But pretty self-sufficient.
The darkness wrapped itself around her, and she hung her head in exhaustion.
Random thoughts drifted through her mind. The summer she was 3. She had climbed a tree and went too high. As she looked down she felt a little lightheaded and swayed in the branch as the wind blew. She had thought that if she just jumped, she would go to heaven.
“Good grief,” she thought. “I was only 3 then. Was there ever a day in my life I didn’t think about dying? Wish I could die? Figure out how to die…??”
She closed her eyes. “Thirty one years. I guess it will go on as long as I live…” Then, she thought, but why? What’s the purpose of my life beyond dreading, thinking about dying, seeing only futility..?”
“Why put it off any longer..?”
And then, something happened.
She opened the drawer in her nightstand, reached to the back, and pulled out a tin of pills she’d been saving for years. The prescription said TWO pills. And she’d taken one and stashed one. There was another bottle she’d squirreled away in her closet, so she felt around till she found it and tossed it on the sofa.
After a bit she dragged herself into the kitchen, and pulled the Kentucky Honey Whiskey from the cupboard a friend had left at her house 6 months ago. As she reached up for it, she saw the Tylenol and grabbed it.
She knew that too much Tylenol would damage the liver, so slipped that into her pocket. The whiskey bottle was three-quarters full. That will help, she told herself. Then she grabbed a glass and took the bottle to the coffee table.
With all she would need in place…she lay down and drifted off to sleep…
Honking from the street below. HONK HONK HONK!! Wondering about the time, she looked at her watch. 11:49. Just a few minutes before midnight.
Methodically, she poured Kentucky Honey into her glass and chased the first few pills. Then poured another glass, and swallowed 4 or 5 more.
Pain pills and sleeping pills… hmmmmmm… It seems to me I should feel a little different by now. She was glad for the late hour. Unlikely anyone would find her too soon. No one ever knocks or stops by.
She popped more pills into her mouth.
The Kentucky Honey was becoming harder and harder to swallow. Her head was spinning from the glasses of it she’d had so far.
No one had any idea…she had always held her feelings and frame of mind close to the vest. Impossible to get her to talk, really…
We do so much research about what drives someone to suicide. But what actually happens– biologically?
Why Now? Why Tonight ?
Some people think about suicide every day of their lives and never act on it. What’s behind the moment someone actually takes the step to end his life? And what role does biology — the biology of suicide — play?
Two prominent researchers are known for their insightful hypothesis about this way back in the 1990’s. Their contemporaries swore by the prevailing belief that depression was caused by low levels of the neurotransmitter serotonin. (You remember those days?) These two were burning the midnight oil trying to figure out HOW that was true.
Their names were Charney and Krystal. Dennis Charney is now the Dean of Icahn School of Medicine at Mount Sinai in New York. He was focused on depression. John Krystal was exploring schizophrenia to better understand and treat it.
In both cases, their work at Yale at the time led them to glutamate, the most prolific neurotransmitter in the human body. As an excitatory neurotransmitter, glutamate helps brain cells communicate, so it’s critical in learning, memory development, mood and …. the list goes on.
So they went to work together to learn what they could.
Now, you need to understand that at that time, even though ketamine was a solid and relied-upon anesthesia medicine, its dark reputation as an abused substance in the club scene — and on the street — kept it from getting much attention in research.
Glutamate Paves the Way to Ketamine
Ketamine causes specific behaviors in people who use it on the street, usually within 2 hours after taking it. But the amount they ingest is around 100 times greater than the doses used in anesthesia, or the even smaller dose these researchers gave their subjects.
This is where some people get the wrong idea about ketamine. If they’ve heard about it or seen it on the street, they tend to be terrified of its use therapeutically because of severe side effects they’ve seen.
But when ketamine is used in tiny doses therapeutically, it’s a completely different “animal.”
Even so, Charney and Krystal didn’t want to miss anything that might show up later so, in an abundance of caution, they decided to monitor their research subjects for a full 72 hours after their ketamine infusion. They chose 9 subjects to try the ketamine infusion, but 2 of them dropped out. So they followed 7 depressed subjects for 72 hours. This was a turning point. Keep reading…
Four hours after the ketamine was administered, they checked on the patients. These patients declared they felt better. In fact, they felt a great deal better! Our researchers were shocked beyond belief. Everyone knew that antidepressants take weeks or months to produce an antidepressant effect, and this medicine produced dramatic results within 4 hours.
They didn’t expect anyone to believe them, and kept these results under the radar for years. When they finally did publish their results in 2000, they got …. not much attention.
Low Serotonin Severely Alters the Brain – Which Plays into the Biology of Suicide
But during the same time another research team, John Mann and Victoria Arango, set out to study the brains of suicide victims. Over time, they discovered that certain areas of the brain showed alterationsin serotonin. A significant kind of alteration.
In fact, this situation reminded them of the well-known story of Phineas Gage, back in 1848. Gage was a railroad worker, and had been impaled by a 43-inch cylindrical iron tamping bar right through his skull.
Amazingly, he survived the accident, but his personality completely changed. His doctor later wrote that Gage’s “character” was altered by the damage and his “animal propensities” emerged, as he put it. He wrote that Gage was fitful and irreverent. He called him capricious and vacillating, and complained that he used the “grossest profanity.” Now Gage had been a foreman: a responsible, circumspect, hardworking man before the accident. So you see, the change was dramatic.
It wasn’t until more modern times that research revealed the area of the brain destroyed by the iron tamping bar is the area that controls inhibitions, and in Gage’s case, his social inhibitions.
And that’s one of the same areas affected by “low levels of serotonin transporter binding.”
So, with low levels of serotonin, the inhibition disappears. In the cases of these suicidal victims, the researchers think the inhibition that kept them from committing suicide was lifted, and they surged forward and ended their lives.
But again, this may have happened as a number of other social, economic, and interpersonal factors were unravelling. There are so many contributing factors to suicide. And even when we can study and pinpoint biological correlates, we know that low levels of serotonin in the cerebrospinal fluid, and probably low levels of serotonin transporter binding don’t always result in suicide.
Of course they don’t.
Moreover, even if the doctors of these patients had known the exact biological areas and brain processes involved in suicide, and had a way to modulate the activity there, it still might have taken weeks or months to reach a therapeutic effect — and it might not even have worked …as it may have been too late.
Ketamine Takes Its Cue From the Biology of Suicide in YOUR Brain
So this is a HUGE key to why ketamine treatment can be so vital to erasing suicidal thinking. Because it can erase those thoughts in an afternoon, in the psychiatrist’s office. No need to wait weeks or months and risk suicide while you wait for it to take effect.
Compassion for Suicidal Loved Ones
People who succeed in, or even attempt, suicide, aren’t thinking about the feelings of others. (There’s some truth to that…but not necessarily what the criticizers think.) Quite honestly, in that condition they can’t. They may have been induced by their disordered brain to think about suicide for a very long time, or maybe just sointensely, whether they wanted to or not. Then, if the biology of suicide kicks in and they have little or nothing to help them hold back, they may act impulsively and without recourse or consideration of consequences.
For those of us who love them, unless we’re tormented by the same suicidal thoughts, we can’t imagine what it’s like to want to die, or to feel compelled to die.
This isn’t selfishness…it’s sickness. It’s also not selfish when a Type 1 diabetic’s blood sugar drops so low he convulses. It’s a consequence of his serious illness.
And it’s for this reason that it’s important to never dismiss or ignore talk of suicide.
Thankfully, IV ketamine treatment can provide the safety stop to put on the brakes and end the suicidal thoughts.
It can give your loved one time to heal and move forward with their lives.
Biology of Suicide at Innovative Psychiatry
At Innovative Psychiatry, we’ve seen so many who fought the torment of suicidal thoughts and inclinations, walk out free of those thoughts after IV ketamine treatment.
Many times they’ve reached the point of emergency late in the day and needed immediate treatment. Then, after ketamine treatment, found immediate relief. The biology of suicide – in those cases — is side-stepped and overcome by the most rapid and effective treatment for suicidal thinking of our time.
We’re also flooded with relief for them as the suicidal thoughts subside, the light comes to their eyes, and they leave relaxed and eager to continue restorative treatment for their depression symptoms.
***If you have suicidal thoughts a few times a week, or 20 times a day: please know that there is hope. Those thoughts can stop. Reach out immediately for support by calling the National Suicide Prevention Lifeline at 800-273-8255. OR text HOME 741741. Someone is available to listen 24 hours every day. ***
And consider IV ketamine treatment. It can help you experience freedom from those tormenting thoughts and find hope and purpose in your life again through relief from depressive and anxious symptoms. Fast.
Your life really can be fulfilling, rewarding, and productive as you experience what ketamine treatment can do for you. While it’s not a one-size-fits-all treatment, IV ketamine treatment can restore your motivation and initiative, your creativity and energy, so you can invest in your relationships, your career, and your hobbies with enthusiasm and joy.
Treatment can help anxious moms relax and enjoy their babies.
Jill was so excited to be pregnant. She’d waited for 4 years after she and Joe were married to start trying. She was just elated three months later when a home pregnancy test showed those two little lines. She was pregnant! Even the slightest thought of antepartum and postpartum anxiety never crossed her mind.
In spite of waves of nausea off and on the first couple months, by the time she got through her first trimester, she was feeling better. Her excitement to see and hold her precious baby was bubbling up like crazy. How could she wait six more months??
But as she moved through the 4th month, she began to feel… uneasy.
Just this vague sense that something bad could really happen… maybe something about her pregnancy wasn’t going as it should? She worried that something was going wrong with the baby. What if there was something wrong that they couldn’t see? Or a problem with his development? What if he was in that 3%? What if something went really wrong during delivery?How would she take care of him?
Day by day the dread grew worse. She asked her doctor about her concern, and she assured her that everything looked good. Told her that she should enjoy her pregnancy.
That was the problem. She couldn’t. She was worried sick.
Then, when she reached her third trimester, the dreams started with a vengeance. Night after night she’d dream she gave birth … to an alien. Or a forest creature. Or a monstrous murderous demon. She was so ashamed that these were her nightmares that she couldn’t tell anyone. No one.
When something is so terrible, who can you tell? Who can you trust?
The nightmares were so cruel, so vivid, that she’d wake up in the wee hours sweating, heart pounding, and screaming. Her husband would try to comfort her, then she’d go back to sleep. And the nightmare would continue. It was as if she couldn’t escape.
By the time the baby was born, her joy was gone, and in its place loomed a terrible dread. She feared for the baby, and what he would grow to be. Not who…but what. She tried to nurse him in the hospital but would break down and cry and ask the nurses to take him for awhile to give her a break.
Going Home From the Hospital Didn’t Help
It wasn’t supposed to be like this! What was happening to her? Why couldn’t she enjoy her newborn son?
The first 6 weeks or so she tried. She really tried. She was exhausted, and wondered if she’d ever get enough sleep to feel better. Waking every hour or two around the clock took a toll she didn’t anticipate. Her thoughts about her baby seemed irrational, even to her. She couldn’t imagine why she ever thought she wanted a baby. Now here she was, stuck in a permanent nightmare. She felt cheated.
Then her worries about what she might do to him if she let her guard down overwhelmed her. She mentioned her concerns to her pediatrician during a routine visit, and he explained that this could be postpartum anxiety and gave her a card to see someone he trusted.
Within a few months after her treatment began, she was beginning to see life, her son, and herself in a new light. She could sort of imagine now that it was possible she could have a good and loving relationship with him.
It helped enormously to know all this was a condition her hormonal imbalances and stress created. To fully realize that neither she nor her infant son were to blame. She read all she could find on antepartum and postpartum anxiety.
There wasn’t much.
But where, oh where, did it come from?
We’re all familiar with postpartum depression, but you rarely hear people talk about postpartum anxiety. While the two often join forces, they’re actually individual disorders. Since postpartum depression is often associated with sadness and anxiety, postpartum anxiety is sometimes overlooked.
It’s actually possible to feel overwhelmed, severely stressed, and have thoughts of harming your baby or… of ending your own life… without feeling sad.
When a woman gives birth, several changes go into high gear in her body. Pregnancy hormones drop, lactating hormones kick in, and the sudden changes in her brain give way to mood swings.
Add to that the painful engorgement in her breasts as milk comes in, lack of sleep from her baby’s waking every hour or two to eat, the soreness in her perineum from stitches, (or in her abdomen from a C-section) and cramping of her uterus as it recovers from pregnancy and childbirth, and this new mother is enduring substantial stress.
Stress + Fear = Anxiety
Even though many people are more familiar with postpartum depression, roughly 6% of all pregnant women and about 10% of those who are postpartum develop anxiety that’s severe enough to need treatment.
It’s natural for a new mother to have mild worries or nervousness about whether her baby is eating enough, whether the baby’s stool is like it’s supposed to be…and wonder if she’ll ever feel rested again.
But when mild worries become more intense, concern becomes a constant dread that something bad is going to happen, or intrusive thoughts begin of harming the baby or yourself, it’s time to seek help.
So why do some mothers seem to adapt to the new addition to the family, along with hormone changes, the lack of sleep, and the new routine, while others feel and think things they don’t want to feel or think, struggle to bond with the baby or enjoy her, and wish for a way to escape … either temporarily or permanently…?
There are a number of factors. And none of them are the anxious mother’s fault.
Risk Factors for Antepartum and Postpartum Anxiety
First, mothers who have relatives with anxiety disorders –or have had anxiety disorders themselves in the past — are at higher risk for postpartum anxiety than woman with no family history of anxiety at all. In addition, women with thyroid imbalance are at higher risk, also.
Most of the time when we refer to postpartum anxiety, we’re talking about a generalized anxiety disorder that develops during or after pregnancy. Symptoms like nervousness, constant worry, difficulty sleeping, racing thoughts, tension…
But there are a couple more types of postpartum anxiety that are important to highlight.
Postpartum Panic Disorder
Panic disorder doesn’t mean being panicky, or having anxiety that escalates easily until you feel wound up. It means having frank, out of the blue, and unprovoked panic attacks. You’re not just worried all the time about whether the baby is eating enough, whether you’re capable of being a good mother, or whether the baby will get sick, you begin to get random episodes of sheer panic.
Sometimes multiple times a day.
Shortness of breath, fast heart rate, chest pain, dizziness, and tingling along with feeling confined or like you’re suffocating can make it extremely difficult for you to take care of your baby, yourself, or the rest of the family. These sensations can come and go, but you may need professional help to cope with them and reduce their impact on you and your new family.
Postpartum Obsessive Compulsive Disorder (POCD)
Symptoms of OCD can emerge during or after pregnancy, too. They’re similar to general symptoms of OCD but tend to be focused on the baby. Intrusive thoughts about harm coming to your baby can crowd your mind, and even shock you.
The next thing you know, you find yourself checking things over and over and repeating things over and over to try to avoid a circumstance that would allow your thought to come true.
And…you’re probably horrified at the thoughts that pop into your mind. But this is why we call them “intrusive” thoughts. They intrude into your thoughts without you inviting them.
They’re a result of disordered circuitry, and misfiring signals, in your brain as the result of relentless and overwhelming stress, shock, and genetics.
Of all of the antepartum and postpartum anxiety disorders, this may be the most difficult and the most upsetting of all. Even though you probably know in your head you would never follow through on the thoughts, and you also know that the repetitions and cycles of checking don’t really help, you probably feel powerless to stop. But treatment can do what you can’t by yourself.
You’re not to blame for the intrusive thoughts, the fears, the compulsive reactions. These are a result of your genetics, your circumstances, your stress, and your family history. But treatment is not only available to you, it also can return your world back to its right and rewarding function.
Antepartum and postpartum anxiety disorders come in various forms with a variety of faces. But it’s vital that you not confront this alone. Rather, seek treatment. And please know that this is not your fault. Even so, you may not get better without help outside yourself.
If you’re pregnant and feeling feelings and thinking thoughts that aren’t what you wish you they were, there is help available. If your baby has been born, and those feelings are just starting or are getting worse, call us. We can help you feel better, or refer you to someone who can.
Don’t face postpartum anxiety disorders alone.
You and your baby deserve a loving and happy relationship together.
We’ve talked about the microbiome, or “second brain,” and how we can weaken or strengthen it with what we eat. We’ve talked about eating fresh vegetables of all colors. And how fermented foods like sauerkraut, pickles, kimchee, and kombucha introduce healthful organisms into our intestinal DNA system. We’ve talked about curcumin, and its benefits against depression. Now let’s talk about the very real effect of fatty acids on your brain.
Did you know that some of the most important, even vital, foods you can ingest are fatty acids? Maybe that sounds a little creepy… But it’s true.
The World Health Organization estimates that major depression is the greatest single cause of disability worldwide.
A study by JR Hibbeln showed that around the world, countries that consume the least amount of fatty fish show the highest levels of major depression (MDD) in their population. And countries where fatty fish is the main diet show the lowest incidence of MDD.
You Have a FAT Brain
You think I’m kidding..??
I’m telling you, your brain is 60% fat. 60% !! Shocking fact when you step on the scale. But don’t try to lose that excess weight from your head, because THAT fat is pretty important.
Fats reside in the neuronal membranes–the brain cell membranes–and in the myelin sheaths that surround them. And they’re important for delicate synapses. Remember that synapses are the connections between neurons.
The saturated fatty acids are combined in what’s called a lipid bilayer and that lipid bilayer forms the membrane that surrounds each brain cell. It’s made up of straight chain carbon atoms so the membrane is more firm like butter is firm at room temperature.
Now–this is where it gets interesting– unsaturated fatty acids are made of bent chain double bond curvy molecule structures. Because of this, there’s more space between molecules so when unsaturated fats are incorporated into the cell membrane, the membrane is more fluid. So, if you compared oil to the firmness of butter, these are more fluid like olive oil, for example.
The omega 3 fatty acids are fluid ones.
Another remarkable characteristic of omega-3 fatty acids is that they’re precursors to eicosanoids like prostaglandin which can reduce inflammation. Super important for psychiatric disorders, which are associated with increased inflammation.
Eicosanoids go by the nickname ‘local hormones’ because they act on cells close to their site of production. So fatty acids in your brain cause the release of prostaglandin, which reduces inflammation that contributes to depression.
That’s a mouthful! But it tells a promising story.
Get the effect of fatty acids by eating more fatty fish.
Fatty acids like omega-3s are considered essential fatty acids, and you can only obtain them from your diet.
So to maintain a healthier, more positive outlook, decrease inflammation that can lead to depression, and actually fight depression symptoms, increase the amount of mackerel, salmon, oysters, sardines, and trout in your diet. Make sense? I hope so, because doing that can make a real, tangible difference for you.
In addition, seaweed is a nutrient dense food that’s rich in omega-3 fatty acids. Nori seaweed typically presents itself in sushi, and is a tasty snack on its own. Also spirulina and chlorella are also in the algae family and are a good source of omega-3s that you can add to shakes and smoothies.
Fatty Acids Are Essential for Your Brain Health
In a presentation at the annual meeting for the Society of Biological Psychiatry in NYC last year, Dr. Roel Mocking spoke about the critical requirement of fatty acids in psychiatric wellness.
He demonstrated that Omega 3 fatty acids reduce inflammation, reduce the release of cortisol from the hypothalamus-pituitary-adrenal-cortex-axis, and activate the amygdala.
The amygdala is one part of the brain that contributes significantly in processing emotion and decision-making. When someone’s amygdala is damaged, or destroyed, they tend to be fearless, and don’t use the necessary caution to make safe decisions since the caution the amygdala would create is absent.
So, by multiplying your fatty fish consumption, you provide your amygdala the fuel to be activated to process fear and enhance circumspect decisions. You can also reduce the release of cortisol, the stress hormone that has a negative impact on your health. And you equip your brain to reduce inflammation…all of which improve your mental and emotional functioning.
The Effect of Fatty Acids on Your Brain
Dr. Drew Ramsey, a nutritional psychiatrist, and author of 3 books on foods that feed the brain, is an assistant clinical professor at Columbia University. Dr. Ramsey promotes better nutrition for the brain with his patients. He laments that most Americans overfeed themselves in calories but starve themselves of the critical micronutrients the brain needs to thrive.
He prescribes antidepressants and other medications for his patients, and engages in psychotherapy with them, too. And he teaches that fresh and nutrition-packed foods help make other treatments more effective.
It’s a shame, according to Dr. Ramsey, that it’s so rare for Americans to eat foods that meet the needs of the “most complex and energy consuming organ in the body” which is the human brain.
Eat the Rainbow
He recommends “eating the rainbow,” as in eating all the colors of fruits and vegetables. Fresh foods like oranges, apples, bananas, pineapple, bell peppers, tomatoes, avocados, kale, sweet potatoes, and blueberries.
Combine these with fish like mackerel, salmon, trout, sardines. And walnuts, pecans, and almonds.
These can help prevent harmful inflammation, and feed your brain, your heart, and your digestive system.
They can reduce symptoms of depression and anxiety, and promote mental clarity.
Ketamine Treatment Can Help Give You a Fresh Start
So, if your diet changes and medications aren’t bringing the relief you hope for, then let’s talk about ketamine treatment. Because this remarkable treatment of at least 6 infusions within 2-3 weeks has been changing lives across the country. It just may change yours, too.
While we don’t center an entire treatment program around food, we do work with patients and guide them in supporting their brain function by avoiding food dyes and preservatives.
In addition, we show them that by adding healthy foods, micronutrients, and lifestyle changes, they give their brains and emotions an optimal environment for restoration.
If you suffer from depression, symptoms of anxiety, or other mood disorders, and other treatments have brought no relief, call us.
We’ll talk with you and determine whether you’re a candidate for ketamine treatment. We’ll guide you to eat foods that improve your well being. And please do follow the links in this article to read more information about your microbiome and your restoration.
It’s all about getting better. Enjoying your life. Watching symptoms fade and your strengths rise.
Call us, and let’s create a plan to help you restore joy and fulfillment in your life.
Obsessive-Compulsive Disorder or OCD is a term that is sometimes thrown around mistakenly. It’s sometimes used to describe someone’s careful behavior… you know, like careful organization, attention to detail, or a tendency toward cleanliness, which of themselves are actually normal behaviors. Many of us may be particular about these things without giving them a second thought. So to use the term in jest to poke fun at someone’s distinctive tidiness, for example, should be discouraged. You know why? Because doing so fuels stigmafor one thing, and trivializes a serious medical condition. But neuroscience research is showing us that with OCD better treatment targets can give you a happier, more fulfilling life.
People with OCD have recurrent, intrusive, unwanted thoughts that just occur—like cardiac arrthymias—out of the blue and over and over, upsetting them, plagueing them and precipitating compulsive behaviors they use to relieve the anxiety spiked by their obsessive thoughts.
Obsessive thoughts can fall into certain categories — such as fear of harm coming to you or someone you love, fear of harming others or yourself, fear of illness or contamination, or preoccupation with things like patterns, numbers, morality, or gender identity. Insecurity about the future. Fear of throwing up.
And so many others.
The thoughts can have a certain theme for weeks or months… and the themes can vary within a day or over time. How often they occur can vary dramatically even for the same person. Their intensity can vary, too — and really affects the degree to which they intrude in your life.
These thoughts — and the behaviors they invoke — can be so upsetting and time consuming that they interfere with your ability to be on time, and be present, and function at work, school, or in your social life. In fact, they can interfere to such a degree that they cause intense discomfort and distress. And it’s the intensity and distress that sets apart those who have OCD and suffer from a disorder compared to those who are just a bit more hygienic or meticulous than their friends. There’s a BIG difference.
If you have OCD, unpleasant or fearful thoughts can fuel a reaction–and if the reaction is a behavior, we call that behavior a compulsive behavior. That reaction always starts and intends to relieve your anxiety. Right? But it becomes so repetitive and time consuming, it distresses you even more.
Compulsions can range from excessive doubting or asking (did she have an accident? is he cheating on me? did I do that right?) to excessive hand-washing, skin picking, or excessive safety checking — checking and rechecking the door knob, the knob on the stove, or locking and unlocking your car, or something else potentially dangerous. You could meticulously clean, re-read, re-write, or arrange objects. You do … and redo.
And there’s so much more.
There are also some other subdivisions of this disorder that you may not have even heard of: like harmOCD, obsessive slowness, tic-relatedOCD, and even pure obsessional OCD — where there are no observable compulsive actions but obsessive thoughts that just won’t stop.
Bottom line: many people suffer from a complex mixture of these types of obsessions and compulsions.
It’s surprising how often the diagnosis is missed.
It may surprise you to know that many people with OCD are aware that their intrusive thoughts aren’t true and that the compulsive actions they take don’t help. But they still can’t make them stop. And this causes them severe distress.
OCD: Better Treatment Targets Are Desperately Needed
Brain and Behavior Research Foundation presented a talk recently regarding the work of researchers to find more treatment options for those with OCD who are not helped by current available medications or psychotherapy. Because there’s a HUGE need.
Treatments for OCD
Serotonin Reuptake Inhibitors (SRIs) have been the only proven monotherapy, or singular form of medication treatment.
The serotonin system is pretty extensive. It’s involved in many different parts of the central nervous system: From the hippocampus, cerebral cortex, cerebellum, basal ganglia, thalamus, limbic cortex, and temporal lobe, to the rostral raphe nuclei, caudal raphe nuclei, and the spinal cord. Exhaustive, isn’t it?
Remission with SRIs is only 10-15% which is wonderful for those who achieve it, but the other 85-90%, need more help than that.
Those who achieve a partial response to an SRI experience a decrease in symptoms in 20-40% of cases… but only 20% still enjoy improvement after ten years.
Not great.
So it goes without saying how seriously we need to explore OCD better treatment targets that are effective. So here are some possible options on the horizon…
Studies continue to investigate IV ketamine treatment for OCD. One study may show good responses, then another shows it’s less effective. Researchers are guessing this may be due to different types of symptoms needing different treatments. You can see that it’s so important to research more deeply — and study different patient populations — to see which ones do respond and which ones don’t. And to learn why.
Is it based on the types of symptoms the patient experiences? Fear of harming others vs. Fear of contamination? Or is it based on comorbidity, such as cognitive rigidity or the presence co-morbid depression or anxiety? Researchers continue to explore these questions.
A common augmentation strategy is with dopaminergic blockade agents, such as atypicals, as they’re called. (A shortcut for atypical antipsychotics–we often avoid saying the “antipsychotic” part and just call them atypicals.) Interestingly, these medicines fast-tracked for FDA approval treat psychotic disorders often have promising results with a variety of neuropsychiatric conditions.
They’re pretty amazing. They can get you unstuck, and get your thoughts unstuck. They’re like Goo Be Gone–you don’t quite know where all of those repetitive stuck thoughts went. They just seem to dissolve.
When the meds work.
Exposure and Response Prevention (ERP)
This form of therapy can be extremely effective, but it’s hard for some patients to see it through. It requires patient and consistent steps to bring about progress.
The steps required can cause so much anxiety that patients sometimes decide it’s not worth it to them… so they quit. It’s also hard to find enough skilled therapists to meet the needs of patients who need this kind of treatment. Here at Innovative Psychiatry we’re not able to offer this therapy to new patients. But we can offer other treatments.
For those who have not improved with medicine or therapy, surgery can be a consideration.
We don’t offer that either. Just sayin…
Ablative Neurosurgery
When medicines and psychotherapy bring no improvement, an option may be ablative neurosurgery. This involves surgically interrupting precise connections between the cortex and striatum.
The cortex is the part of the brain where you make decisions and decide what action you’re going to take. The striatum is important for carrying out those actions. So creating a disconnect between the two interrupts the cycle. This procedure can be 50-70% effective.
The problem with ablative neurosurgery is that it’s surgery…. and its non-reversible
It’s non-reversible.
Deep Brain Stimulation
Deep brain stimulation is high-frequency stimulation achieved by implanting electrodes deep into the brain that are powered by a device planted in the chest…something like a pacemaker for the brain.
When there’s a disturbance in the reward system of the brain it can lead to addiction, depression, and/or OCD.
And good outcomes have been achieved with deep brain stimulation.
For instance, the most common target site that’s been used for DBS is the ventral capsule/ventral striatum (VC/VS) and the nucleus accumbens (NAc) area. This area is approved for deep brain stimulation and is also being investigated for other purposes.
A newer target was utilized in a recent and exciting study. Keep reading…
A recent study (March 2019) seeking an alternative to ablation neurosurgery was conducted by Tyagi et al., and compared the effectiveness of deep brain stimulation at the ventral capsule/ventral striatal (VC/VS) region and the anteromedial subthalamic nucleus (amSTN) region in the same patients. They tested to determine the differences on mood and cognitive flexibility and associated neural circuitry. They also used cognitive behavioral therapy throughout the process.
Each patient received DBS in one region at a time, then at a separate time in the other region. Each patient received significant improvement of OCD symptoms following DBS to each site. But they didn’t get any real additional improvement after having stimulation to both sites at once.
But listen to this – It was so exciting to find that when patients received DBS to the VC/VS region, they experienced improved mood. When they received DBS to the limbic STN area, it improved their cognitive flexibility without affecting their mood at all.
Better Treatment Targets
So while DBS was effective for OCD symptoms at both targeted sites, this implies that if a patient is having more difficulty with co-morbid depression, then she might receive relief for both conditions following DBS to the VC/VS region. However, if the patient’s greatest difficulty is with rigid cognitive thinking and needs more cognitive flexibility, then the NAc region might be the preferred target for DBS. Very cool. How many more sites can be mapped for this?
All in all, this study opened up more possibilities to be investigated for treating OCD by isolating the specific sub-symptoms different people endure. Just imagine how much more effective OCD treatment could be if we were able to identify the targets in the brain where stimulation would relieve each OCD symptom.
OCD: Better Treatment Targets Will Improve Quality of Life
At Innovative Psychiatry, we’ve worked with a variety of treatments for OCD including SRIs, Transcranial Magnetic Stimulation (TMS), and IV ketamine treatment. Both TMS and ketamine treatment continue to be studied to improve outcomes for patients with OCD. There’s lots of work to be done still. And so we keep a close eye on advancements in neuroscience research to help us provide the most personalized care possible at this point.
With each passing year, we hope for more discoveries to guide us to more and more finely-tuned options.
Effective Treatment Includes Tools to Restore What’s Missing
If you suffer from a disorder that has not responded to multiple treatment strategies, call us. We specialize in finding effective treatment for your individual symptoms. No matter what advances are being made in psychiatry and neuroscience, if you don’t feel better, it’s hard to see the relevance. We get that.
