By Dr Hena Jawaid, Psychiatrist
The Contemporary Age
The modern era is moving to apply the holistic approach in practice of medicine. This practice takes an individual as part of society, treating him with consideration of his/her role, responsibility, emotionality and association with other people in his/her living setting, and not only focusing on the biological part of the illness. It implies anticipation of the social and psychological sequel of illness so that appropriate preventive or therapeutic measures can be provided on time.
Thus, World Health organisation (WHO) has emphasised not only on physical, mental and social domains of health but also stressed upon the fact that merely absence of illness does not rule out its presence.
Considering basic mental health in the third world countries seems like talking about some luxurious facility. As scarcity in the provision of primary health measures have diminished the significance of mental health.
Long-term stresses and repeated traumatic events jeopardise individual's thinking, judgment, and productivity on personal level. Before proceeding forward, two things should be cleared as how science defines trauma and classifies it in terms of its influence on human beings.
A traumatic event is defined as “an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others.”
It is further classified into two classes Type I and Type II Trauma.
Type I deals with a single, dangerous and catastrophic event like an earthquake, tsunami or flood; whereas type II deals with sustained, repeated and series of stresses. It also includes human-designed stresses; like sexual or physical abuse or combat (1).
The Psychological Sequel of Trauma
According to studies on the psychological impact of these traumas; type II is said to contain more prolonged, strained effects and leads to self-destructive behaviour. The constellation of these problems often stated as “Complex Post Traumatic Stress Disorder”.
Personal and Social Trauma
Unfortunately, today the whole world is going through both kinds of traumatic violence. On collective level, we are facing natural disasters; like rainfalls, floods, hurricanes, earthquakes (with no proper fulfillment of biological needs afterwards) and man-made political violence (suicide bombings, assassinations, mass murder of health communities [polio team]), ethnic-conflicts (blasts at mosques/churches/synagogues, martyrdom/assassination of politico-religious figures, shootings on school buses, explosions at academics).
On the other hand, on individual level crimes (homicide, acid disfigurement, rape, harassment, persistent threats for illegal monetary share, kidnappings and interpersonal vengeance), a provisional crisis like deficits of electricity, clean water resources, inflation and opportunistic crisis in form of economic frustration.
Social Manifestations of Trauma
Amid of such chaos, there are explicit findings of different suicidal patterns; that have surfaced out including the killing of children by parents and subsequent suicide of themselves. Beside increment in suicidal ratio, it can be noted that threshold of the general population regarding tolerance has decreased significantly; pertaining to the prevalent status which is characterized by a lack of education and submerging heritage of ethics, one can easily feel the intellectual activity, and decision-making abilities are affected too.
Use of substance like Heroin, Cannabis, Alcohol, Ecstasy, and Cocaine also increased which is prominently consumed as a part of personal coping to stressors. Pleasure seeking behaviours have increased (reflected by contents of billboards and media presentations) which are mostly focused on fulfillment of physical desires including eating habits, indulging in different sexual practices, perversions and other self-harming attitudes like addictions of various drugs.
Intellectual Decay and Religious Fanaticism
When a strained person is asked to contemplate, then it’s a natural reflex to seek easy way out for things to avoid effort. Playing shortcuts and tricks become a central theme when any society quits thinking. One should never forget that the logic and rationality are imperative attitudes of life and a demand of one’s mind to recognize existential purpose. Morality is also observed to be at stake in parallel to this intellectual decay (2).
A moral-based approach reduces in various aspects of social life in such a trauma-ridden society where one can easily find a general demoralizing trend in a community secondary to regressive grounds of personal values of individuals. To fill this void, religious fanaticism takes place. This reaction further restricts the capacity of freethinking of common men.
No Society prospers or progresses by the mere presence of physical health. Mental health is as significant for keeping individual’s sanity and motivation alive as it is ought to be. But, basically the deprivation of health community services and the lack of integrated network services to treat bio-psychological and emotional effects of trauma are raising a question in our minds as what we are going to deliver to our next generation?
Cite this article as-
Hena Jawaid (2017). The Effects of Trauma on Mental Health. The Beautiful Space-A Journal of Mind, Art and Poetry. October 2017: TBSB124
Continued cannabis use in people with a first-episode psychosis – why checking on their prescribed medication use actually needs to be addressed.
By Dr. Minal Mistry, Psychiatrist
First episode psychosis refers to the first time that a person may experience psychotic symptoms or a psychotic episode. Psychotic symptoms include hallucinations, delusions and disorganized thinking which can be very distressing, and leave the person confused, distressed and frightened. Early Intervention Psychosis teams, within the mental health services, will usually encounter young people suffering a first-episode psychosis, and are adept at helping them. However, even with the specialist help, risk of these people becoming unwell is becoming too much of a frequent reality.
First-episode psychosis relapse.
There is a potentially high risk of people with a first-episode psychosis becoming unwell again i.e. relapsing. Relapse has obvious implications for the person with the psychotic illness and their families. If doctors can identify who is at risk of relapsing, then there is a chance that we can prevent the chances of that person relapsing. With this in mind, there are factors we already know that are worth looking at in those with a first-episode psychosis, who are usually our young people:
Research up to now?
Research already showed a possible relationship between these two factors i.e. CCU increased the risk of MNA but it has remained unclear about the mechanism:
The Lancet Psychiatry Study!
This study was impressive:
So, what is the significance of this?
The implications of this latest British research are:
Cite this article as-
Minal Mistry (2017). Continued cannabis use in people with a first-episode psychosis – why checking on their prescribed medication use actually needs to be addressed. The Beautiful Space-A Journal of Mind, Art and Poetry. September 2017: TBSB123
By Dr Nosheen Kazmi, Trainee Psychiatrist ( CT2)
What is OCD?
Obsessive-compulsive disorder (OCD) is a mental disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), and behaviors that drive them to do something over and over (compulsions). Often the person carries out the behaviors to get rid of the obsessive thoughts.
Who is at risk?
Factors that may increase the risk of developing or triggering obsessive-compulsive disorder include:
CAUSES OF OCD
Obsessions often have themes to them, such as:
As with obsessions, compulsions typically have themes, such as:
When to see a doctor?
If your obsessions and compulsions are affecting your quality of life, see your doctor or mental health professional.
LIFE STYLE AND HOME REMEDIES:
-Take your medications as directed
-Pay attention to warning signs
-Check first before taking any other medications
-Practice what you learn
Problems resulting from OCD may include, among others:
Cite this article as-
Nosheen Kazmi (2017). Obsessive Compulsive Disorder Explained. The Beautiful Space-A Journal of Mind, Art and Poetry. August 2017: TBSB122
By Dr Beenish Memon, Psychiatrist
People with mental illness have three times more A&E attendances and five times more emergency inpatient admissions than people without mental illness (Dorning et al., 2015). This does not come as a revelation when patients with severe enduring mental illness are more prone to develop co-morbid physical health conditions (De Hert and others, 2009), and their life expectancy is reduced by 10-30 years (Bressington et al., 2014).This reckons that a more holistic approach to physical and mental health is needed.
Treat as one is a recent report from the National Confidential Enquiry into Patient Outcome and Death published in Jan 2017 which outlines the findings of a recent review of the mental health care provided to patients who attend UK general hospitals with physical health problems. Those of you who haven’t come across NCEPOD before, their object is to assist in maintaining and improving standards of care for patients, and they do this by very well organised national surveys and research.
The study was put forward by Dr Natasha Robinson, formerly Associate Medical Director and Consultant Anesthetist at Northampton General Hospital. The full report is quite lengthy, nevertheless worth a read for the details.
It is evident from their report that mental health patients being treated for physical disorders are seriously disadvantaged. This report has drawn attention to the gap between mental and physical health services. It highlights some very important causes for these divisions are
To overcome this split between mental and physical healthcare it has been suggested that
Good quality working between general hospital and psychiatric hospitals can help the staff to work with confidence, and manage risk better. We not only need to improve mental health care but also physical health care provided to mental health patients in General hospital and community.
There needs to be a more robust system to allow communication and sharing of relevant Information Between various healthcare providers.
Finally, at present moment, patients access mental health needs and physical health needs via different doors, it is detrimental to a person’s overall well-being to regard these as two separate entities. Thus maybe it’s time patients just need one access for treatment of all of their healthcare needs?
Alleway, R. (2017). NCEPOD - Mental Health in General Hospitals: Treat as One (2017). [online] Ncepod.org.uk. Available at: http://www.ncepod.org.uk/2017mhgh.html
Bressington, D., Mui, J., Hulbert, S., Cheung, E., Bradford, S. and Gray, R. (2014). Enhanced physical health screening for people with severe mental illness in Hong Kong: results from a one-year prospective case series study. BMC Psychiatry, 14(1).
De Hert, M., Dekker, J., Wood, D., Kahl, K., Holt, R. and Möller, H. (2009). Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). European Psychiatry, 24(6).
Dorning, H., Davies, A. and Blunt, I. (2015). Focus on: People with mental ill health and hospital use: Exploring disparities in hospital use for physical healthcare [online]. London: The Health Foundation and Nuffield Trust. Available at
Cite this article as:
Beenish Memon (2017). Treat as One: new report highlighting gap between physical and mental health services. The Beautiful Space-A Journal of Mind, Art and Poetry. August 2017: TBSB121
By Dr. Minal Mistry, Psychiatrist
Psychosis and immigration
We are currently seeing the highest rates of immigration than ever in society, which is likely to increase with more migrants entering western countries looking for a better quality of life for themselves and their families. However, there is another side to immigration that has attracted mental health research: the known association of migration with certain psychiatric conditions. For instance, a psychotic condition such as schizophrenia has been known have a higher incidence amongst immigrants compared with nonimmigrants. This finding is particularly well established in some European countries – the Netherlands, Denmark, Germany, the United Kingdom (UK) – and Canada.
The missing part of this jigsaw – the missing link – is whether the psychosis seen with those who migrate are associated with actual biochemical abnormalities i.e. does the social mobility seen in migration, a risk factor for psychosis, manifest with biological changes in the brain?
We may finally have an answer to the question of whether the migration-induced psychosis plays out with biochemical brain changes. We already know that dopamine is the key neurotransmitter implicated in people with a psychosis – increased dopamine function in an area of the brain called the “Striatum”. Alice Egerton at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK, has conducted research in this area (see “Dopamine and schizophrenia research paper” in “useful information” section of this blog).
Alice Egerton has now published a new paper, thanks to her collaboration with colleagues in UK and Toronto (Canada), to show that dopamine function is indeed elevated in those who migrate (and similar findings were found in the children of those who have migrated).
“These data provide the first evidence that the effect of migration on the risk of developing psychosis may be mediated by an elevation in brain dopamine function.” (see Dopamine and immigration research paper)
Why does migration increase the risk of Schizophrenia?
We do not really know the answer to this question, but there are theories regarding contributing factors, as Alice Egerton goes on to explain in her UK-Canadian study paper that it is the role of stress brought about by migrants being at increased risk of:
What is the significance of this study?
Firstly, I am excited by the findings of this paper as it unearths an interesting connection between social and biological components of mental illness especially with respect to the “stress-vulnerability model”. As the authors of the study remark:
“This suggests that adverse psychological, social, and environmental experiences associated with immigration may increase the risk of schizophrenia by influencing brain dopamine function, a key pathophysiological component of psychosis.”
Secondly, and more importantly for me, it highlights the strong social component of mental illness especially as a mediating factor in determining the risk of developing biological abnormalities in our brains that increase risk of developing a serious psychiatric condition. Why is this part so important? It is important because psychosocial factors can be remedied. For instance, we can intervene to reduce the problems of social isolation and discrimination that migrants may endure – by intervening in this way we help reduce mental illness as well as practicing kindness in welcoming those to come to our country looking for a fresh start in life.
Egerton A Chaddock CA Winton-Brown TT et al. Presynaptic striatal dopamine dysfunction in people at ultra-high risk for psychosis: findings in a second cohort. Biol Psychiatry. 2013;74:106–112.
Egerton A, Howes OD, Houle S, McKenzie K, Valmaggia LR, Bagby MR et al. Elevated Striatal Dopamine Function in Immigrants and Their Children: A Risk Mechanism for Psychosis. Schizophrenia Bulletin. 2017 Jan 5. Available from, DOI: 10.1093/schbul/sbw181
Cite this article as:
Minal Mistry (2017). The social-biological connection in immigration and psychosis: The missing link. The Beautiful Space-A journal of Mind, Art and Poetry. July 2017: TBSB120
Are antipsychotics safe? International panel of experts reveal that benefits outweigh potential risks.
By Dr. Minal Mistry, Psychiatrist
My first blog on the Beautiful Space was about depot (injection) antipsychotics in young people. I wrote about the benefits of these medications, but did not raise the question regarding the safety of them. This is a highly relevant question because there have been concerns over the years about the side effects and long term safety of psychotropic medication such as antipsychotics.
Today we will focus on antipsychotics, medications that are commonly prescribed for people with conditions in Schizophrenia, but also used to treat Bipolar Disorder and as an add-on therapy in those who are depressed. The prevalent use of these drugs in a range of conditions begs the question: Are antipsychotics safe?
Antipsychotics, also known as “neuroleptics” or “major tranquilizers” are the cornerstone of treatment for Schizophrenia. Antipsychotics are divided into two main classes:
Are antipsychotics safe?
The safety of antipsychotics, even with the second-generation ones, have often been questioned. It should be noted that these concerns are valid. As shown by a 2006 paper by Dr John Newcomer and Dr Dan Haupt in the Canadian Journal of Psychiatry, metabolic effects (weight gain, insulin resistance, hyperglycemia, dyslipidemia, and type 2 diabetes mellitus) have been well established for over 10 years, and known about for much longer. Other concerns relate to questions about other potential adverse effects including impact on brain volume.
Question: So, what do we really know about the long-term effects of these drugs now in 2017?
Answer: Enter this month, a study published in the American Journal of Psychiatry.
Study into long-term effects of antipsychotics
Professor Donald Goff, based in New York, is a psychiatrist who has published 100’s of papers in the past 30 years. His research focus has been on Schizophrenia and antipsychotics. His most recent instalment in this impressive research portfolio is that he is first author of a review involving other experts around the world. This has led to a May 2017 publication in The American Journal of Psychiatry: The Long-Term Effects of Antipsychotic Medication on Clinical Course in Schizophrenia.
This study involved the merging of an international group of experts (from various sub-disciplines) in order to answer, once and for all, questions about the long-term effects of antipsychotics by examining theoretical and clinical research in this area. These experts concluded: “Little evidence was found to support a negative long-term effect of initial or maintenance antipsychotic treatment on outcomes, compared with withholding treatment”. In other words, the latest expert advice has reached a consensus that the benefits of these medications outweigh any potential side effects.
Although they acknowledge that stopping antipsychotic treatment or using non-drug treatments may benefit some patients with Schizophrenia, the experts also concluded that “early intervention” to reduce the time of untreated psychosis may improve long-term outcomes. This fits in well with my earlier blog on the Beautiful Space (“Schizophrenia: starting depot medication early may help”) where I described research reporting the benefits of starting treatment early.
There has been much scepticism in recent years regarding the effectiveness of drugs in psychiatry. For instance, antidepressants have been heavily criticised for their lack of benefits and potential for side effects. Another class of drugs is the antipsychotics, which may be slightly more convincing in their benefits compared with antidepressants, but there has been considerable debate regarding their potential toxic effects. Hopefully this latest research involving worldwide experts can allow doctors, and their patients, to have a more informed discussion as to whether these medications should be used or not.
Cite this article as:
Minal Mistry (2017). Are antipsychotics safe? International panel of experts reveal that benefits outweigh potential risks. The Beautiful Space-A journal of Mind, Art and Poetry. June 2017: TBSB119
By: Dr Aadil Jan Shah, a Psychiatrist
What is spice?
Spice is a synthetic cannabinoid drug sometimes known as “fake weed” because of its similarity to cannabis. Synthetic cannabinoids (SCs) are also referred to as synthetic cannabimimetics or synthetic cannabinoid receptor agonists. The chemicals in the drugs attach themselves to same nerve cell receptors as THC, the mind-altering substance found in cannabis, but can have much stronger effects. They have a strong effect on the endocannabinoid system.
The term ‘Spice’, is the brand name of one the most common synthetic cannabinoid products sold in Europe and is often used as a generic term for all synthetic cannabinoids.
In the pure state, Spice or synthetic cannabinoids are either solids or oils. Smoking mixtures are usually sold in metal-foil sachets, typically containing dried vegetable matter to which one or more of the cannabinoids have been added. Sachets usually contain 0.5–3 g of finely ground plant material. Most synthetic cannabinoids are produced in China and exported, usually in powder form, using wrong declarations, such as ‘polyphosphate’, ‘maleic acid’, ‘fluorescent whitening agent’ or ‘ethyl vanillin’. Once in Europe, the retail products are assembled by lacing inert herbal products with synthetic cannabinoids. They are then dried and packaged for sale.
Spice in the UK has gained popularity, among adolescents and young adults and prison populations. Spice use in the homeless community has been ‘creeping up’ for some years. A recent news item suggested that the police in Manchester are battling an epidemic of the use of spice and attended nearly 60 incidents related to the drug in the city centre in one weekend.
Those who take spice are often left incapacitated or seriously ill and are often referred to as “Zombies”. They can also become aggressive and become a danger to themselves and others.
Is spice legal?
The mind-altering substance in Spice, JWH-018, was banned in 2010 – but manufacturers started to change its formula so that they could continue to sell it.
The Psychoactive Substances Act 2016 made it an offence to produce or supply any substance intended for human consumption that is capable of producing a psychoactive effect, with exemptions for alcohol, tobacco and other “legitimate” substances.
Before the ban in 2016, spice and other so-called legal highs were available to purchase online and in head shops. They were often sold as plant food and were labelled as not fit for human consumption.
How is spice taken?
The primary route of administration of is inhalation, either by smoking the ‘herbal mixture’ as a joint or by utilising a vaporiser, bong or pipe. Both oral consumption and snorting of the compounds have also been described. There are also reports that it can be ingested as an infusion, although this is rare.
Effects of Spice on your brain?
The desired effects of spice are similar to those of cannabis intoxication and include relaxation, altered consciousness, disinhibition, a state of ‘being energised’ and euphoria. The effects on brain include cognitive impairment, behavioural disturbances, changes in mood and sensory and perceptual abnormalities (both auditory and visual). Spice is more likely to be associated with hallucinations than cannabis. There can also be negative mood changes, irritability, paranoid thoughts, difficulties with memory and severe anxiety.
There has also been evidence of sedation, while other users have reported agitation.
What does spice do to your body?
Spice can cause sickness, hotflushes, burning eyes, mydriasis and xerostomia (dryness in the mouth). The most commonly reported unwanted physical effects are nausea and vomiting. It can also cause fast heart rate, changes in the blood pressure, etc
Because the make-up of spice is constantly varying, its effects can greatly differ. Many chemicals used in spice and other drugs are as-yet unidentifiable, and as such research has not yet made clear exactly how the brain is effected
Spice use has been linked to a rising number of emergency department visits and some deaths.
Features of acute intoxication
2. Cardiac- Tachycardia, hypertension, chest pain, palpitations, ECG changes
3. Renal- Acute kidney damage
4. Muscular- Hypertonia, myoclonus, muscle jerking, myalgia
5. Other - Cold extremities, dry mouth, dyspnoea, mydriasis, vomiting, hypokalaemia.
Loss of eyesight and speech also reported.
Management of acute toxicity
Spice cannot be detected by the routine drug screening tests although laboratory techniques have been developed to detect some compounds, but there are currently no widely available tests. One has to heavily rely on the history and presenting symptoms.
Symptoms of intoxication may be self-limiting and resolve spontaneously. In the emergency departments, hydration and monitoring may be enough for patients with mild to moderate intoxication. Benzodiazepines may be of benefit to patients who present with symptoms of anxiety, panic and agitation. Antipsychotic medication may be indicated for some patients, especially those who present with agitation or aggression, when the patient has a history of psychotic disorders, and when the psychotic symptoms do not remit spontaneously or with supportive care. The management of spice toxicity is symptomatic and supportive, as no antidotes exist. Supportive treatment is dependent on a patient’s specific presentation.
For up-to-date guidance on the management of acute toxicity related to synthetic cannabinoids, it is recommended that information be sought from the National Poisons Information Service (NPIS), specifically the NPIS 24-hour telephone service and the poisons information database TOXBASE®: http://www.toxbase.org/Poisons-Index-A-Z/S-Products/Synthetic-Cannabinoid-Receptor-Agonists/
Dealing with dependence
Spice may have a higher addictive potential than cannabis, due to the quicker development of tolerance. The withdrawal symptoms could include drug craving, nocturnal nightmares, profuse diaphoresis, nausea, tremor, hypertension and tachycardia. Psychosis has also been reported among frequent users.
Psychosocial interventions remain the mainstay treatment for dependence apart from symptomatic management with medications like benzodiazepines, antipsychotics and antidepressants.
Overall a multi-agency approach is needed to deal with this problem, and this includes public awareness and education about the effects of synthetic cannabinoids including spice.
1.The Guardian, Manchester police attend 58 spice-linked incidents in one weekend, 10/04/2017.
2. TOXBASE®: http://www.toxbase.org/Poisons-Index-A-Z/S-Products/Synthetic-Cannabinoid-Receptor-Agonists/
3. Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances, Novel Psychoactive Treatment UK Network (NEPTUNE), 2015
Cite this article as:
Aadil A Shas (2017). Spice: The Zombie Drug: The Beautiful Space-A journal of Mind, Art and Poetry. May 2017: TBSB118
By Dr Javed Latoo, a Psychiatrist
One thing I particularly admire about my psychology colleagues is that they evolve, innovate, adapt and change, unlike my psychiatry colleagues. Once they realise their treatments like CBT or Mindfulness can be given even by those who are not psychologists, they innovate something new like Mindfulness based CBT called MCBT. Once they realise someone else can do MCBT as well, they will innovate something new. Fifteen years ago many psychologists would frown on the diagnosis of personality disorders made by psychiatrists. They would not even believe in the diagnosis of personality disorders. Today most of personality disorders services are run and led by psychologists.
Psychology until recent times mainly focussed on the treatment of mental illness like depression and anxiety and combating negative thinking. It was not until early 1980's that a new branch of psychology popularly known as Positive Psychology developed under the guidance of its founder Martin Seligman. Positive emotions like Happiness, Gratitude, Kindness and Compassion became a focus of research to understand ways to improve well-being, contentment, and happiness.
Positive Psychology or pursuit of happiness has become a multi-billion dollar industry. Happiness gurus, pundits, self-help books, DVDs, talks, and mindfulness are all part of this movement. All are trying to help people to achieve happiness by the development of positive emotions. This industry has become particularly popular in the West. Most of the information contained in these resources is centuries old and is part of traditional eastern wisdom, philosophy, and major religions. We have now realised that our economic prosperity in last few decades has not necessarily increased general happiness or contentment of people or nations.
Function of negative and positive emotions
As humans, we experience both positive and negative emotions. Both play a significant role in our being. Research has shown that negative emotions play a vital role in our lives. For example, an emotion of anger helps us to correct injustice. As far as anxiety is concerned, it can warn us about impending dangers. Do positive emotions have any survival role?
While studying positive emotions, Barbara Fredrickson developed her Broaden-and-Build model. She proposes that when we are in the negative emotional state, we develop cognitive tunnel vision that can narrow our cognitive range. But if we are in the positive mental state, we have broad cognitive range and tend to think more broadly. We already know from our experience that we tend to be more social and interactive when in the positive mental state as compared to when we are in the negative mental state.
A recent survey by Columbia University and Sustainable Development Solutions Network (SDSN) reported that Norway, Denmark and Iceland are three happiest countries in the world. Even though Qatar is the richest country in the world, it did not even rank in the list of top 20 happiest countries. The USA ranked 14 on happiness index despite being a country with the largest economy. Again Japan is at 51st place even though it has the longest life expectancy. This survey highlights that money, or high life expectancy does not necessarily make people happy.
As we all have probably heard about there being two ways to look at life " glass half full or glass half empty." People who look at life as "glass half full" are more optimistic, less stressed, and have increased contentment with their lives. Studies have shown people who maintain a regular gratitude journal can be more positive, less stressed, less anxious and more satisfied with their lives as compared to those who don't write a gratitude journal. Amy Morin summarises benefits of Gratitude including better sleep, mental health, physical health, relationships and self-esteem. These reports are not surprising as this research again confirms ancient wisdom on gratitude contained in most major religions and eastern traditions.
We all know that emotions like compassion and kindness can have a positive impact on our lives. Loving-kindness meditation is an exercise to develop compassion and kindness. Though it is part of all the main religions. Meditation guru Sharon Salzberg popularised it in the West. A study by Helen Weng has reported that daily practice of loving-kindness meditation can not only increase empathy, but it can also make one more altruistic. Thus compassion, kindness, and altruism can be learned through an exercise called loving-kindness meditation. In another Barbara Fredrickson reported that loving-kindness meditation could increase the daily experience of positive emotions as well as an increase in personal resources including purpose in life.
Benefits of positive emotions
Studies have highlighted following advantages of various positive emotions
Strategies to promote positive emotions
Researchers like Judith Moskowitz have studied various strategies that can us help with developing positive emotions. Research now supports some of following strategies to develop positive emotions
Reference and further reading
Jason M Satterfield ( 2015) Cognitive Behavioural Therapy: Techniques for Retraining Your Brain. The Great Courses
Cite this article as:
Javed Latoo (2017). Developing Positive Emotions: The Beautiful Space-A journal of Mind, Art and Poetry. April 2017: TBSB117
By Dr. Minal Mistry, Psychiatrist
In my professional practice, I diagnose and treat people with “Post-traumatic Stress Disorder”, or PTSD. I work in a specialized clinic for veterans and a general mental health clinic, and have noticed how common PTSD is becoming. PTSD has a lifetime prevalence of 7.8% in adult Americans, with women twice as likely as men to develop the disorder. PTSD is a widely recognized mental disorder that is potentially very disabling and impacts on the sufferer and their loved ones.
What is PTSD?
You may have heard of PTSD from the media as a condition that can affect ex-military and first responders who have been exposed to life threatening traumatic incidents in the course of their work e.g. war combat. You may have also come across people in the general population who suffered PTSD as a result of being involved in severe events - natural disasters such as earthquakes.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM–5), symptoms to watch out for include:
Cancer and PTSD associations
A qualitative review, published in The Lancet this year, confirmed the connection between PTSD and cancer based on the trauma of dealing with a life-threatening medical diagnosis such as cancer. This strikes a chord with me as a close family member of mine received a diagnosis of cancer recently. The latest research suggests links between cancer and PTSD.
The researchers, Cordova and colleagues, showed that 37-60% of cancer survivors had PTSD symptoms. Specific aspects of phases of cancer diagnosis acting as a trauma include: events prior to an official diagnosis being made (“cancer-scare”), receiving the diagnosis, undergoing investigations with associated uncertainty, and worry about the cancer returning. They also state that, amongst other risk factors, having a prior history of trauma correlates with cancer-related PTSD.
The authors have stated that are warning signs that may predict who are more likely to get PTSD:
Cardiovascular disease is a consequence of, and a risk factor for, PTSD
We already know that cardiovascular disease (e.g. heart disease) and depression are closely linked because depression is a risk factor for heart disease, and having heart disease can increase the risk of depression. However, another 2017 The Lancet paper, a large systematic review and meta-analysis by Donald Edmondson and Roland von Känel, adds to this knowledge with respect to cardiovascular illness and PTSD.
Similar to the cancer and PTSD research, the authors stated that the environmental factors involved in receiving diagnosis and care for cardiovascular disease (e.g. being in an overcrowded emergency room, perceived poor communication with the clinician, exposure to other people who are close to death, and intensive care unit stay) may increase the likelihood of subsequent PTSD. They also revealed that the reverse is true: PTSD increases the risk of cardiovascular events by 53% (or 27% when the results were adjusted to take into account depression).
The researchers also raised our attention to warning signs to help predict who is more likely to experience PTSD-induced cardiac problems:
What does all this mean?
The significance of the findings from these Lancet research papers is two-fold:
The importance of understanding how our mental health interacts with our physical health (mind-body connection) should not be underestimated. We must look after our health so that our physical and mental health is being addressed simultaneously since they are intricately linked. Regardless of whether we are going through mental or physical illness, non-medication strategies (e.g. yoga, meditation, exercise, keeping active, healthy eating and lifestyle changes) can create harmony between the physical and mental – hopefully leading to a happier and healthier path in life.
Cite this article as: Minal Mistry (2017). Post Traumatic Stress Disorder and Physical Illness: The Beautiful Space-A journal of Mind, Art and Poetry. April 2017: TBSB116
By Dr Javed Latoo, Psychiatrist
Psychiatry is a branch of medicine that deals with disorders of the mind. The mind has a physical understructure called the Brain. According to the most accepted current theory of mind, Functionalism, the brain is like a hardware and mind is like a software of a computer.
The brain is the most complex organ of the body even though it weighs only three pounds on an average. Some of the hair-raising facts about brain include that on average a brain contains about 100 billion brain cells called neurons and each neuron connects with about 40,000 synapses. It is estimated that a human brain can generate around 50,000 thoughts per day. Due to such complexities, the brain is often referred as the "three-pound universe."
Even though we use the brain and the mind for every action, their complete functioning is still hidden from our plane sight, and unfortunately, our eyes cannot see beyond our noses. We still don't know a lot about the Brain. However, due to advances in brain imaging technology and neurosciences, our understanding of the functioning of the brain and its role in mental illness is improving and is going to improve vastly over the next two decades. I believe a forest of new knowledge about the brain and mind is waiting to be discovered.
However, due to the nature of the territory psychiatrists deal with, there may always be an element of uncertainty about the exact nature of things as Psychiatric disorders develop at the fence of the matter( Brain) and non-matter ( Mind).
Psychiatry is not the only branch of medicine or science that is shrouded in a degree of uncertainty. We now know even our physical world, we are so certain about, is characterised by uncertainty and unpredictability at the Quantum ( sub-atomic ) level. The Uncertainty Principle, also known as Heisenberg's uncertainty principle, in the field of Quantum Mechanics was proposed only to highlight our limitations to know things with certainty. The principle of uncertainty was considered a blow to the believers of absolute Determinism.
Even though we do not know the exact cause of chronic psychiatric illnesses like Schizophrenia or Bipolar Disorder, but we know a lot, indirectly, by the effectiveness of medication and their mechanisms of action. Various psychiatric medications including antipsychotic and mood stabilisers are very effective drugs that help many patients to live a productive life in the community.
Regarding the exactness of causality, it is important to emphasise here that psychiatric illnesses are not different from physical health conditions. There are many physical health problems ( too many to produce an exhaustive list here) where we do not fully understand the cause of the condition. In many physical health conditions also, ( e.g. Hypertension, Cardiomyopathy, Parkinsons Disease, Multiple Sclerosis, Sarcoidosis, Pulmonary Fibrosis, Bronchiectasis, Ankylosing Spondylitis, Chronic Fatigue Syndrome, Autoimmune Hepatitis, Ulcerative Colitis, Crohns Disease, Fibromyalgia, types of Glomerulosclerosis and Arthritis), we do not know the cause of the condition.
In the medical field, we often use a word idiopathic when we do not know the exact cause of the problem. For example, In 95% of essential hypertension cases, the cause of the hypertension is not known. However, we still treat them with medications including anti-hypertensive to stabilise blood pressure and reduce risks associated with high blood pressure.
Curability and chronicity
There is another misconception among doctors as well as the public that most physical health conditions are curable as compared to psychiatric disorders. I probably would run out of space to mention all medical conditions by name that cannot be cured like some mental illnesses. My colleagues in Primary care, Internal Medicine, Cardiology, Respiratory Medicine, Neurology, Geriatrics, Rheumatology, Dermatology, Oncology and many other medical specialities spend most of their time in the management of chronic physical conditions that can only be treated but not cured.
Hypertension, Ischemic Heart Disease, COPD, Bronchiectasis, Rheumatoid Arthritis, Diabetes Mellitus (DM), Osteoporosis, Parkinson's disease, Multiple Sclerosis, AIDS, Chronic Liver Disease, Chronic Kidney Disease, Hepatitis B, Hepatitis C and SLE are just some of the chronic physical conditions that immediately come to my mind. Just like some psychiatric conditions, these physical conditions are treated to improve symptoms, improve the quality of life and reduce risks without any permanent cure.
On the contrary, many patients who develop a depressive episode might not have another episode and thus is potentially a curable disease. One fourth of Schizophrenia patients have only one episode and can achieve complete recovery with medications.
Just like many chronic physical conditions like DM, COPD, Asthma, Arthritis, Hypertension and Parkinson's Disease, many psychiatric patients would need long-term treatment to stabilise symptoms and improve the quality of life. Treatment significantly reduces relapses, readmissions, and risks to themselves or others. Most of the psychiatry conditions can be successfully managed, and patients can make a reasonable recovery on various effective treatments available including medication and talking therapy.
Just like physical conditions, including Hypertension, Diabetes, Ischaemic Heart Disease, COPD, and Asthma, many psychiatric patients may need more than one medication to control symptoms. In short, both psychiatric and physical conditions can be chronic as well as incurable, but they can both be treated to minimise symptoms, reduce risks, reduce hospitalisations and improve the quality of life.
What needs to change
We, as doctors, need to change our attitude by improving our knowledge about psychiatric conditions. Both physical and psychiatric conditions can be idiopathic (unknown cause), treatable, curable, incurable, acute and chronic. Both, physical as well as psychiatric conditions, may need short term or long term treatment. Both may need one or more than one medication or treatment to reduce symptoms. Moreover, both types of conditions can be treatment resistant. Education should start at medical school when attitudes are developing.
We need to educate patients by drawing comparisons between psychiatric and physical conditions. In my clinical practice, I have found these comparisons very helpful and efficient to educate patients, carers and healthcare professionals about the causation, treatability, curability and prognosis. Above all this education helps to infuse a hope. It also contributes to improving compliance with treatment as well as the acceptability of the diagnosis and management.
Awareness about the uncertainty being a feature of whole medicine and physical world is vital. It is important to impart a hope by talking about treatability as well as potential curability of psychiatric conditions by drawing comparisons with physical conditions. Such an approach may go a long way in combating the stigma of mental illness among patients, carers, and healthcare professionals. I believe, given the complexity of brain and mind, psychiatrists need to have the shoulders of an ox. They not only need to treat their patients but also become advocates of their vulnerable patients and educate both patients as well as their medical colleagues in other branches of medicine.
Take Home Points
Cite this article as:
Javed Latoo (2017). Causation and curability in psychiatry and other branches of medicine. The Beautiful Space-A journal of Mind, Art and Poetry. March 2017: TBSB114
By Dr Hena Jawaid, Psychiatrist
Alcoholism in teenagers is a common problem these days. It has various implications and effects on the individual and collective level. On a biological level, it can cause liver damage, hypertension, ischemic heart diseases, stroke, sensory deficits and gastric problems. Well, on the psychosocial level the manifestations like social disinhibition, confusion, impaired executive functioning, depression, psychosis (disconnection from the reality) and anxiety can take place.
On a collective scale, from a biological point of view, alcoholism is an inheritable trait. For example, if a father is a heavy drinker then the son would ultimately be at-risk. On the psychosocial scale, teenagers get into heavy drinking by modelling their elders, road-traffic accident secondary to driving under the influence (DUI), legal problems, and issues like abuse and violence can be surfaced.
What one can do to prevent youngsters from diverting towards the substance use is to identify those who can be at risk!
Recently, the study was done in California (1) that recruited 137 substance naïve adolescents (ages 12-14). Neuropsychological testing and structural and functional magnetic resonance imaging (sMRI and fMRI) were conducted. These adolescents have followed annually. By age 18, 70 youths (51%) started moderate to heavy alcohol use, and 67 remained nonusers. The aim of the study was to find out the neural predictors of alcohol use by age 18. The identified risk factors are male gender, higher socio-economic status, early dating, more externalising behaviours, and positive expectations from alcohol use.
The previous studies (2) point out lesser brain activation on tasks of working memory (recent or short-term memory), inhibition (social and movement restraints on behaviours in response to environmental situations or demands) and reward processing. The localised areas in a brain for mentioned behaviours can be used to anticipate the alcohol use amongst adolescents. The brain volume in some areas of a brain responsible for impulsivity, reward sensitivity, and decision-making noticed to be reduced (3). The reduced volume in these areas has also been used as a predictor for alcohol and other substance initiation during adolescence. The other interesting feature came out to be the early maturation of neural fibres at adolescent age (4). This can increase the sensation-seeking behaviours and ultimately result in behaviours like early dating, substance use and social disinhibition.
These findings are in line with the previous studies, which were conducted amongst moderate to heavy users to assess biological and psychosocial risk factors for their early use.
These inferences can be translated into clinical practice by identifying the high-risk group to avoid morbidity and mortality in future. The diagnostic tools like fMRI can be employed to screen at-risk group and initiate early preemptive measures.
Similar studies should be conducted in the future too to build the evidence for the Alcohol screening clinics to administer these diagnostic tools besides running screening questionnaires. The early interventions can diminish legal, medical, social and interpersonal complications of an individual and can help in building the healthy society for the generations to come.
Cite this article as:
Hena Jawaid (2017). Alcoholism in Teenage: The Beautiful Space-A journal of Mind, Art and Poetry. March 2017: TBSB115
By Dr Beenish Memon, Psychiatrist
Psychosis is a condition which affects people's mind in such a way that it alters the way they think, feel and behave. They find it hard to separate reality from non-reality. Core clinical symptoms include hallucinations (perceive to hear, see, taste, feel things which are not real), delusions (false fixed beliefs), Thought disorder (patient feels his thoughts are not his own or other people can read their thoughts).They can also present with emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect. When someone experiences any or group of these symptoms for the first time than they are diagnosed as having “First Episode Psychosis ( FEP)”.
What are EIP Services?
Early Intervention in Psychosis services works with people who are at risk of developing psychosis or have been diagnosed as having First Episode Psychosis (FEP). It is crucial that people with FEP are identified, provided with support and treatment early on in their diagnosis as it significantly improves the outcome and prognosis. The delay in treatment or people with long duration of untreated psychosis are difficult to treat and they more likely to experience poor physical health, poor social and occupational functioning and poor educational outcomes.
What led to the establishment of EIP?
Around 1980’s extensive research was done on First episode psychosis and it was identified that delay in treatment in First episode psychosis was leading to high risk of morbidity/disability (Johnstone et al., 1986; Rabiner et al.,1986). It was felt that there was a lack of services available to identify and treat the First episode in Psychosis. In the 1990s there was more evidence to support this (Wiersma et al., 1998) hence early psychosis clinical services were established, first in Melbourne and later on in many important locations in the UK, Europe and North America
Recent changes to EIP and Why?
Recent evidence suggests that Early Intervention in Psychosis reduces the severity of symptoms, risks, relapse rates, and inpatient admissions (Garety et al., 2006; Craig et al., 2004).It is also identified as being cost-effective (McCrone et al., 2011). There is a significant impact on patient’s health, personal and social needs when treatment and support are not provided earlier in the illness.
It is essential to provide better access and care with a full range of interventions recommended by NICE to enable recovery in patients who are at risk of developing psychosis and First episode psychosis. EIP services now treat patients between the age of 14-65 instead of 14-35.
The government in England introduced following New standards in April 2016 for EIP services. These standards are derived from the NICE quality standard for the care of people with psychosis and schizophrenia in adults 2015 (QS80)
EIP have got an open referral policy, and patients can be referred by anyone including Primary care services, family, educational services, and other mental health services.
Finally, new Early Intervention in Psychosis standards and targets introduced in April 2016 are par with The National Cancer targets since they both aim to promote earlier diagnosis, increased access to treatment thus improving survival rates and reducing morbidity and mortality through a variety of means.
1. Johnstone, E.C., Crow, T.J., Johnson, A.L. and MacMillan, J.F. (1986) ‘The Northwick Park study of first episodes of schizophrenia. I. Presentation of the illness and problems relating to admission’, The British Journal of Psychiatry, 148(2), pp. 115–120. doi: 10.1192/bjp.148.2.115.
2. Rabiner CJ, Wegner JT, Kane JM. Outcome study of first-episode psychosis. I: Relapse rates after 1 year (1986) American Journal of Psychiatry, 143(9), pp. 1155–1158. doi: 10.1176/ajp.143.9.1155.
3. Wiersma, D., Nienhuis, F.J., Slooff, C.J. and Giel, R. (1998) ‘Natural course of schizophrenic disorders: A 15-Year followup of a Dutch incidence cohort’, Schizophrenia Bulletin, 24(1), pp. 75–85. doi: 10.1093/oxfordjournals.schbul.a033315.
4. Garety PA, Craig TK, Dunn G, Fornells-Ambrojo M, Colbert S, Rahaman N, et al. (2006) ‘Specialised care for early psychosis: Symptoms, social functioning and patient satisfaction: Randomised controlled trial’, The British Journal of Psychiatry, 188(1), pp. 37–45. doi: 10.1192/bjp.bp.104.007286.
5. McCrone, P., Park, A. and Knapp, M. (2011) ‘Cost-effectiveness of early intervention services for psychosis’, Psychiatrische Praxis, 38(S 01). doi: 10.1055/s-0031-1277798.
6. Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, et al. (2004) ‘The Lambeth early onset (LEO) team: Randomised controlled trial of the effectiveness of specialised care for early psychosis’, BMJ, 329(7474), pp. 1067–0. doi: 10.1136/bmj.38246.594873.7c.
Cite this article as:
Beenish Memon (2017). What are Early Intervention in Psychosis( EIP) services? .The Beautiful Space-A journal of Mind, Art and Poetry. March 2017: TBSB113
By Dr Javed Latoo, Psychiatrist
As humans, we have all experienced stress at some point in our lives. Most of us know how it feels when we are stressed. Stress is a normal response to a stressful trigger or event. It can have detrimental impact on our mental, physical and social well-being if it is prolonged in nature. Stress causes a surge of various hormones in our body including cortisol and adrenaline that can have both physical and psychological consequences.
My motivation to write this article was triggered by a recent study published in a leading medical journal the Lancet as well as the response of my medical colleagues to such research. Their attitude to mental sufferings of their patients due to stress was disappointing. They seem to think stress either does not exist or can't be defined or measured or even treated.
Stress is commonly defined as a response to a perceived threat or challenge that includes biological, behavioural, cognitive, and emotional elements. The stressor can be a real or imagined thing that sets the whole process off. As we all know we can stress ourselves out with things that never happen or might never happen.
We, humans, can get stressed for various reasons including work problems, family problems, legal problems, physical health problems, financial problems and even exams. Displacement due to political conflicts can also be a major source of stress for those involved in such ordeal.
Research has shown that chronic stress has a significant impact on our health as well as social and economic conditions. In the U.K. 10.8 million working days are lost due to stress i.e. 11% of all sickness absence. Work-related stress costs the UK economy > £4 billion every year. People working in the health, social and education sectors are more likely to experience work-related stress.
How stress presents
Individuals who experience chronic stress can present with various problems including mood swings, anxiety, depression, fatigue, headaches, sleep problems, loss of libido, dry mouth, aches and pains, chest pains, poor concentration, increased use of smoking, alcohol, and caffeine. It can even worsen other medical conditions including asthma, psoriasis, and migraine. Various studies have reported that stress can even increase the risk of heart attacks and strokes.
New research shows stress increases cardiovascular events
A recent Harvard Medical School study published in a leading medical journal the Lancet reported an increased risk of cardiovascular accidents including heart attacks and stroke in patients with stress. For the first time, researchers also proposed a model to explain the mechanism behind this increased risk.
The researchers suggested increased stress causes increased amygdalar activity in the brain, leading to increased bone-marrow activity, leading to increased arterial inflammation, leading to cardiovascular disease events involving what they call a neural-hemopoietic-arterial axis. In the past studies had shown that stress increases metabolic activity in a particular area of the brain but now this new study reports that "amygdalar activity independently and robustly predicts cardiovascular events,"
The authors of this study while highlighting the clinical implications suggest that chronic stress could be routinely assessed and managed like the other risk factors for the cardiovascular disease, e.g., smoking, obesity, hypercholesterolemia and high blood pressure.They emphasize that stress is as strong a risk factor as any other and there is need to screen and treat it routinely by health care professionals. The study even suggests that there is a straightforward and useful scale called Perceived Stress Scale PSS10 that can be used to screen stress in our patients. An editorial in the same issue of the Lancet supports this approach of routine screening of chronic stress along with other risk factors for cardiovascular disease.
What needs to change
We know people are reluctant to seek help regarding stress and doctors are not always robust in screening it routinely. Both patients, as well as physicians, need to change their attitude, about stress, given recent research. People working in cardiology, internal medicine, and primary care, particularly, need to get training in assessment and management of chronic stress as a recent study in 151 patients showed that adding stress management to cardiac rehabilitation lowered the risk of 5-year Cardiovascular events by 50%.
There is an urgent need to develop training for doctors so that they can routinely ask patients about stress and offer advice to reduce it. Doctors need to explore the reasons for the stress in their patients and offer management strategies. They may have to treatment medical condition arising due to stress like depression when necessary. Stress can often be managed by ensuring that patients have enough sleep and rest, avoid using caffeine, alcohol or drugs to relieve stress and do regular physical exercise. Patients can also try relaxation techniques like mindfulness, prevent interpersonal conflicts, learn the art of acceptance, learn to say no, manage time in a better way, spend time with their families and friends and commune with nature.
Cite this article as: Javed Latoo (2017). Why doctors need to screen their patients for stress.The Beautiful Space-A journal of Mind, Art and Poetry. February 2017: TBSB112
Dr Abida Sajjad, Psychiatrist
One of the hardest decisions women make during pregnancy is to stop or continue using their antidepressants. It is hard to stop them because untreated depression can have harmful effects on both the mother and the baby. But, taking antidepressants while pregnant may increase the risk of problems for the baby.
Bonari et al report that untreated depression during pregnancy appears to carry substantial perinatal risks. These may be direct risks to the fetus and infant or risks secondary to unhealthy maternal behaviours arising from the depression. Recent human data suggest that untreated postpartum depression, not treated with antidepressants in pregnancy, results in adverse perinatal outcome
Pregnancy has historically been described as a time of emotional well-being, providing "protection" against psychiatric disorder; however, studies have shown that Pregnancy is not "protective" with respect to the risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation(Journal of the American Medical Association)
Recommendations for treatment:
NICE recommends that clinicians should consider following for treatment of depression in a pregnant woman:
Side effects of antidepressants during pregnancy:
Antidepressants do pass through the placenta to the baby, and some studies have suggested that they may be responsible for a small increase in the risk of congenital heart problems. Other studies have not shown this to be the case. It is not known if they increase rates of miscarriage, preterm birth or low birth weight due to conflicting study results.
Around one in every three babies born to mothers on antidepressants, will have mild symptoms of withdrawal which can include jitteriness, poor feeding, agitation and fast breathing. These symptoms usually disappear without the need for any treatment, within the first two weeks of life. There is also a slightly increased risk to these babies of a condition known as Persistent Pulmonary Hypertension of the Newborn (PPHN). PPHN is a very rare but potentially very serious problem causing breathing difficulties in the newborn. The rate of PPHN in mothers who are not being treated with antidepressants is about 1 per 1000, and this increases to about 3 per 1000 in women who take antidepressants. In order to exclude PPHN and to monitor any withdrawal symptoms, we recommend that babies born to mothers who have been taking antidepressants from 28 weeks onwards are observed with their mothers on the postnatal ward for a minimum of 24 hours following delivery.
Bonari, L., Pinto, N., Ahn, E. et al. (2004) Perinatal risks of untreated depression during pregnancy.Canadian Journal of Psychiatry49(11), 726-735
Cohen, L.S., Altshuler, L.L., Harlow, B.L. et al. (2006) Journal of the American Medical Association295(5), 499-507
Jong GW, Einarson T, Koren G, Einasron A. Antidepressant use in pregnancy and persistent pulmonary hypertension of the newborn: A systematic review. Reproductive toxicol 2012; 34 (3) 293-297
Levinson-Castiel R, Merlob P. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006; 160:173-176
Nice guidelines, Antenatal and postnatal mental health: clinical management and service guidance (CG192, updated June 2015)
Cite this article as:
Abida Sajjad(2017) Use of antidepressants in pregnancy.The Beautiful Space-A journal of Mind, Art and Poetry. February 2017: TBSB111
By Dr. Minal Mistry, Psychiatrist
Following on from my December 2016 blog “Depression: medication is not working? Try exercise and the internet!”, people have been asking me about other treatments for depression that do not involve antidepressants. I get the sense that professionals and the public are becoming more skeptical of medication and, with the rise of popularity of treatments that do not involve swallowing a “happy pill”, it is time for me to start this new year with a blog on other approaches…using the latest evidence of course!
New evidence for “non-pharmacological” treatments for depression.
My previous December 2016 blog coincided with research published in Evidence-Based Medicine – owned by the British Medical Journal (BMJ) – regarding treatments for depression without the use of medication (“non-pharmacological”). The study was aptly named “Non-pharmacological treatment of depression” and demonstrated the effectiveness of such treatments … we will return to the results later, but what are these other treatments that do not involve conventional medication?
What treatments do not involve conventional medication?
The list of treatments that do not involve conventional antidepressant treatment is extensive. In addition to other “medication” such as naturopathic medicine (e.g. herbals, acupuncture) and “biological interventions” (e.g. electroconvulsive therapy, transcranial magnetic stimulation) the research evaluated:
Non-pharmacological approaches and evidence.
This above list of non-pharmacological treatments to improving one’s mental health is not exhaustive. Moreover, there is nothing “new” about them because non-medication approaches have been around for a long time. For instance, I have received training in an approach called “Adaptation Practice”, which has existed as long as I have been alive, since 1974, and now has research supporting its effectiveness.
There are countless other approaches to improving mental well-being that have existed for so long, but only recently are we seeing evidence for their effectiveness. I often question the merits of “waiting” for research to “prove” a treatment works, but that is the way the scientific community works…so let’s move onto the new research!
The new research.
In the December 2016 edition of Evidence-Based Medicine, Wigdan H. Farah and colleagues (mostly affiliated with the famous Mayo Clinic in Minnesota) published: “Non-pharmacological Treatment of Depression: a systematic review and evidence map”. This research was comprehensive because it was an “umbrella systematic review”. Systematic reviews are regarded as the strongest form of medical evidence. However, this new research was a “systematic review of systematic reviews” which included an incredible 367 Randomised Controlled Trials (RCTs - the most reliable type of evidence) with outcomes about non-pharmacological treatments.
Although it is unclear about the effectiveness of non-pharmacological treatments relative to each other, this study found three interesting results in comparing such treatments with antidepressants:
The authors of this study are not necessarily dismissing the role of antidepressants. They do say that since non-medication methods are also effective in depression, “shared decision-making” (which engages patients and carers, and is based on the person’s values and preferences) is needed.
For years, I have been implementing the advice from this research in my own psychiatric practice by:
My open-minded approach allows the person with depression to make an informed decision about their treatment…it is all about one’s human right to make one’s own choices based on accurate, up-to-date and unbiased information. Hopefully this latest research from the United States will now allow a person with depression to explore non-medication options with greater confidence – leading to better choices and improved mental health.
Wigdan H Farah, Mouaz Alsawas, Maria Mainou, Fares Alahdab, Magdoleen H Farah, Ahmed T Ahmed, Essa A Mohamed, Jehad Almasri, Michael R Gionfriddo, Ana Castaneda-Guarderas, Khaled Mohammed, Zhen Wang, Noor Asi, Craig N Sawchuk, Mark D Williams, Larry J Prokop, M Hassan Murad, Annie LeBlanc. Non-pharmacological treatment of depression: a systematic review and evidence map. Evid Based Med 2016; 21: 214-221.
Cite this article as:
Minal Mistry (2017) Treating depression without antidepressants. The Beautiful Space-A journal of Mind, Art and Poetry. January 2017: TBSB110
By Dr Hena Jawaid, Psychiatrist
The world, today is a strange place to live where people are migrating from a downtrodden, war-ridden, perished country to the one, which is more established, progressive and developed. The differences in social, cultural, ethnical and religious backgrounds affect the psychological well-being of any migrant. Inability to adjust in a new social role manifests in different forms. It influences an individual's attitude towards the life, purpose, identity and motivation. It changes the struggle of a person to find his place in a world. All these elements breed a new identity for an immigrant and drive him to adopt an extreme form of devotion to fighting for himself and his related group.
Time has changed the globe into more distant and polarised mindsets, which have been developed as a result of identity differences and allegiance to one's origin.
A study published in British Journal of Psychiatry (1) has caught my attention recently although it has its own limitations. But the study overall has touched the sensitive pulses of politics, international adversities, war-prone factors and mindsets on the basis of religious adherence. It mainly deals with the extremism, religion, and psychiatric comorbidity.
The study mainly pinpoints the phenomenon of radicalization (2), which starts from the larger proportion of a population who maintains neutrality towards ‘anti-’ and ‘pro-’ groups; amongst them the vulnerable or abused one climbs the next ladder as being sympathetic towards radicals. Factors like persistent alienation, ‘identity confusion’ and security threats in a new place change their reactions towards the radicals, and they become supportive to the extremists’ cause. The opportunities then ultimately turn them into radicals.
This Cross-sectional study has been done in Great Britain amongst 3679 participants; their age ranges were 18–34 years, The attitudes, psychiatric morbidity, ethnicity, and religion were not only explored, but associations were also critically analysed. It has been done in a mixed cohort of White, the UK born, and non-UK born, from rich and deprived areas and on different ethnicities. The two main cohorts were named as “pro-British” and ‘anti-British’ to reveal the polarised attitudes of the population.
The main findings showed that the extremist mindsets of both sides lack higher education and are associated with poor social and economic status. The ‘anti-British’ radical group moves to acquire the extremist conviction to protect itself from the disillusionment of a new social identity and also to ensure the adherence with one's religious/cultural origins.
The most interesting finding lies where one with the extreme version of faith (anti or pro) is protected from depression. The need to belong to one's society (religious, ethical and cultural aspects) is essential to know one's existence and life’s purpose when such needs are not fulfilled properly then it can cause depression. The depression is more common at a baseline layer of a population who maintains neutrality to both sides of extremism. The religious practices protect an individual from the substance use and dependence. The strong religious adherence was also linearly associated with the extremist behaviour and motivation to fight for one's identity conflict. The process of the sectarian grouping and Jihadization was also explored.
The investigation of the four-stage model of Al-Qaeda-influenced radicalization (3) reveals its seven sub-stages. The pre-radicalization stage starts from the justification of a radicals’ approach to deal with basic identity conflicts. This further takes one to the Salafi (literalism) form of Islam (without contextual links), which further moves one away from the old identity/position. The association with a similar set of mentality helps one in adopting a new belief and eventually progressive acceptance of jihadi-Salafism. This ultimately leads one to jihadization against the system, nation or ideology.
This is the era where people are migrating in collective masses and suffering from the local and global trauma of refuge, displacement, and homelessness. This movement has its own short-term and long-term consequences. This phase of an identity crisis, confusion, distrust and stereotypical beliefs is generating the wave of anger, frustration, and alienation in a migrating group for a new social setup. The recruited groups, their variables, and confounding factors were not explored. The readiness of expressed priority (in the assessments/questionnaires of study) of pro and anti groups cannot be practically established.
Cite this article as:
Hena Jawaid (2017) Anger, resentment and reactions amongst immigrants. The Beautiful Space- A Journal of Mind, Art and Poetry. January 2017: TBSB109
By Dr. Minal Mistry, Psychiatrist
WHO and depression
The World Health Organization (WHO) describes depression as the “leading cause of disability worldwide” and as a “major contributor to the overall global burden of disease” (see World Health Organization Fact Sheet below). WHO highlights that depression is more common in women, can lead to suicide, but “effective treatments” are available.
Regarding treatment, WHO state that:
Psychosocial treatments for depression
WHO go on further to say that “psychosocial treatments are also effective for mild depression.” WHO mention therapies such as cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT), and behaviouraI activation (BA). I have already written a blog on The Beautiful Space about one of WHO’s recommendations (see my blog on: “Behavioural Activation (BA): The forgotten therapy for Depression.”)
I have now encountered newly released research that proves that other psychosocial treatments can help depression: enter stage… EXERCISE and ICBT:
New Swedish randomized controlled trial
Doctors love randomized controlled trials (RCTs)! We also love the Swedes…and not just for bringing us ABBA and IKEA! This new study from Sweden, published in the prestigious British Journal of Psychiatry (November 2016), claims to be the first community-based RCT comparing exercise, ICBT, and usual care for depression (see study reference at the end of this blog). It involved nearly 1000 participants, most of whom were women (73%) with mild to moderate depression, who were followed up over a period of one year. Impressive, eh? Even more impressive were the results that I am completely thrilled by:
“The largest treatment effect was obtained at the interim assessment (3 months), when severity had reduced significantly more in the exercise and ICBT groups compared with usual care.”
The results of the Swedish study get even better for the long-term outlook:
“Importantly, the long-term follow-up assessment reported in this study adds the observation that the short-term treatment benefits reported previously were maintained 9 months later.”
What does this mean?
WHO state that depression results from “a complex interaction of social, psychological and biological factors.” With this in mind, we must not forget that treatment also requires a biopsychosocial approach. If we neglect the (now proven) psychosocial elements of treatment, we are ignoring the best scientific evidence to date from Europe. The authors of this groundbreaking study advocate for light exercise in helping depression, or ICBT for those who are physically limited.
Moreover, there have been recent discussions in the United Kingdom (UK) about medication being the cause of disability. For instance, the UK recently had an All-Party Parliamentary Group meeting on “Rising Prescriptions, Rising Disability” in May 2016 (see video via blog link below). This has prompted many professionals to explore non-medication ways to help people with depression. ICBT and exercise may be very effective, without the side effects of medication, and should be considered amongst the front-runners for improving mild to moderate depression.
Declaration of competing interests (!)
The author of this blog would like to declare that he does at least 30 minutes of brisk walking daily; cycling and running in the spring and summer; and skiing and snowshoeing in those cold Canadian winters…brrrr!
Cite this article as:
Minal Mistry (2016) Depression: Medication is not working? Try exercise and internet!.The Beautiful Space-A Journal of Mind, Art and Poetry. December 2016: TBSB108
1. World Health Organization fact sheet on Depression (updated April 2016). http://www.who.int/mediacentre/factsheets/fs369/en/
2. Hallgren M, Helgadottir B, Herring MP et al. Exercise and Internet-based cognitive-behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up. British Journal of Psychiatry 2016; 209: 414-420.
3. Video of All-Party Parliamentary Group meeting on “Rising Prescriptions, Rising Disability” (May 2016) - see the relevant blog.http://www.adaptationpractice.org/blog/
Dr. Aadil Jan Shah and Dr. Ovais Wadoo Psychiatrists
Sleep is important for our well-being and optimal functioning. If we are not getting proper sleep, our body struggles, and various problems can occur including tiredness, irritability, problems with concentration and deterioration in overall functioning.
Importance of sleep:
Sleep provides an opportunity for our bodies to recover, revive and repair themselves with some forms of sleep being associated with physical repair (e.g. helping fatigued muscles to recover) and other forms of sleep being associated with psychological repair (e.g. laying down memories, working through anxiety, etc.).
A normal night's sleep has three main parts:
•Quiet sleep: This is divided into stages 1-4. Each stage becomes deeper. Quiet sleep is sometimes called deep sleep.
•Rapid eye movement (REM) sleep: REM sleep occurs when the brain is very active, but the body is limp, apart from the eyes which move rapidly. Most dreaming occurs during REM sleep.
•Short periods of waking for 1-2 minutes.
Each night, about 4-5 periods of quiet sleep alternate with 4-5 periods of REM sleep. Also, several short periods of waking for 1-2 minutes occur about every two hours or so but occur more frequently towards the end of the night's sleep.
On average, adults cycle through all forms of sleep every 90 minutes. Therefore if a person sleeps for 8 hours, he or she will have five opportunities to repair both the physical and psychological systems. It has been found that 8 hours is the average length of time adults sleep but many studies have shown that people range between needing 4 hours a night up to needing 10 hours or more.
Age influences the balance of the 90-minute cycles. Babies spend the bulk of their sleep time in a dream state since their bodies require very little repair. Older adults, on the other hand, spend a disproportionate amount of their sleep time in physical repair, as aging bodies are more vulnerable to damage.
When emotional distress and worry interfere with sleep patterns, the natural ability of the body to repair itself becomes disrupted. If sleep is disrupted over a long period, necessary physiological and psychological repair cannot take place, which can lead to pain, fatigue, and memory and thinking difficulty.
Insomnia means poor sleep. About one-third of adults do not get as much sleep as they would like. Sleep problems are particularly common in women, children and those over 65. In fact, roughly half of the elderly population complains of insomnia.
The most common causes of insomnia are a big change in daily routine and normal effects of ageing. Other causes can be pain, nausea, need to go to toilet at night time, sleep apnoea or problems with breathing, stress, depression and anxiety, alcohol use, stimulants like caffeine, cannabis, cocaine, amphetamines etc, prescribed medications like 'water tablets' (diuretics), some antidepressants, steroids, beta-blockers, some slimming tablets, painkillers containing caffeine, and some cold remedies containing pseudoephedrine. The disrupted sleep routine can also be due to working shifts or the surroundings not being feasible like bed being too hard or too soft, bedroom temperature not being appropriate, etc.
The different sleep problems people can encounter are:
Insomnia can get better by itself at times but sometimes problems continue for longer, and these problems start affecting your functioning.
When insomnia is ongoing, the most common approach to treatment is to alter sleeping habits.
• Try to go to bed at the same time each day.
• Try to set the alarm and get up at the same time every day.
• Try avoiding any naps during the day time.
Strategies to help with sleep behaviour
• Try to go to bed only when sleepy
• Use the bed only for sleep e.g.; don`t watch TV, eat and use mobile phones or talk on the telephone in bed.
• If unable to sleep within 30 minutes – get out of bed and have a malty drink. Listen to relaxing music, read a relaxing book or watch something boring on TV until you feel sleepy.
• You must teach your body to associate the bed with sleep, not frustration.
• Restrict the amount of time you spend in bed to your usual amount of sleep (e.g. 7 hours) even if you did not get to sleep as well as you would have liked.
Surroundings and Temperature Tips
• Maintain a steady temperature in the room throughout the night.
• Fluctuations in room temperature can cause sleep disturbances.
• Keep the room dark.
• You can raise body temperature by exercising 3 to 4 hours before bed.
• You can raise body temperature by taking a warm bath 20 minutes before bed.
• Sleeping is associated with a decline in core body temperature from a state of relative warmth.
Food and drinks
• Caffeine containing drinks like tea, coffee, cola, etc. should be discontinued 4 to 6 hours before bedtime.
• Nicotine or cigarettes should be avoided near bedtime and upon night waking.
• Alcohol (a depressant) causes awakenings later in the night (though initially may promote falling asleep).
• A light snack may be sleep inducing; a heavy meal too close to bedtime is an interference.
• Making an “effort” to fall asleep will not produce sleep.
• Sleep should not be effortful.
• Avoid mentally stimulating activity just before bed (e.g. action movie, stimulating conversation).
• Relaxation techniques such as visual imagery and the tense-relax skill can help.
Daytime exercise can prove beneficial as it makes your body tired and this can help with sleep.
There are behavioural and cognitive therapies like CBT to help with sleep problems as well. One needs to discuss this option with their GP.
A short course of sleeping tablets can be an option if nothing works. It is suggested to avoid any sleeping tablets and use only if other techniques fail. The sleeping tablets to help could include Z-drugs like Zopiclone, Zolpidem etc. Sometimes benzodiazepines like Nitrazepam, Temazepam etc. are also used for short-term. A doctor can also prescribe antihistamines with a sedative effect. A melatonin supplement is sometimes advised in older people (more than 55 years of age) with persistent insomnia.
Cite this article as:
Aadil Shah, Ovais Wadoo (2016). Sleep Problems.The Beautiful Space-A Journal of Mind, Art and Poetry. October 2016: TBSB107
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NHS Choices – your health, your choices
Insomnia: doctor I can`t sleep
By: Adrian Williams
The Insomnia kit: practical advice for a good night`s sleep
By: Chris Idzikowski
Overcoming Insomnia and Sleep Problems
By: Colin A Espie
Klink ME, Quan SF, Kaltenborn WT, et al. Risk factors associated with complaints of insomnia in a general adult population. Influence of previous complaints of insomnia. Arch Intern Med. 1992;152:1634–1637
Morin CM. 2005. Psychological and behavioral treatments for primary insomnia. In: KrygerMH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia:Elsevier/Saunders. Pp. 726–737.
NICE: Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia NICE 2004
UMHS 2003, Dr. D. A. Williams and Dr. M. Carey
By Dr Beenish Memon, Psychiatrist
People with the severe enduring mental illness have a higher mortality as well as morbidity rate as compared to general population. Highest mortality rates are found among patients with schizophrenia, followed by major depression and then BPAD.
Various factors have been linked such as unhealthy lifestyle (heavy smoking, recreational drug use, alcohol abuse, poor nutrition and sedentary lifestyle); inadequate physical healthcare but the potential impact of psychotropic medications on mortality risk has always been the subject of intense debate.
While antipsychotics have potential to adversely affect physical health (obesity, diabetes, and hyperlipidemia), it is important to note that there have been several studies which have suggested that all-cause mortality is higher in patients with schizophrenia not receiving antipsychotics (Torniainen et al., 2014; Tiihonen et al., 2009).
Additionally, heavy smoking, recreational drug use, alcohol abuse, poor nutrition and sedentary lifestyle in a population diagnosed with the psychiatric disease are associated with increased mortality risk. There is a possibility that there are other intrinsic factors to psychiatric illness which might be contributing to excess mortality (Fran, 2016).
We have to be mindful that Psychiatric patients are less likely to talk effectively about their medical problems especially when they are mentally unwell. Once a patient is commenced on psychotropic medication, specific medication side effects are monitored via regular physical health check. This contributes to improving physical and well as mental health outcomes. Patients who are left untreated are at high risk of disengaging not only with mental health but physical health services as well. They are more at risk of using alcohol and drugs to cope with their symptoms. Thus, at increased risk for morbidity and mortality.
Moreover, there is evidence to suggest that some psychotropic such as clozapine, antidepressants, and lithium are associated with reduced mortality from suicide.
We have to understand that patients with Severe Mental Illness need psychotropic medication in addition to psychosocial intervention to improve their mental health and prevent relapse. Hence, the potential risks of antipsychotics, antidepressants, and mood stabilizers need to be weighed against the risk of the psychiatric disorders for which they are used and the lasting potential benefits that these medications can produce.
Despite the fact that psychiatric patient carries a high risk of mortality and morbidity, The medical care of physical disorders provided to psychiatric patients is less adequate than for the population in general (Björkenstam et al., 2012). They are not vigilantly monitored by primary care services for early detection and intervention of medical conditions.
Finally, I feel psychotropic medications not only improve the mental health of patients they improve their engagement with medical care and will significantly reduce mortality if this patient group is provided with best possible medical care. The entire blame of increase mortality cannot be attributed to the adverse effects of psychotropic medications because these effects should be proactively and vigilantly monitored and treated by a joint effort from psychiatric and primary care services. Furthermore, 50% to 80% of people with Severe Mental Illness smoke tobacco, an important reversible risk factor for cardiovascular disease. If we look into providing this patient group with better physical health care provisions and encouraging them into adopting a healthier lifestyle we can significantly reduce the mortality rate.
Cite this article as:
Beenish Memon (2016)Are psychotropic medications associated with increased risk of mortality.The Beautiful Space-A Journal of Mind, Art and Poetry. November 2016: TBSB106
Björkenstam, E., Ljung, R., Burström, B., Mittendorfer-Rutz, E., Hallqvist, J. and Weitoft, G. (2012). The quality of medical care and excess mortality in psychiatric patients—a nationwide register-based study in Sweden. BMJ Open, 2(1), p.e000778.
Fran, L. (2016). Psychotropics Lower, Don't Raise, Mortality in Psych Patients. [online] Medscape. Available at: http://www.medscape.com/viewarticle/810209 [Accessed 19 Oct. 2016].
Khan, A., Faucett, J., Morrison, S. and Brown, W. (2013). Comparative Mortality Risk in Adult Patients With Schizophrenia, Depression, Bipolar Disorder, Anxiety Disorders, and Attention-Deficit/Hyperactivity Disorder Participating in Psychopharmacology Clinical Trials. JAMA Psychiatry, 70(10), p.1091.
Tiihonen, J., Lönnqvist, J., Wahlbeck, K., Klaukka, T., Niskanen, L., Tanskanen, A. and Haukka, J. (2009). 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). The Lancet, 374(9690), pp.620-627.
Torniainen, M., Mittendorfer-Rutz, E., Tanskanen, A., Bjorkenstam, C., Suvisaari, J., Alexanderson, K. and Tiihonen, J. (2014). Antipsychotic Treatment and Mortality in Schizophrenia. Schizophrenia Bulletin, 41(3), pp.656-663.
By Dr Abida Sajjad, Psychiatrist
Mental disorder in pregnancy is a significant public health challenge. Data from the 2000- 2002 Confidential Enquiries into Maternal Deaths found that suicide was the leading cause of maternal deaths and, while the data for 2006-2008 shows this is no longer the case, suicide remains one of the major causes of maternal death.
The use of antipsychotics in pregnancy has increased substantially in the past decade, but information as to their safety has been limited(JAMA Psychiatry,2016). Exposure to antipsychotics (APs) during pregnancy is increasingly common. Antipsychotics are a range of medications that are used for some types of mental distress or disorder - such as schizophrenia or bipolar disorders - or used with antidepressants to treat depression.
There are two different groups of antipsychotics. The first type is titled "typical" - an older type of drug that first appeared in the mid-1950s. They block the action of dopamine, some more strongly than others."Atypical" antipsychotics - newer medications - still block dopamine, but on a smaller scale. They also work on different chemical messengers in the brain such as serotonin.
Little is known regarding the safety of APs on the developing fetus, however, and concerns have previously been raised about a potential association between antipsychotics and congenital malformations. The latest study, published in JAMA Psychiatry, examined the risk of congenital and cardiac malformations associated with first-trimester exposure to antipsychotics.
Krista F.G. Huybrechts, M.S., Ph.D., an associate epidemiologist in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital and Harvard Medical School, and co-authors used a nationwide Medicaid database sample of over 1.3 million pregnant women enrolled from 3 months before their last menstrual period through at least 1 month after delivery.
Exposure to antipsychotics was defined as filling at least one prescription during the first trimester of pregnancy and individual drugs including aripiprazole, olanzapine, quetiapine fumarate, risperidone, and ziprasidone were assessed.
According to the results, among the more than 1.3 million women, 9,258 women (0.69 percent) filled a prescription for an atypical AP, and 733 women (0.05 percent) filled a prescription for a typical AP during the first trimester. The most frequently used atypical APs in order of frequency were quetiapine, aripiprazole, risperidone, olanzapine, and ziprasidone.
Evidence from this large study suggests that use of APs early in pregnancy generally does not meaningfully increase the risk for congenital malformations overall or cardiac malformations in particular. The small increase in the risk for malformations observed with risperidone requires additional study.
Katherine L. Wisner, M.D., of the Northwestern University Feinberg School of Medicine in Chicago, IL, and co-authors write about the above report in a related editorial: "This landmark report, with the largest population of women exposed to APs published to date to our knowledge, demonstrates that exposure to APs (other than risperidone) does not significantly increase the risk of birth defects, which has been a major source of concern for women and prescribers,".
According to another study taking atypical antipsychotics in the first trimester of pregnancy does not seem to be associated with an increased likelihood of major malformations or premature birth, although there is some evidence to suggest that it may reduce birth weight (McKenna,2005).
To summarize, it is evident that clinicians and patients generally are cautious when prescribing or using antipsychotics during pregnancy, inadequately controlled psychiatric illness poses risks to both mother and child.
Cite this article as:
Abida Sajjad(2016) Are antipsychotics related to birth defects? The Beautiful Space-A Journal of Mind, Art and Poetry.. October 2016: TBSB105
1).Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000–2002: The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004.
2).Katherine L. Wisner, M.D., M.S. et al., JAMA Psychiatry, published online 17 August 2016.
3).McKenna K, Koren G, Tetelbaum M, et al. Pregnancy outcome of women using atypical antipsychotic drugs: A prospective comparative study. J Clin Psychiatry 2005;66:444–9.
4).JAMA Psychiatry. 2016;73(9):938-946. doi:10.1001/jamapsychiatry.2016.1520
Dr Aadil Jan Shah, Dr Ovais Wadoo and Dr Javed Latoo, Psychiatrists
Carer’s play a vital role in supporting family members who are sick, infirm or disabled. There is no doubt that the families of those with mental disorders are affected by the condition of their near ones. The demands of caring can bring significant levels of stress for the carer and can affect their overall quality of life including work, socializing and relationships. Research into the impact of care giving shows that one-third to one-half of carer’s suffer significant psychological distress and experience higher rates of mental ill health than the general population.
The association between feelings of burden and the overall caregiver role is very well known. Caregivers provide assistance with activities of daily living, providing emotional support to the patient, dealing with incontinence, feeding and mobility. Due to high burden and responsibilities, caregivers experience poorer self-reported health, engage in fewer health promotion actions than non-caregivers, and experience lower life satisfaction.
There is evidence that depressive symptoms are twice as common among caregivers as noncaregivers. Family caregivers who have significantly depressed mood may be adversely affected in their ability to perform desirable health maintenance behaviour or self-care behaviours in response to symptoms. Women have higher rates of depression than men in the care giving role. Carers can also end up neglecting their own physical health leading to various issues and poor quality of life. Caregiving is also associated with decline in social support, increased isolation and withdrawal.
The impact of caring for different mental disorders and associated risk factors:
Schizophrenia with associated risk factors like; high disability, very severe symptoms, poor support from professionals, poor support from social networks, less practical social support and violence can lead to guilt, loss, helplessness, fear, vulnerability, cumulative feelings of defeat, anxiety, resentment, and anger among caregivers.
Dementia with associated risk factors like decline in cognitive and functional status, behavioural disturbances and dependency on assistance can lead to anger, grief, loneliness and resentment in caregivers.
Mood disorders with associated risk factors like symptoms, changes in family roles, cyclic nature of bipolar disorder, moderate or severe distress can lead to significant distress, marked difficulties in maintaining social and leisure activities, decrease in total family income and considerable strains in marital relationships.
It is therefore very important that carers make sure they are looking after themselves well to do their role better and help reducing any physical or psychological distress. Also, the efforts to identify and treat caregiver psychological distress will need to be multidisciplinary, consider the cultural context of the patient and caregiver, and focus on multiple risk factors simultaneously.
Signs and symptoms of caregiver’s psychological distress can be following:
•Anxiety, low mood, irritability
•Feeling tired and exhausted
•Overreacting to minor problems
•New or worsening health problems
• Problems concentrating
•Feeling increasingly resentful
•Drinking, smoking, or taking drugs to cope
•Cutting back on leisure activities or not socialising well
Coping styles and Interventions to reduce psychological distress in carers are:
Below is the list of websites for different organisations who can provide advice, support, guidance and interventions for carers suffering from any psychological distress or other stresses related to their role.
By Dr. Minal Mistry, Psychiatrist
Marijuana, derived from the Cannabis plant, is also known as “cannabis,” “weed,” “pot,” “ganja” and a variety of other slang terms. It is one of the oldest substances known to have psychoactive effects on our brains. However, with the growing use of marijuana in the general population, increased trends of the legalization of marijuana in United States of America (USA) with similar proposals being made in Canada, and the increased availability of prescribed medical marijuana, should marijuana consumption in younger people be placed under the microscope for further scrutiny?
Marijuana and Psychosis?
Tetrahydrocannabinol (THC) is the main component that binds to cannabinoid receptors in the body. Marijuana can cause a variety of subjective effects which may be positive, such as feeling relaxed, or negative effects such as lethargy, cognitive problems, anxiety or psychotic symptoms. Psychotic symptoms include hallucinations where you may hear or see things where nothing is there, or delusions in which you may believe things that are not true.
One of the major concerns is that marijuana use can lead to the development of psychotic conditions such as Schizophrenia. Although there are conflicting views about the extent to which marijuana truly causes a clinical psychosis in adults, we know that the risk of a clinical psychosis is greater if marijuana is used in adolescence as the developing brain is more sensitive to these psychoactive substances.
However, we now have a new concern about marijuana use in adolescence causing a persistent subclinical psychosis i.e. prolonged psychotic symptoms that are less severe and/or not reaching the threshold for a full diagnosis.
Subclinical psychotic symptoms and marijuana use
New research by Jordan Bechtold, PhD, at University of Pittsburgh Medical Center in Pennsylvania, published in the American Journal of Psychiatry, found that every year of regular marijuana use led to a 21% rise in subclinical psychotic symptoms.
There were three main messages conveyed by this research:
Marijuana and the adolescent brain
Dangers of marijuana use may be less of an issue in the older mature brain. The young adolescent developing brain is a different matter. Compared to a fully developed adult brain, an adolescent’s brain may be more vulnerable to sustained damage. This is an issue that needs to be taken into account with the proposed legalization of marijuana, especially on age limits (just as we have age limits with the use of alcohol and nicotine). These concerns about marijuana are supported by experts who say:
2. Regarding marijuana use: “Starting young and using frequently may disrupt brain development.”Susan Weiss, PhD, director of the division of extramural research at the National Institute on Drug Abuse (NIDA).
The latest research by Bechtold and colleagues magnifies these views. We ought to be looking more closely at this area and educating young people further about the risks.
Cite this article as:
Minal Mistry(2016)New dangers of adolescent marijuana use. The Beautiful Space-A Journal of Mind, Art and Poetry. October 2016: TBSB104
By Dr Abida Sajjad, Psychiatrist
ECT is a treatment for a small number of severe mental illnesses. The use of electricity to treat mental illness started out as an experiment. In the 1930s psychiatrists noticed some heavily distressed patients would suddenly improve after an epileptic fit. Passing a strong electric current through the brain could trigger a similar seizure and - they hoped - a similar response. By the 1960s it was widely used to treat a variety of conditions, notably severe depression.
The idea developed in the days before effective medication. Perhaps more significantly, new anti-depressant drugs introduced in the 1970-80s gave doctors new ways to treat long-term mental illness. But for a group of the most severely depressed patients, ECT has remained one of the last options on the table when other therapies have failed. Annually in the UK around 4,000 patients, still undergo ECT. According to Professor Reid in Aberdeen University "It's not intuitive that causing seizures can be good for depression but its long been determined that ECT is effective”.
We do know that it can change patterns of blood flow through the brain and change the metabolism of areas of the brain which may be affected by depression. There is evidence that severe depression is caused by problems with certain brain chemicals. It is thought that ECT causes the release of these chemicals and, probably, more importantly, makes the chemicals more likely to work, and so help recovery. Recent research has also suggested that ECT can help the growth of new cells and nerve pathways in certain areas of the brain.
Uses of ECT:
It is very helpful for someone who has severe depression, resistant mania or catatonia. ECT should be considered for the rapid treatment of severe depression that is life-threatening, or when other treatments have failed. According to Sienaert P, et al. (Dec 2014) ECT is generally a second-line treatment for people with catatonia who do not respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. NICE recommends it only in life-threatening situations or when other treatments have failed and as a second-line treatment for bipolar mania.
It should not be used routinely in moderate depression, although it can be helpful for someone with moderate depression if they have not responded to several different drug treatments and psychological treatment.
ECT has been shown to be the most effective treatment for severe depression. It would normally be offered if several different medications have been tried, but have not helped, the side-effects of antidepressants are too severe or ECT has been found helpful in the past.
The National Institute for Health and Care Excellence (NICE) recommends that before ECT, doctors should consider the risks of the treatment which include:
Immediate side effects:
Drowsiness (you may sleep for a while), confusion, headache, feeling sick, aching muscles and loss of appetite
Very rarely, people may experience prolonged fits, especially if they are taking drugs or have medical conditions which lower the seizure threshold. The general anaesthetic (as for any procedure where it is used) carries a risk of illness and a very small risk of death, separate from the ECT treatment itself.
This is the most important side effect of ECT, and the one which causes most concern.It is usually a short-term effect, and most people find their memories gradually return as they recover from ECT.
However, for some people, memory loss can mean both losing personal memories, and having difficulty remembering new information. Some people have been so badly affected that they have lost key skills or knowledge, such as expertise needed to continue their professional work or career.
Guidelines say that you should have a standard test of your memory and thinking abilities as part of your assessment before treatment and after each treatment session
People’s experience of ECT varies enormously. Some people find it the most useful treatment they have had, and would ask for it again if they needed treatment for depression. Others feel violated by it, and would do anything to avoid having it again.
Sixty-four-year-old John Wattie says his breakdown in the late 1990s was triggered by the collapse of his marriage and stress at work. John likens the feeling to being in a hole, a hole he could not get out of despite courses of pills and talking therapies.
But now, he says, all of that has changed thanks to what is one of the least understood treatments in psychiatry - electroconvulsive therapy (ECT).
He says “Before ECT I was the walking dead. I had no interest in life; I just wanted to disappear. After ECT
I felt like there was a way out of it. I felt dramatically better." ( Why are we still using electroconvulsive therapy? By Jim Reed, BBC Newsnight)
Cite this article as:
Abida Sajjad (2016). Role of ECT in mental health. The Beautiful Space-A Journal of Mind, Art and Poetry. September 2016: TBSB103
1. NICE Guidance on the use of electroconvulsive therapy. NICE technology appraisals TA59. Published date: April 2003
2. Sienaert P, et al. (Dec 2014). "A clinical review of the treatment of catatonia." Front Psychiatry. 5: 181.doi:10.3389/fpsyt.2014.00181. PMID 25538636.
3. Malhi GS, et al. (Dec 2012). "Mania: diagnosis and treatment recommendations." Curr Psychiatry Rep. 14 (6): 676–86. doi:10.1007/s11920-012-0324-5.PMID 22986995.
By Dr. Minal Mistry, Psychiatrist
“Depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease” (World Health Organization Fact Sheet, updated April 2016).
Depression affects 350 million people worldwide. Treatment involves a biopsychosocial approach, which means that psychological and social measures should be used as well as medication. Antidepressants are effective but not in all patients. With the recent controversies about whether antidepressants do more harm than good, psychological therapy is becoming popular. We have all heard about Cognitive Behavioural Therapy (CBT), but let’s look at an alternative: Behavioural Activation (BA) – the forgotten therapy of our time.
What is BA?
“You'll never plough a field by turning it over in your mind” (Irish proverb)
The first behavioural treatment for depression was developed 40 years ago by Peter Lewinsohn (1976) who recommended that patients increase the number of activities and social interactions. BA therapy evolved from that. Rather than focusing on your cognition (internal factors), BA looks at your depression with respect to context (environmental factors).
BA involves understanding how your mood is affected by your behaviour. In other words, the more we do with physical and social activities, the better we feel. BA is a component of CBT. However, BA by itself is much simpler with less emphasis on what you are thinking when depressed, and more on what you are doing, e.g. activity scheduling, to lift you out of your depression.
Is BA making a resurgence?
COBRA - Cost and Outcome of BehaviouRal Activation (LATEST RESEARCH, JULY 2016)
Back in 2006, a North American Randomized Controlled Trial, by Sona Dimidjian and colleagues, published in the Journal of Consulting and Clinical Psychology, showed that in severe depression BA was as good as Paroxetine (an antidepressant) and more effective than cognitive therapy. This challenged the assumption that directly changing our thoughts, or even taking medication, was essential to treating moderate to severe depression.
Turn the clock forward 10 years and British researcher Prof. David Richards and colleagues have published, in The Lancet in July 2016, a ground-breaking randomized controlled trial (the gold standard research method) called the “COBRA” trial. This showed that two thirds of patients improved in both BA and CBT groups after one year. More significantly, it showed that BA was more cost-effective than CBT.
3 Reasons why BA is recommended as first-line treatment for Depression
“I have a bee in my bonnet” – about the B in CBT: Behavioural Activation
Should BA be the first treatment for depression? Perhaps now is the time to ACT to help your depression with BA because it is:
Cite this article as:
Minal Mistry (2016) Behavioural Activation(BA): The Forgotten therapy in the treatment of depression. The Beautiful Space-A Journal of Mind, Art and Poetry. August 2016: TBSB102
Below is an introduction to how BA can help your depression:
And here comes the science bit … links to the research papers discussed:
By Dr Minal Mistry, Psychiatrist
Schizophrenia is a serious and enduring mental illness that affects 1% of the population worldwide. It usually starts in late teens or early 20’s and so it is prudent to identify symptoms at this early age. Symptoms include hallucinations, delusions and disorganized thinking which can be very distressing. Whilst there is no cure, the condition is treatable with antipsychotic medication that can reduce the severity of symptoms, improve quality of life, and reduce burden on family.
People with Schizophrenia may have poor insight and not understand why they have to commence medication. Even if medication is started, symptoms may improve to the point where the person feels so well that they choose to stop their medication. If people start and then stop medication, this can lead to a relapse of symptoms of the underlying illness and/or “rapid onset psychosis” after withdrawal of medication. Therefore, the challenge is ensuring medication is commenced early and then continued.
How can we ensure medication is commenced early?
This has been partly achieved by the introduction of Early Psychosis Teams who play an important role to identify the illness in adolescence and commence treatment. Young people may be reluctant to take medication. In these cases, depot (injection) medication may be a preferable option for a young person who would then rely on the care team to administer medication which has the additional advantage of ensuring they are seen regularly and monitored.
How can we ensure medication is continued?
If medication is commenced, taking an injection can be the answer to the risks of a person stopping their medication. It is understandable that a young person who is feeling well may not see the continuing need for tablets. However, it may not in their best interest to stop the tablets without careful assessment. Even if medication can be reduced in dose, they may decide to stop it on their own. In any event, a depot injection will help to ensure medication is administered.
What is the evidence to support the use of depot early?
A recent University of California, Los Angeles (UCLA) study, by Kenneth Subotnik et al (2015) found that the early introduction of depot medication in newly diagnosed people can have multiple benefits including better symptom control, and improved cognition and “intracortical myelination” (ICM). Our knowledge about ICM is an interesting development in Schizophrenia. An earlier UCLA study, by George Bartzokis et al (2012) suggested that early treatment with antipsychotic injections can change the trajectory of ICM decline leading to reduced problems with the person’s function and less “treatment resistance”.
We have seen many cases of young people and their families’ lives being disrupted by poor control of symptoms at an early stage leading to recurrent hospitalization and continuing distress. We also know that people with Schizophrenia can suffer later on in their illness. Something can be done to reduce these problems, and the answer is to “nip it in the bud”.
Latest mental health research is showing that early identification of the condition needs to be coupled with early and reliable medication administration. Therefore, psychiatrists ought to consider early use of depot medication which may increase the chances of better outcomes hence changing the future of those who suffer from this worldwide debilitating condition.
Cite this article as:
Minal Mistry (2016) Schizophrenia: starting depot medication early may help. The Beautiful Space-A Journal of Mind, Art and Poetry. July 2016. TBSB101
Please check author names highlighted with each article.
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