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
Tel: 020 8994 9874 (6pm – 8pm)
The Sleep Council
Helpline: 0800 018 7923
Tel: 0845 058 4595
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
By Jennifer O'Neill, Senior Mental Health Nurse Practitioner
Self-harm is when somebody intentionally damages or injures their body. It's usually a way of coping with or expressing overwhelming emotional distress.
Types of Self-harm include:
Please know, if you do self-harm as a way of bringing attention to yourself, remember that you deserve a respectful response from those around you, including from medical professionals and deserve the support to change these methods and actions.
If you engage in self-harm, you may feel embarrassed or ashamed about it. This may mean that you keep your self-harming a secret. This is a common reaction, although not everyone does this.
There are no fixed reasoning, rules and theories to why people self-harm. For some people, it can be linked to a significant experience or feeling, and be a way of dealing with something that is happening now or that happened in the past or that causes distress when remembering events or similar experience’s and feelings. For certain people, it isn’t as clear cut as that. Some people are not able to understand the reasons for their self-harm, and, it’s important to be reminded that this is OK, and the reason for self-harm doesn’t need to be known to ask for help or support.
There are many reasons people engage in self-harm:
Any stressful experience can cause one to feel a possible need to self-harm. People who self-harm can seriously hurt themselves, so it's important that they speak to a General Practitioner (GP), or medical professional about the underlying issue and be provided with the relevant treatment or therapy that could help these behaviours and reduce distress and upset.
Cite this article as:
Jennifer O'Neill (2016) Self Harm. The Beautiful Space-A Journal of Mind, Art and Poetry., June 2016. TBSB100
A safe, supportive online community where you can listen, be heard and share your experiences with others.
User-led organisation for people who self-harm, friends and families.
National Self Harm Network (NSHN)
Survivor-led forum for people who self-harm, friends and families.
NICE (National Institute for Health and Care Excellence)
0845 003 7780
Provides guidance on health and social care.
Freepost RSRB-KKBY-CYJK, PO Box 90 90, Stirling, FK8 2SA
24-hour helpline: 116 123 (freephone)
24-hour emotional support for anyone feeling isolated, distressed or struggling to cope.
0300 304 7000
Support and information about mental health problems including online support.
Support for people aged 16–25.
By Dr Javed Latoo, Dr Minal Mistry and Dr Francis Dunne
We now recognize that patients with mental illnesses have higher rates of physical health morbidity and mortality when compared with the general population. Furthermore, life expectancy is reduced by at least 10 years. The side effects of psychotropic medication, lifestyle, and poor access to physical healthcare are among the aetiological factors. Difficulty in comprehending health care advice and/or carrying out required changes in lifestyle, poor compliance with treatment, unawareness due to cognitive deficits or reduced pain sensitivity (induced by antipsychotic medication), poor communication and deficient social skills, all account for the shortened life-span of these patients. Sometimes physical symptoms are misinterpreted as psychosomatic and together with poor quality of care, unequipped teams, and lack of continuity of care, it is not surprising that psychiatric patients are forgotten.
Service-provision needs to clearly delineate where the responsibility of physical health lies between mental health and primary care. Poor resourcing of mental health limits the ability of psychiatrists to focus beyond their own speciality. Reforms in mental health have led to reduced inpatient resources leading to shorter and infrequent hospital admissions and thus less emphasis on physical health. Increased emphasis is placed on community care yet the management of physical health issues by community mental health teams may be poor because of inadequate training and learning. A greater effort to increase awareness of the problem among primary care and mental health care providers is needed.
We would recommend that psychiatrists need to play a leading role in highlighting discrimination and stigmatisation of patients with mental health problems. Education and training of mental health professionals needs to be improved with mandatory training in acute medicine and training to update knowledge of recognising physical illness and performance of basic medical tasks. Community mental health teams and outpatient clinics need to be appropriately designed and equipped to assess physical health monitoring. Financial Initiatives such as CQUIN can be used by the commissioners to improve the physical health of psychiatric patients by mental health providers.
It is vital that trainees become more aware of the interaction between mental health disorders and various physical illnesses because of the high morbidity rates. Legislative changes to address the discrimination faced by people with mental illness and learning disabilities need to be made. The Disability Right’s Commission has already recommended appropriate physical health care screening for example, annual physical health checks, and the government’s health inequality agenda should incorporate these conditions into its indicators of disadvantage.
Originally Published in British Medical Journal (BMJ)
Please check author names highlighted with each article.
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