Shrinks In Sneakers

Author: Dr. G

  • Lifestyle Revolution in a Pandemic

    Lifestyle Revolution in a Pandemic

    These are unprecedented times around the world. The situation escalated much quicker than most people predicted. Now, many people in the United States are facing continued statewide stay at home order for all non-essential persons. If you are stuck at home you may be trying to find alternative ways to use your time. Maybe it’s time to clean the garage or work on the yard as the weather in most parts of the country starts to improve. One way I’ve observed many people using their time is walking, running, or doing home workouts to improve their health and wellbeing. Despite the situation we can use this time to focus on lifestyle changes that can continue long after the pandemic ends. 

    I’ve always believed that lifestyle interventions specifically diet, exercise, sleep, and stress reduction is key to improving both mental health and physical health. I’ve been using lifestyle modification to help improve symptoms of depression and anxiety for the past year in my patients. I’ve been successful in reducing depression ratings on the Hamilton depression inventory (HAM-D), medication dosage, and reducing body weight in several patients with these interventions. There is also a growing body of literature on the topic of lifestyle modification and mental health. I’m going to provide some general tips for getting started with lifestyle modification. 

    Before starting any diet or exercise program you should consult with your doctor. 

    1. See a primary care provider (might be difficult under the current circumstances): Make an appointment with a primary care physician, and get baseline results including waist circumference, BMI, blood pressure, fasting blood glucose, fasting lipid panel, basic metabolic panel, thyroid stimulating hormone, and complete blood count. There are additional tests that could be relevant on a case by case basis, but these are the basic things we want to see to establish a baseline. At the very least you can get a weight and BMI calculation if you have a scale and a measuring tape at home. 
    2. Nutrition: Schedule a consult with a registered dietician to help create a manageable diet. You can also research diets on your own, but I suggest you have a professional guide you in the process to ensure the information you are getting is accurate and not harmful. The best diets in my opinion are whole food plant-based diet or Mediterranean diet. However, it’s important to remember that dietary recommendations are individualized and should suit the needs and lifestyle of each person. At the very least you want to increase your consumption of fruits and vegetables while limiting the intake of red meat, sugar, processed foods, and alcohol. These are staples in the standard American diet (SAD) which almost everyone agrees is harmful to your health. 
    3. Stress management: The modern life of most Americans is filled with more stress than any previous time in history. Finding ways to reduce stress, and recharge our mental batteries is essential to enhanced performance and overall well-being. The most prevalent method is mindfulness training and there is a verity of ways to incorporate this into a busy daily schedule. I personally prefer meditation applications like Headspace (free for the first few sessions then subscription fee) to help guide patients initially, but this is not essential and there are many free guided meditations available on YouTube free of charge. I will also provide a beginner’s guide to meditation in future posts. 
    4. Exercise: The question of aerobic Vs strength training and which is better to incorporate in your daily life is a common one. I believe both forms of training have value and should be used on a daily basis if possible. Like many things it depends on the individual patients’ goals and needs. Strength training increases lean body mass, protects bone health, improves balance and flexibility among other things. Aerobic training helps with efficiency of respiration, improves blood flow to muscles, improves cardiovascular efficiency among other things.  I believe if your goal is improved general or mental health finding ways to use both types of exercise is essential.   
    5. Sleep: Helping people sleep is a large part of a psychiatrist’s job. Sleep plays an essential role in mental health. Many people fail to get enough quality sleep and suffer excess day time sleepiness or poor work performance as a result. The first step from anyone who has trouble sleeping is to keep a sleep log for one month that we can analyze together. You can gain a lot of information from asking specific questions about sleeping patterns, but you still want to see the log because it brings the persons attention specifically to how they are sleeping. I also go over basic sleep hygiene which is a series 

    I realize that some of these thigs will be difficult to do under the current circumstances. The key with anything in life is to just start. I cannot count how many times my life would have been improved if I made the decision to just start. 

  • Is Depression A Genetic Disorder?

    Is Depression A Genetic Disorder?

    Introduction:

    This is a common and difficult question I get asked. Like everything in psychiatry, the answer is not clear.

    When people think about genetic disorders, they tend to think about classic genetic diseases. Some examples would be sickle cell anemia or cystic fibrosis. There is a clear pattern of inheritance with a single gene involved in these diseases

    The human genome project set out to sequence the entire human genome. While it accomplished the goal it did not offer the personalized medicine and targeted interventions initially promised. What it did reveal was a more complicated interplay of genetics and environmental factors. Depression is a multifactorial disease and does not have a single gene involved in the disorder. 

    Let’s look at some the evidence supporting the genetic influence on the development of depression.

    What Can Family studies tell us ?

    The first place to look for a genetic link is family studies. This is one reason we obtain a family history in a psychiatric interview.

    MDD is common in families. It’s found 2 to 3 times more often in first-degree biological relatives (e.g. mother or father) of individuals with the disorder than the general population. It’s important to note that the influence of genetics on the development of depression depends on the percent of the genome shared by the individuals. For example, first-degree relatives who share 50% of their genome will have a much greater influence than a second-degree relative who shares 25% of the genome.

    What can twin studies tell us ?

    The second area of evidence that supports the influence of genetics on depression comes from twin studies.

    From the data we know for monozygotic twins (identical twins), there is a 50% chance that one twin will develop the trait (e.g. depression) if the other twin has depression. This number decreases to 20% for fraternal twins who only share 50% of their genome. One flaw in many of these studies is the twins were often raised together in the same environment. There is clearly something to be said for the influence of environment. Some researchers believe twins will influence each other’s behavior when raised together. Identical twins have been known to be treated more similar by their parents than fraternal twins. Taken at face value, when a twin with 100% of the same genetics (identical twins) develops depression the other twin is more likely to also develop depression. Keep in mind, they do not always develop depression even if they share 100% of the genome. 

    What do adoption studies add?

    Adoption studies make an attempt to differentiate the influence of genetics from environmental factors. These studies examine differences in rates of illness among biological relatives as opposed to adoptive relatives. The studies show higher rates of illness among biological parents rather than adoptive parents. This provides some additional evidence to support a genetic influence. 

    Conclusion

    There is clearly a genetic component to depression. However, it’s a complicated process that involves multiple genes interacting with the environment. This makes identifying a single causal gene difficult and likely impossible. There are people biologically predisposed to developing depression, but not everyone with biological predisposition will go on to develop depression. 

    If you found this helpful please like, comment and share your thoughts for future posts on genetics.

  • Diagnosis Depression: Major Depressive Disorder (MDD) with Seasonal Pattern

    Diagnosis Depression: Major Depressive Disorder (MDD) with Seasonal Pattern

    With this specifier, the name provides most of the information. There has to be a clearly defined relationship between the onset and remission of depression with the changing of the seasons. For example, a patient becomes depressed in the late fall or winter and their depression remits once spring arrives. This is the most common pattern in clinical practice.

    The relationship between the depressive episodes and season is present for at least the prior two years. Furthermore, the number of seasonal episodes is significantly more than nonseasonal episodes. Basically, what this means is there must be an established pattern related to the changing of the seasons for two years.

    If the depressive episode is clearly related to another factor (e.g. start of school or change in work stats) the specifier does not apply. 

    In the two-year period where the pattern is established there cannot be any nonseasonal episodes. 

    For this specifier to apply, the person must clearly become depressed in the months where day light is reduced (possible mechanism for these episodes), and have remission of symptoms once the days become longer. (this is one example, there are others)

    Like, Share, and leave a comment below if you ever felt depressed during the winter months

  • Diagnosis Depression: Major Depressive Disorder (MDD) with Melancholic Features

    Diagnosis Depression: Major Depressive Disorder (MDD) with Melancholic Features

    I wanted to finish the discussion on the various specifiers for major depressive disorder. In this post I will discuss melancholic features. 

    The most distinct feature in MDD with melancholic features is profound loss of interest (anhedonia) in all or almost all activities. This is a common feature in MDD as well, but the loss of pleasure in activities is far more severe. There is also a complete lack of reactivity to anything that would usually be considered by the person as pleasurable. 

    In addition, at least three of the following are required: 

    1. Depressed mood that is experienced as qualitatively different from the feeling experienced after a loss. 
    2. Depression that is worse in the morning. 
    3. Awakening at least two hours prior to the usual wake time 
    4. Marked psychomotor retardation (slow movement) or agitation 
    5. Significant anorexia or weight loss 
    6. Excessive or inappropriate guilt 

    I think of this specifier as a more profound form of MDD. 

    One thing we try to do with modern pharmacology is treat specific symptoms with classes of medication that match the neurotransmitter profile. The medication selection or augmentation strategy may change depending on the symptoms we want to target. For example, fatigue and concentration are largely regulated by norepinephrine and dopamine, so we may choose a medication that targets these neurotransmitters. In this example of melancholic depression sleep and appetite may be the primary issues, we may select a more sedating medication like mirtazapine. I will provide more details on the symptom-based selection of medication for depression in future posts. 

  • Diagnosis Depression: Major Depressive Disorder (MDD) With Atypical features

    Diagnosis Depression: Major Depressive Disorder (MDD) With Atypical features

    I like the DSM-5 and I think it provides us with a conceptual framework for evaluating patients. In clinical practice it’s rare to find patients that fit all diagnostic criteria perfectly. When that does occur it’s nice and makes life easy. 

    Major depressive disorder with atypical features is one of those situations. Many patients have some of the symptoms but not enough to clearly make the distinction. Nonetheless, some of these symptoms are common and need to be discussed.

    What makes this type of depression atypical?

    I like to think of the symptoms as the opposite or reverse of major depression discussed in previous posts. 

    A key distinction to look for is mood reactivity in response to positive events. In major depressive disorder nothing usually makes the patient feel happy. They may even present with a restricted, constricted or blunted affect. In the atypical case, these patients can react and show emotion when positive events occur. 

    Along with mood reactivity, they must have two of the following features: 

    • Increased appetite or significant weight gain 
    • Hypersomnia (excessive sleep) 
    • Leaden paralysis often described as a heaviness of the arms and legs 
    • A longstanding pattern of sensitivity to interpersonal rejection 
    • It must be impairing social and occupational function 

    When you look at the list above you see why we can think of these symptoms as the opposite of typical major depression.

    Hope this post helps to clear up some question about atypical depression. Please like, share and comment. 

  • What’s Your Therapy

    What’s Your Therapy

    The other day, I was working out in my home gym and I started to think about the topic of therapy. Most of my thinking is done in the solitude of the gym. I keep a small pad and pen to write my thoughts down in between sets. On this particular night, I began thinking about what my own therapy looks like.

    The things I was thinking about were not necessarily the standard type of talk therapy most people are accustomed to. I absolutely believe in talk therapy. Honestly, every psychiatrist should be in therapy and it’s often recommended to trainees. The work of a psychiatrist is deep emotional work and its good to analyze these experiences with someone. However, it’s not always easy to find a good therapist.

    People often wonder outside of formal talk therapy, what activities do psychiatrists use to reduce stress. 

    My personal form of therapy is physical training. I learned a lot about myself over the years by demanding a lot of my body. I stress to all of my patients the importance of self-care in the form of physical activity. The human body is made to move, and we have slowly grown into lives of inactivity. Much of our work, education, and leisure activates involve no physical movement. I highly recommend incorporating various sports, running, weight training and other fitness actives into your daily life. If you can bring a friend along for the workout even better. This covers both physical and social areas of wellbeing. 

    This biggest barrier to this process is getting started. Patients often say, “I could never do that” to which I say you don’t have to. Start off simple call a friend or two that can serve as workout partners and start with one 20-minute walk per day. It’s low impact and can be accomplished in almost any setting. There is no need to invest in the best pair of running shoes, a gym membership, or personal trainer. It’s about creating a sustainable habit that will continue for a lifetime. All you need to do is literally take that first step. 

    Feel free to share what helps you stay mentally fit and reduce stress in the comment section below.

  • Car Buying Philosophy That Saves Money

    Car Buying Philosophy That Saves Money

    If you graduated medical school or any college with tons of student loan debt, chances are you have little extra money to purchase a new car. Most people are still driving their car from undergrad, with the sole purpose of getting you from point A to point B. Once you start making a salary, and that car is beginning to reach the end of its life you may be in the market for a new car. Here I will provide five tips that helped me secure reliable transportation without the huge car payment. 

    I do not share the same views as some who believe you should be able to buy a car for $2500 and allocate the money saved elsewhere. Sure, a case can be made for a beater that you use to commute back and forth to work. It will save you money provided the car continues to run reliably and doesn’t require a major repair such as a transmission. I believe the success of this plan depends largely on how far you commute to work and whether or not you can live with poor reliability. I was tired of driving a car like that, and while I see no reason to purchase luxury model cars for commuting purposes, I knew I wanted something with good reliability ratings, good gas millage, and some functional features like hands free calling. 

    Tip 1: 

    Never buy new. One of the main reasons financial gurus recommend you do not buy new cars is they depreciate in value rapidly beginning the moment you drive the car off the dealer lot. Most cars from reliable brands like Honda, and Toyota will run from 0 to 100,000 miles without any major mechanical failures. If you do the routine maintenance and replace parts that are subject to wear such as tires and brakes, you should be good. Most new cars lose 20% of their value in the first year, this has been fairly consistent over time. It makes far more financial sense to buy a certified used car from places like CarMax, or the local Honda dealer. Most of these cars have been on the road for 2-3 years and have less than 30,000 miles. They have already suffered the initial depreciation and can be purchased for much lower prices. The dealers usually replace many of the commonly worn parts such as brakes, filters, and tires. All of these cars go through a thorough inspection process and are carefully selected for quality. If the car has 25,000 miles on it, you still have 75,000 good miles before you have to worry about major mechanical problems. Most of the maintenance items were already performed by the dealer prior to the sale. The fact that many of these cars have been on the road for a few years, allows organizations like consumer reports to gather data on the reliability, safety, gas millage, and customer satisfaction. This lets you make a more informed decision. The long-term reliability of a brand-new car will not be available since there is no road time for that year. You are stuck basing your decision off of the initial road testing which clearly cannot provide data on long term reliability. I would suggest getting the consumer reports, and looking up the models you are interested in, and seeing how they fared over time. 

    Tip 2: 

    Spend the extra money for a 100,000-mile warranty if it’s a reasonable price. Normally I would say this is a mistake, but the warranty is further protection, and if reasonably priced might save you in the future. Since many of these cars do have more road time, some of the non- maintenance items have the potential to fail. Things such as third brake lights or starters can cost several hundred dollars out of pocket. If it fits your budget it’s not a bad investment, if it doesn’t it’s not essential either. 

    Tip 3: 

    This tip involves gap insurance. Gap insurance is another debatable point. I believe it depends on how fast you plan to pay the car off. Gap insurance provides protection if the event you are in an accident, and the car is totaled. The insurance company will give you the value of the car at the time of the accident which may or may not be what you owe on the loan because of depreciation. If you are like me, and you pay your car off in one year, gap insurance is an unnecessary expense. The risk is low enough to take the chance and save the $600. However, if you plan to take a 5-year loan to pay the car off, there are far more opportunities to be in an accident, and the car will lose most it’s value over that length of time. In this case it’s best to protect yourself with gap insurance. 

    Tip 4: 

    Avoid luxury, and performance cars. Luxury brands like BMW, and Mercedes Benz make cool cars, with the driver’s comfort in mind. However, the prices are significantly higher and the maintenance over time will continue to cost you throughout the life of the car. If you are on a budget, it’s going to be hard to afford a car like that, and the overall reliability on some of the cheaper models is actually poor when you read through consumer reports. Performance cars are not built for reliability or practicality, they are intended to go fast, and handle well often at the expense of these things. This was a hard-learned point for a person who built several Ford mustangs over the years and wasted countless amounts of hard-earned money. From a financial, and daily driver standpoint it makes no sense to buy one of these cars until you have saved enough money to comfortable afford a weekend car. 

    Tip 5: 

    The final tip is to make sure you do all the routine maintenance at the dealer specified times. The easiest way to figure out when you need to change the transmission fluid, or cabin air filter is to look at the owner’s manual. The philosophy is simple, $140 for transmission fluid is a lot cheaper than precision machined parts. 

  • Diagnosis Depression: Major Depressive Disorder (MDD) With Psychotic features

    Diagnosis Depression: Major Depressive Disorder (MDD) With Psychotic features

    In the last post we covered MDD and we introduced the specifiers. In this post I will talk about MDD with psychotic features. 

    You may have guessed already, but what separates this disorder from MDD is the presence of delusions, and hallucinations along with symptoms of major depression. Fairly simple, right?

    First, we need to define psychotic symptoms. 

    In general, we can think about the following symptoms: 

    1. Delusions: which can be defined as fixed false beliefs. Something that the person believes despite evidence to the contrary. 
    2. Hallucinations: A hallucination is a sensory perception in the absence of external stimuli. There are several types including auditory (most common, consists of hearing a voice or several voices), visual, olfactory (smell), tactile (touch), and gustatory (taste). 
    3. Disorganized speech or behavior: This is an indication of the persons thought process. If the person is not thinking in a clear logical manner their though process may be difficult or impossible to follow for an outside observer.  

    These psychotic symptoms can be congruent with the depressed mood (content is consistent with depressive thoughts) or mood incongruent (content is not consistent with typical depressive thoughts). Mood congruent psychotic symptoms will consist of depressive themes such as guilt, death, poor self-worth, and punishment. Mood incongruent symptoms include things such as delusions of control, thought broadcasting, or thought insertion. Both mood congruent and incongruent themes can occur in the same episode.  

    Another key point is the psychotic symptoms only occur during a depressive episode. They are not present when the patient is not depressed. Once psychotic symptoms appear with an episode of depression, they tend to be present on subsequent episodes. 

    In the next post we will cover atypical features of depression. Please like, comment, and share the content. Feel free to offer suggestions for future posts. 

  • Telepsychiatry Revolution Amid COVID-19 Outbreak

    Telepsychiatry Revolution Amid COVID-19 Outbreak

    If you are a psychiatrist or patient, chances are there has been a transition to telemedicine for outpatient services. With the COVID-19 pandemic creating chaos for patients and psychiatrists alike, many systems worked frantically to implement telemedicine platforms. As the world of technology moves at ever increasing speeds, we as physicians must keep up. There is a saying barrowed from motivational interviewing that goes “meet the patient where they are at.” Of course, I’m not talking about where they are in the process of change, but rather we can meet the patients literally where they are at. This provides convenient access to psychiatric care for patients who cannot make it to the office. 

    The current situation is terrible, but it provides us new opportunities to learn and grow. If there is one thing I learned in my residency training, it’s how to be flexible and role with the punches. I have learned over the last several years that resistance to the reality of a situation will lead to unhappiness. While I miss the deep personal connections with my patients during in person visits, I have learned that most of that experience can be maintained through telepsychiatry. 

    Telepsychiatry is becoming more common, and many younger psychiatrists are making a career out of it. In the past, telepsychiatry required patients be seen in places such as the primary care clinic, now we are able to see patients in their homes. With most patients having access to a smart phone, they are able to complete the consultation in their car, or while on break at work. For busy people such as physicians who need a psychiatric consultation, the convenience of telepsychiatry is unparalleled.   

    Here are some of the questions I had after I found out I would be doing telemedicine visits. 

    Are We Compromising Patient care?

    One of my biggest concerns moving to a telemedicine platform is the quality of patient care. It’s important to consider, since one of the most therapeutic aspects of a psychiatric consult is the physician patient relationship. Countless articles have detailed the importance of physician patient relationship in treatment outcomes. I believe it influences treatment outcomes even more in psychiatry than other specialties. Multiple studies in the literature have shown that telepsychiatry is just as good as in person visits for many psychiatric disorders including depression, anxiety, and PTSD. If you work with children, it may even be a clinical advantage to use telepsychiatry. Most child and adolescent patients actually prefer using technology to interact, and doctors’ appointments are no different. 

    Is telepsychiatry HIPAA Compliant? 

    It’s important to remember that not all video-based systems are HIPAA compliant. The ones we are most familiar with (Facetime, google hangouts) are not HIPAA compliant. There are a number of companies that offer telemedicine platforms that do comply with HIPAA regulations. Skype for business is a HIPPA compliant product but the free version is not for example. The companies that offer HIPAA compliant services will provide you with a Business Associate Agreement (BAA). It’s basically a document that indicates the data transmitted over the service is confidential. The company agrees to provide the service and cannot look at any of that data transmitted over the platform. Ensuring you have the BAA in place will confirm HIPAA compliance. 

    How does State Licensing Work?

    In order to use telepsychiatry you have to be licensed within the state that the patient is located in. For example, if you are licensed in Florida and the patient is located in South Carolina you would need a license in the state of South Carolina. However, the physician is allowed to be located anywhere in the world.  

    Are There Limitations to Medication Prescribing?

    For routine psychiatric medications, these can be electronically sent to the pharmacy like an outpatient visit. The one caveat to be aware of is prescribing controlled substances such as stimulants and benzodiazepines should not be done via telepsychiatry. Careful monitoring of patients on these medications necessitates the need for in person follow up. The legal guidelines are not clear at this point, so it’s best to avoid prescribing controlled substances. 

    What About High risk situations?

    Another area of concern is what to do in the event that a person is suicidal or needs emergency care. These situations are rare, but they can happen, and you need to be prepared. It’s a misconception that someone has to be in the room with the patient during the consult. This is not true, however it’s prudent to have a person you can contact in the event of an emergency. This can be a friend or family member who lives close to the patient and can reach out quickly. You should also get a list of the local police departments in the area where your patients are residing. This is a last resort but may be required in some situations. To summarize you should have the patient’s address, phone number, a friend or family member’s contact information, and the local police departments number. This should be enough information in the event you need to alert emergency services. 

    What Is The Out of Pocket Cost to Physicians?

    One issue that may be more important to the private practice psychiatrist is the equipment required to start telepsychiatry. In many cases the equipment required is already possessed, a laptop computer with built in speakers, camera, and microphone will likely be enough for most practitioners to get started. You can purchase higher end microphones and cameras which may be important to psychiatrists who plan to continue using telepsychiatry after COVID-19 however, it’s not required. The take home point is a basic laptop computer will cover most physician and patient needs. 

    How Do I Get Vital Signs?

    Blood pressure, pulse, height and weight are usually recorded on every patient, at every visit. A simple way to get around this issue is having the patient purchase a blood pressure cuff from the store, which is relatively inexpensive. Have the patient perform the blood pressure check while in the session and show you the monitor. This will allow you to record pulse and blood pressure easily. Many patients will have a scale in the house, and if not one can be purchased. 

    What about Urine Drug Screen and Routine Labs?

    This is a simple situation to handle and much like regular outpatient visits the patient can be sent to LabCorp or Quest diagnostics for these tests. Other examinations like the Abnormal Involuntary Movement Scale (AIMS) test for patient’s taking antipsychotics can be easily completed with telepsychiatry. 

    Final Points:

    In conclusion, I do not think telepsychiatry will replace all in person psychiatric evaluations and follow ups. However, it does provide a convenient option for busy patients with time constraints, and those who are more comfortable communicating electronically. I have embraced the change and I really have enjoyed the process of transitioning to telemedicine. 

    I would love to hear any thoughts on telemedicine from the patient or physician perspective. Please, like comment, and subscribe to the blog. 

  • Diagnosis Depression: Major Depressive Disorder (MDD)

    Diagnosis Depression: Major Depressive Disorder (MDD)

    This is the beginning of a series on depressive disorders starting with MDD. I want to keep the posts short and to the point, less than 500 words each. 

    Major depressive disorder (MDD) is very common. The lifetime and 12-month prevalence are 13-17% and 6-7% in American adults over the age of 18. For adults under the age of 50, it’s twice as likely to affect females when compared to males. MDD is associated with high rates of psychiatric and medical morbidity, impaired work function, and disability. 

    DSM-5 Criteria for Diagnosis

    To diagnose MDD you must have at least 5 of the following symptoms over the same two-week period. At least one of the symptoms must be depressed mood or loss of interest. 

    The symptoms are as follows, depressed mood; diminished interest in pleasurable activities; changes in appetite either increased or decreased; insomnia or hypersomnia (increased sleep); psychomotor agitation (restlessness) or retardation (slow movement); decreased energy; guilt or feelings of worthlessness; diminished ability to concentrate; and recurrent thoughts of suicide. These symptoms must occur every day or nearly every day and last all day over that same two-week period. The symptoms can be either a subjective account, observed by others, or some combination of both.

    It must cause significant disruption in social, occupational, and other important areas of function. It cannot be caused by a medical condition or substance use. 

    Specifiers for MDD: 

    Mild; Moderate; Severe; without psychotic features; Severe with psychotic features; in partial remission; in full remission; chronic; with catatonic features; with melancholic features; with atypical features; with post-partum onset; with or without full inter-episode recovery; and with seasonal pattern. 

    In the next post we will cover the highlighted specifiers and what specific symptoms separate them from each other. Please like, share, and comment we want to hear from you.