Grounding Technique For Anxiety

Anxiety is something most of us have experienced. This five-step exercise can be helpful during periods of anxiety by helping to ground you in the present moment. 

Start the exercise by drawing attention to your breathing. Slow, deep, breaths can help you induce a feeling of relaxation. Once you feel relaxed, go through the following steps to ground yourself: 

One: Note ONE thing you can taste

Examples may include: gum, sugar free candy, coffee, sparkling water (anything you can taste in the moment). 

Two: Note TWO things you can smell 

Examples may include: fresh air, scented candle, flowers, food cooking (anything around you that you can smell)

Three: Note THREE things you can hear 

Examples may Include: people talking, cars driving, wind blowing, rain falling (anything in the environment you can hear) 

Four: Note FOUR things you can touch 

Examples may Include: desk, chair, pen, phone (anything around you that you can touch) 

Five: Note FIVE things you can see 

Examples may include: door, computer screen, car, tree, house (anything you see around you)

Intramuscular Medication (IM) in Psychiatry: Is it Better?

Intramuscular medication as the name implies is a long-acting injectable form of medication that is usually administered into the gluteal muscle or deltoid muscle and it’s designed to take the place of PO or oral formulations.

The medications available in IM formulations

  • Aripiprazole (Abilify Maintena) 
  • Aripiprazole lauroxil (Aristada) 
  • Fluphenazine (prolixin)
  • Haloperidol (Haldol)
  • Olanzapine pamoate (Zyprexa Relprevv) 
  • Paliperidone (Invega Sustenna, Invega Trinza) 
  • Risperidone (Risperdal Consta) 

Most last between 2-4 weeks but medications like Invega trinza lasts up to 3 months 

This solves one of the major issues when prescribing medication, which is adherence with treatment. 

Notice that all these medications are first- or second-generation dopamine blockers. These medications are commonly used to treat disorder like Bipolar and Schizophrenia (serious mental illness). These populations often have difficulty with medication adherence. 

Clinically most psychiatrists will tell you IM medication improves patient outcomes. However, they may not outperform PO medication taken daily and consistently. Where these medication formulations have the biggest impact is for people who had improvement on oral medication but often forget to take medication or do not want to take medication daily. Many patients with serious mental illness stop taking medication when symptoms resolve making relapse likely. 

Side effects will be similar to the oral medication with the added logistical issue of coming to the office for the injection, and pain at the injection site. Normally we assess tolerability and risk of side effects with oral medication before giving IM medication. This avoids the potential for long lasting side effects. 

Olanzapine (Zyprexa) Without the Weight Gain

While Olanzapine is an effective medication, it’s side effect profile can be nasty. Things like weight gain, changes in blood lipids, and changes in blood glucose are common. ALKS 3831 attempts to fix this problem by adding Samidorphan to olanzapine to reduce weight gain.

Can Benzodiazepines be Prescribed Ethically?

Benzodiazepines are quickly gaining a reputation as the new opioids in terms of risk for abuse and potential for adverse events. The question remains, is there a way to ethically prescribe these medications to patients while reducing the risk of abuse? 

Immediate Release Vs Extended-Release Formulations in Psychiatry

Highlights From the Video

Immediate release the medication is released immediately and results is quick onset and a peak blood level. This type of formulation is generally less expensive and may be advantageous in some cases. For example, if you are using quetiapine at night in part for its sedating effects, I will use immediate release because I want a rapid effect. The same with methylphenidate or bupropion. 

The problem is this formulation requires twice a day or even three times per day dosing and results in more peaks and troughs. In general, for medications that are being used for maintenance you want consistent blood levels and not peaks and troughs.

With IR formulations, there can be more side effects and addictive potential. We believe it’s the rapid rise in blood levels of the medication that cause side effects and with medications like amphetamines for ADHD it’s the rapid rise in medication levels that can result in euphoria and thus addictive potential.

Extended release does not change the active ingredient in the medication, rather it provides a different delivery mechanism that slows the release of medication over an extended period of time. This has the opposite effect on blood levels when compared to IR. There will be less peaks and troughs and more sustained blood levels of medication. The advantage is once daily dosing and potentially fewer side effects for the pervious mentioned reasons. 

The downside is these medications tend to cost more money and some have argued when initiating these medications, a patient who has an adverse reaction will have symptoms longer with XR. Although clinically I’m not sure this is true and will generally use extended release if possible for maintenance medications.

Introducing Shrinks In Sneakers on YouTube

I’ve done a soft rollout of the Shrinks In Sneakers YouTube channel over the past several months. I think I’m finally comfortable introducing it on the blog. I made the decision to start making videos because I can create content at a more rapid rate, and I can connect with the viewer in a more personal and intimate way. Please subscribe to the channel for updates. If you have specific topics you want covered, or have questions about existing content please comment. I will try to answer all questions and continue creating engaging content based on your interests. 

Cheers,

Dr. G

Link to YouTube Channel

https://www.youtube.com/channel/UCaaywi6nWB4zzpqBCMvxbsA

Record number of guns sold in 2020: Should We Be Concerned?

Amidst the abundance of coverage of the 2020 presidential election mixed with an evolving pandemic, here is a news story you may have missed: it’s 2020 and guns are more popular than ever in the US. According to data from Small Arms Analytics  to date, Americans have purchased nearly 17 million guns in 2020. This is more than any previous year on record. Handgun sales increased by 81% and long-gun sales increased by 51%. We saw a similar trend in 2016 when 16.6 million guns were sold. This was driven by increased rhetoric calling for strict gun control laws in the wake of several mass shootings. 

As psychiatrists and concerned citizens, this data is alarming. We know that the presence of a gun in the home alone increases the risk of suicide. Specifically, owning a handgun is associated with a dramatic increase in suicide risk. Men who owned handguns were eight times more likely to die by self-inflicted gunshot wound. Women who owned handguns were 35 times more likely to kill themselves with a gun. Access to guns in the home is such a concern for depressed patients that it’s a part of every psychiatric evaluation. Suicide is often an impulsive act, and many of those who survive a suicide attempt regret their actions. Guns permit people to be dangerously impulsive. Lethality of means determines whether a person will survive a suicide attempt. In the United States, where more civilians’ own firearms than any other country, our most lethal means are guns. Suicide attempt by firearm will most likely result in death: an irrevocable and permanent result of the combination of an impulsive decision and a gun.

So, what is this about? Is there an increased interest in hunting that some of us missed? The plain answer is no. Most guns purchased in the US are not intended for hunting; instead, people are purchasing guns for “protection.” The increase in gun sales comes at a point in history of great political and social unrest. Maybe it is unsurprising that people feel an urge to protect themselves and their families. Fear is at an all-time high.

You know what else is at an all-time high? Isolation, loneliness, anxiety and depression. The most well-adjusted people are struggling in 2020. Depressed moods can progress to clinical depression which may include suicidal thoughts as part of the diagnostic criteria. Now, we have a country full of depressed people buying guns. In the mental health field, we are scared. You should be too. The financial, political, and public health uncertainties of today’s world form a perfect substrate for depression, fear, and impulsivity. Adding a gun is not the way to fix it.

We know that gun access provides a substantial risk for suicide. It remains important that we educate our patients about the risk of gun ownership. This is especially important for patients who have a history of depression or other psychiatric disorders. All this could be a potentially dangerous combination of psychopathology, and access to lethal means. 

Why Labels Matter: A Personal Perspective

Introduction:

I’ve been writing a lot lately about the why words matter, and how the language we use can go on to influence our lives in many ways. In my clinical work with patients, I make an extra effort to explain the process of making a diagnosis. I also stress to my patients that diagnosis is a way of conceptualizing mental illness to help physicians design appropriate treatment plans. I want them to know that diagnosis is an imperfect process. When we label someone as “depressed or anxious,” we may not understand the lasting impact this can have on them. Many patients internalize and identify with being “depressed” sometimes to the detriment of their treatment. 

True Story:

I can share a personal perspective on the power of labels, because one particular label almost prevented me from becoming a physician. Imagine you are in fourth grade, and to that point you were already identified as “one of the least academically gifted” children in the class. At this point it was already clear there would be no gifted and talented classes for me. After another year of painful struggle academically, my parents requested I be tested by the child study team for a learning disability. At the time I did not know this was going to pretty much set the course for the rest of my academic career. Sure, enough, after what seemed like endless testing I was classified, given an individualized education plan (IEP), and placed in slower paced classes with fewer students. Now I had been officially labeled as having a learning disability. I had a real excuse to give up on any academic ambitions. 

Looking back on it, I’m not sure I even had a learning disability as much as the educational material and teaching was just so uninspiring. I continued through middle school, and high school and average student in below average classes, and I thought I was okay with that, after all I had a learning disability. I identified with this label which had a profound impact on my academics and ultimately set my medical career back five years. 

Famous Last Words:

The point of this is to help people who have been affected by labels. If you find yourself continually self-sabotaging, you may be allowing early labeling and the conditioning that comes with it to limit your potential. It’s important to accept your circumstances, and to try the treatments or interventions offered if you are not functioning well. However, we should not allow our life to be defined by these labels. Just because you have a learning disability or depression does not mean you cannot be successful. It took me many years to accept that I might actually be smart enough to go to medical school. I often think about how much further along I could have been if I did not identify with and internalize the idea of having a learning disability. Do not make the same mistake.

Medication Side Effects: “I feel nauseous”

Introduction:

Did you know that the researchers that conduct drug trials do not ask patients about specific side effects? Rather, they ask a generic question such as “are you having adverse reactions to the medication” the patient then has to self-report any specific side effects they are having. Sometimes physicians during medication management sessions will use a similar question when asking about side effects. Some physicians also make statements when prescribing the medication such as “don’t worry most people do not have side effects with this medication.” This is egregious, considering we know these medications have side effects as all medications do. What I want to do over the next several posts, is discuss the common side effects of SSRIs and what you can do about them. The biggest issue we face with psychiatric medications is adherence, and many times side effects play a role. 

I want to start with the most common side effects and work our way down. Nausea is one of the early side effects that is disturbing to patients and may result in discontinuation of the medication. Several things can be done to reduce the risk of nausea. 

Medication Starting Dose and Titration

One simple step could be to start the medication at the lowest possible dose and titrate slowly. Titrating the dose over one week has been shown to cut the risk of nausea in half. Another potential intervention is to split the dose and give the split dose with separate meals. If possible, use sustained/extended release preparations of the medication. For example, starting a patient on escitalopram 5 mg instead of 10 mg might help reduce the risk of nausea. Another simple change could be the timing of medication administration. Taking the medication after a meal may be helpful. Many patients find that food helps reduce the nausea and most of these medications can be taken with or without food. 

Ginger Is Good

If the above interventions fail to help you can consider ginger root. This dietary supplement can be purchased over the counter from your local health food store. Ginger root 550 mg one to two capsules up to three times per day if the slow titration and other intervention are ineffective. 

If All Else Fails

Finally, if the nausea does not respond to the above interventions then anti-nausea medications are appropriate. The two most commonly used at ondansetron and Mirtazapine which also blocks 5HT-3 receptors leading to reduced nausea. 

Medication Side Effects: Doctor my mouth is a little dry

Regular Dental Care and Oral Hygiene

Dry mouth is another common side effect from psychiatric medication. Patients on psychiatric medication often have poor dental care and poor dental outcomes. There is increased incidence of dental caries and oral ulcers in this population. This patient population is also three times more likely to lose all their teeth. Let that sink in for a moment. Now some of this is related to not following the recommended dental hygiene guidelines such as regular cleanings at least every 6-months. Thus, this is the first step in the process. Ensure the patient first has a dentist, and second be sure they are making regular 6-month appointments, and if they have issues with dental health, they should be going for cleanings as often as every 3 months. Oral hygiene is the foundation for the remainder of the interventions.

Gum, Candy, and Pilocarpine

Most patients are told to carry a bottle of water around and take frequent sips throughout the day. This does not work. It provides temporary relief, and does not address the underlying issue. You can educate the patient about drinking more water while eating which can help facilitate the swallowing process especially when dry mouth is an issue. Carrying a cup of ice can be helpful but is not convenient. What I prefer is the use of sugarless gum or candy which can be easily carried and chewed as needed. Studies have demonstrated that xylitol containing gum can reduce the levels of Mutans streptococci and lactobacilli in saliva and plaque. This has the potential to reduce the incidence of dental caries, and is an inexpensive option for most patients. I will also recommend as a second line using a mouth wash for dry mouth such as Biotene. If these interventions are not effective a medication to stimulate saliva production such as pilocarpine. In many cases pilocarpine eye drops which act locally is a better option than a medication that acts systemically. 

Final Words

Dry mouth is a common side effect patent’s experience but may not always bring to the clinician’s attention. There are interventions to treat this side effect that range from simple interventions like xylitol containing gum to pharmacological interventions such as pilocarpine eye drops. Most patients will experience relief with the above treatments. This highlights the importance of asking about specific side effects so they can be treated early and prevent long term Complications such as tooth loss. 

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