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. 

Reducing Anxiety and Altering Patterns of Avoidance

Thinking Style in Anxious Patients 

  • There is a heightened level of attention to potential threats in the environment 
  • Example: A women with fear of airplanes has to fly across the country for work, she believes the plane is likely to crash despite the low risk of this actually occurring.

Predominant thinking patterns in Anxiety 

  1. Fears of harm and danger 
  2. Increased attention towards potential threats 
  3. Overestimation of the risk of situations 
  4. Automatic thoughts associated with danger, risk, uncontrollability, incapacity
  5. Underestimates of ability to cope with fearful situation 
  6. Misinterpretation of bodily stimuli 

Avoidance

  • The emotional and physical response to the feared object or situation is so severe that the person will do anything to avoid it. 
  • Because the avoidance behavior is rewarded with emotional relief, the behavior is more likely to occur when the person is faced with similar circumstances. 
  • Example: A person with anxiety is invited to a party and decides to make up an excuse not to go and the anxiety is relieved. Each time the person is faced with a similar situation they are likely to act the same way. 

CBT Model for Anxiety

  1. Unrealistic fear of objects or situations 
  2. A pattern of avoidance reinforces the belief that I cannot deal with the feared object or situation 
  3. The pattern of avoidance must be broken to overcome the anxiety. 

Behavioral Treatments

  • There are two general methods of behavior treatment for anxiety 
  • Reciprocal inhibition: A process of reducing emotional arousal by helping the person experience a positive or healthy emotion in place of the unhealthy one. (deep breathing, relaxation techniques) 
  • Exposure: expose yourself to the stressful situation, fear will occur but cannot be sustained indefinitely and the person will begin to adapt to the situation. 

Assessment of symptoms, triggers, and coping strategies

  1. What is the event that triggers the anxiety? 
  2. What are the underlying automatic thoughts, cognitive errors, and schema involved in the overreaction to the feared stimulus?
  3. What is the emotional and psychological response? 
  4. Habitual behaviors such as avoidance?

Cognitive Errors

  • Cognitive errors have been found to occur more often in people with depression and anxiety.
  • There are 6 main categories of cognitive errors 
  • Selective abstraction: A conclusion is drawn after looking at only a small amount of information. Other contradictory information is screened out to confirm the persons biased view of the situation.
  • Arbitrary inference: A conclusion is reached in the face of contradictory evidence or lack of evidence
  • Overgeneralization: a conclusion is made about one or more isolated incidents and then extended illogically to cover broad areas of functioning.
  • Magnification or minimization: The significance of an attribute event or sensation is exaggerated or minimized.
  • Personalization: external events are related to oneself when there is little or no evidence for doing so.
  • Absolutistic thinking: judgments about oneself, others or personal experiences are placed into one of two categories: All good or All bad

Techniques:

  1. Relaxation training: reducing muscle tension induces a state of relaxation and often results in reduced anxiety
  • Rate the level of anxiety and muscle tension on a scale of 0 to 100, with 0 being no tension and 100 being max tension 
  • Try making a fist and squeezing to a level of 100, then release it to a level of 0. Try doing so with the other hand. Notice that we have voluntary control over how much tension we feel. 
  • Starting with the legs tense and release each muscle group working your way up to the head. (I prefer to do this laying down) 
  • Try to keep positive mental images in your mind while doing this. Example: picture your tension and worries melting away like ice when left out in the sun. 
  • Try doing this daily for 1 week and record how you feel before and after a session.

2. Thought stopping: Stop negative thoughts and replace them with positive adaptive thoughts. 

  • Recognize: that a dysfunctional thought pattern is active 
  • Give self-instructions to interrupt the thought pattern:  Shift attention away from the anxiety provoking thought. (STOP! Or Don’t go there!) 
  • Consider guided images: try to imagine doing something enjoyable, playing a game, watching a sport, going on vacation. This can be combined with muscle relaxation  

3. Distraction: Develop several positive scenes that you can go to when anxious. Examples include walking in a nice park, going to your favorite restaurant, and spending time with friends/family 

4. Decatastrophizing: examine the evidenceto see that the likelihood of adverse outcomes is much less than we estimate

  • Estimate the likelihood: of the event occurring. Rate it on a scale of 0 to 100% 
  • Evaluate the evidence: for and against the event occurring 
  • Review the evidence list: now re-estimate the risk of the event occurring after going through the evidence 
  • Create an action plan: brainstorm strategies to reduce the likelihood of catastrophic occurring. Write down actions that you could take to prevent the feared outcome. 
  • Develop a plan for coping: if the event should occur. 
  • Reassess: compare the original rating to the new rating 
  • Debrief: What was good about working through a catastrophic event in this manner?

5. Deep Breathing

  • Aim for 30-60 breaths, 1-2 cycles
  • Start in the sitting position, hands on la or knees 
  • Take 10 breathes in through the nose and out through the mouth 
  • Take 10 breaths in through the nose and out through the nose 
  • Take 10 breaths in through the nose and hold for 5-10 seconds, then release out through the mouth 

6. Exposure: systematically or all at once (flooding) exposing yourself to the feared object or situation. This is the most important part of CBT for anxiety. Systematic desensitization: graded exposure, starting with less anxiety provoking situations 

  • Be specific: details matter, “stop being afraid to go to parties” is not specific “go to my neighbor’s house party for 20 minutes and talk to one person” 
  • Rate each step on a scale of 0 to 100 depending on how much anxiety you expect to occur 
  • Develop at least 8-12 scenarios that go from lowest to highest anxiety 
  • Work with the therapist to select to order of steps for graded exposure therapy 
  • Two types: imaginal and real-world exposure, depending on the case both may be used (good for OCD and PTSD)  

Help, I think I’m a Narcissist

Introduction

It seems like everywhere I look there’s a video or article with titles such as “how to tell if you’re a narcissist” or “is your significant other a narcissist.” This got me thinking about narcissistic personality disorder (NPD), and why everyone thinks they or someone they know has this disorder. 

Brief Review of NPD Criteria from DSM-5 (5 out of 9 required) 

-Grandiose sense of self-importance 

-Preoccupied with fantasies of unlimited power, success, beauty etc. 

-Believes they are special and unique 

-Requires excessive admiration 

-Has a sense of entitlement (unreasonable expectations) 

– Interpersonally exploitative 

-Lacks empathy 

-Often envious of others or believes others are envious of them 

-Shows arrogant, haughty behaviors and attitudes 

Distinction Between a Disorder, and being a Jerk 

There is an important distinction between having NPD and having narcissistic traits. In diagnosing NPD there is a long list in DSM-5 of which the person must have 5 out 9 criteria to qualify for the diagnosis. These criteria will be present in all circumstances and relationships. Most importantly it must cause impairment in function and a subjective sense of distress. If the person meets these criteria, and it’s working for them in their life, they would not be diagnosed with NPD. You need to have the functional impairment, that is what makes it a disorder. Although these people may not have a disorder, it still does not make them a pleasure to be around. There can still be relationship difficulties both professionally and on a personal level.

Common Types of Narcissism 

The classic grandiose narcissist, this is the kind of person who cannot stop bragging about what they have, and what they have done. They tend to enjoy showing off symbols of status such as new cars or even attractive partners. They do things based on what will get them the most admiration and recognition from others rather than personal values. These types are encountered on a regular basis, you may know people like this in your personal life. 

There is a classic example of the highly successful professional who will stop at nothing to achieve their goals even if it’s at the expense of others. So naturally one place you may encounter these individuals is in the workplace. These types will exploit other people, cheat, work the system, whatever they can do to get ahead. They are usually successful and superficially charming. This pattern is less commonly encountered in daily life.

Oregon First to Legalize Psilocybin for Mental Health Treatment

On Tuesday Oregon became the first state to legalize the psychedelic prodrug found in magic mushrooms. Measure 109 will give legal access to psilocybin for mental health treatment in supervised settings. 

Having followed the research on psilocybin at Center for Psychedelic & Consciousness Research, I am aware of the growing body of research on this topic. Most of the results presented seem to indicate significant benefit with limited side effects. The research I reviewed involves the use of psilocybin for the treatment of substance use disorder. However, I am aware of positive results in the treatment of post-traumatic stress disorder and to enhance the effects of psychotherapy. I am a believer that we need to look at all potential options for the treatment of psychiatric disorders. We know that our current medications only solve some of the problem’s patients are facing. Chronic disorders like substance use and depression remain major clinical challenges. 

As a psychiatrist I’m conflicted about the decision to start offering this treatment even in supervised settings. Like Cannabis, we are only in the beginning stages of studying these drugs as medication. As a physician you remain a scientist first, and as a scientist you want to give the research time to develop. In the United States cannabis remains federally illegal (schedule I). This means funding for research is difficult to obtain. The same is true for psilocybin. We need increased ability to study these drugs as medications and determine the true risks and benefits. There are many anecdotal accounts of the benefits of both these drugs, but I do not believe this is enough to potentially risk your health on. 

I believe research will elicit positive benefits for both cannabis and psilocybin. However, I urge caution when considering these options as potential treatment for mental health disorders. 

Election Anxiety Solutions

Anxiety is a part of life; we all experience it. The amount of anxiety a person experiences is to some degree related to how important a particular outcome is to that person. It seems like everything these days is high stakes and anxiety provoking. There is a global pandemic that continues to create chaos around the world, economic uncertainty, gender and racial inequality, and now a presidential election.

People are more anxious than ever about this presidential election. According to a recent article by the American Psychological Association 68% of U.S. adults say the 2020 U.S. presidential election is a significant source of stress. This is compared to the 2016 election where 52% of U.S. adults found the election stressful. It might just be a symptom of the times, but it remains a significant concern. If you are having election anxiety here are some simple ways to reduce stress and anxiety during this election cycle. 

  1. Make sure you are getting enough sleep. Set a regular sleep time and wake time. Make sure the room you sleep in is as conducive to sleep as possible (e.g. dark room with no ambient light). Limit the bed to sleep and sex only, do not play games on your phone or read in bed. If you can’t sleep get out of the bed and do a mildly strenuous activity. A good example is a crossword puzzle, then come back to bed when you feel tired. If you are not sleeping well it can cause problems in other areas of life such as mood and cognitive function. 
  2. Get outside or stay inside whichever you prefer, but make sure to move. Exercise is a great way to cope with stress and anxiety. There are countless free guided exercise routines on sites like YouTube that require little or no equipment to perform. If you do not like that option, take a walk in your favorite park, take a bike ride, or go for a hike on your favorite trail. 
  3. Limit your consumption of news throughout the day. Set aside one or two times per day to check the news and see what is going on with the election. Resist the urge to continually check in and get play by play updates. This simple, but difficult to follow advice will save you a lot of stress and anxiety. 
  4. Avoid talking to people in your life about the election who are unable to keep their emotions under control while discussing the topic. You should have a good idea of who these people are in your life. This will save you a lot of stress and anxiety by simply choosing to talk about other topics with those individuals.
  5. The last thing I recommend for people who want an activity they can perform to reduce stress is a thought journal . This can be as simple as a piece of paper that you record the thoughts on. There are printable versions of this online. I will provide a link to one such example here. This is a common technique used in cognitive behavioral therapy (CBT) all the time.

Complementary Alternative Medicine (CAM) in Psychiatry

This is one of the most popular topics patients ask about. Often psychiatry gets a bad reputation for prescribing medication without addressing lifestyle and “natural” options for the treatment of psychiatric illness.

A 2007 National Health Interview Survey (NHIS) reported 4 out of 10 American adults and 1 out of 9 children used CAM. The most commonly cited reasons for using CAM are depression, insomnia, anxiety, and chronic pain. Typically, integrative care involves the use of traditional medical therapy with appropriate evidence-based CAM. This is not always the case, and often times you will find many people who are not licensed medical doctors offering advice on CAM. What I hope to accomplish in this post is to introduce some of the CAM options that are evidence based for depression.

While the use of CAM is widespread, randomized controlled trials for specific CAM interventions have issues with their study design. They are usually conducted for short durations, and have a small number of participants. Despite these limitations, many CAM research studies report positive benefits for depression. Likewise finding high quality products with appropriate dose of active ingredient can also be a challenge. There are many companies and not all of them are reputable. 

It’s unlikely that CAM will be enough to treat severe cases of major depressive disorder alone. For mild to moderate cases of depression, it may be effective based on the evidence detailed below.

Below are the options I would consider CAM for primary treatment of depression. In the next post I will talk about adjunctive treatment for people who have had response to antidepressants but not remission of symptoms.

Hypericum Perforatum (St. John’s Wort) 

St. John’s Wort (SJW) is a medical herb with antidepressant activity. The exact mechanism by which this herb improves mood is not fully understood. SJW is known to inhibit monoamine reuptake, and down regulate monoamine receptors in the brain. In 2005 Linde et.al conducted a meta-analysis of 37 randomized double-blind placebo-controlled trials (RCT) which demonstrated superiority of SJW to placebo. It’s important to note SJW was equivalent to antidepressant treatment for mild cases and inferior for severe depression. In 2017 Ng QX et al. conducted a meta-analysis which found a similar result. They looked at 27 clinical trials and a total of 3808 patients, comparing the use of SJW with SSRIs for the treatment of depression. They concluded that for mild to moderate depression, SJW had comparable efficacy and safety when compared to SSRIs.

How does SJW stack up against traditional SSRIs? Fava et al. conducted a randomized double-blind trial of SJW, fluoxetine and placebo for major depressive disorder. SJW was significantly more effective than fluoxetine and showed a trend toward superiority over placebo. Sarris et al. analyzed date from a 26-week RCT that studied SJW vs. Sertraline and placebo for major depressive disorder. The comparison between all treatments was not significant. Both SJW and sertraline were therapeutically effective, but they could not say one was superior to the other. 

Although SJW is effective for the treatment of depression, it’s not my favorite choice. SJW is a known inducer of the cytochrome P450 enzymes. SJW can increase clearance of medications including antiretrovirals, oral contraceptives, benzodiazepines, digoxin, and phenobarbital. When SJW is combined with other antidepressant medication there is increased risk of serotonin syndrome. 

S-Adenosyl-Methionine (SAMe)

SAMe is an amino acid that is distributed widely throughout the brain and is the major methyl donor required for the synthesis of monoamine neurotransmitters. It’s available in the United States over the counter. Studies indicate that SAMe levels may be reduced in patients with MDD.

Several reviews of the literature on SAMe and depression have been conducted. Most of the reviews conclude that SAMe is generally effective for the treatment of depression. However, more carefully designed higher quality studies need to be conducted. A meta-analysis that looked at 28 studies concluded that SAMe was superior to placebo for the treatment of depression, and it was found to be statistically significant. Again, this study did not find a difference between SAMe and traditional antidepressant treatment. Another review of 11 studies concluded that SAMe resulted in a reduction in depressive symptoms and was superior to placebo. One study showed benefits of SAMe as an adjunctive therapy to SSRIs in patients who were non-responders.

SAMe does have some associated side effects including mild gastrointestinal (GI) problems and insomnia. There is risk of inducing a manic episode in patients with bipolar disorder, and SAMe should be avoided in this population. Patients taking medication for Parkinson’s disease may have reduced efficacy of the medication when taken in conjunction with SAMe. Thus, we should avoid SAMe in this population as well. 

References

  1. Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database Syst Rev. 2008;2008(4):CD000448. Published 2008 Oct 8. doi:10.1002/14651858.CD000448.pub3
  2. Ng QX, Venkatanarayanan N, Ho CY. Clinical use of Hypericum perforatum (St John’s wort) in depression: A meta-analysis. J Affect Disord. 2017;210:211-221. doi:10.1016/j.jad.2016.12.048
  3. Fava M, Alpert J, Nierenberg AA, et al. A Double-blind, randomized trial of St John’s wort, fluoxetine, and placebo in major depressive disorder. J Clin Psychopharmacol. 2005;25(5):441-447. doi:10.1097/01.jcp.0000178416.60426.29
  4. Sarris J, Fava M, Schweitzer I, Mischoulon D. St John’s wort (Hypericum perforatum) versus sertraline and placebo in major depressive disorder: continuation data from a 26-week RCT. Pharmacopsychiatry. 2012;45(7):275-278. doi:10.1055/s-0032-1306348
  5. Galizia I, Oldani L, Macritchie K, et al. S-adenosyl methionine (SAMe) for depression in adults. Cochrane Database Syst Rev. 2016;10(10):CD011286. Published 2016 Oct 10. doi:10.1002/14651858.CD011286.pub2
  6. Sharma A, Gerbarg P, Bottiglieri T, et al. S-Adenosylmethionine (SAMe) for Neuropsychiatric Disorders: A Clinician-Oriented Review of Research. J Clin Psychiatry. 2017;78(6):e656-e667. doi:10.4088/JCP.16r11113

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. 

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