Use of Antidepressants is on the Rise

August 16, 2017

The CDC’s National Center for Health Statistics just put out a report about the increasing use of antidepressants.  As a psychologist (as opposed to a psychiatrist), I have mixed feelings about this.  On the one hand, there have been many studies that have demonstrated the superior or at least matched efficacy of psychotherapy over medication to treat depression and anxiety, so I find this trend concerning.  But on the other hand, when I recommend that some of my patients should consider consulting with their primary care provider or a psychiatrist and they express concerns about stigma, weakness or other reasons not to consider this treatment option, I attempt to reassure them that “antidepressants are one of the three most commonly used therapeutic drug classes in the United States” according to the report, and thus they should not feel self-conscious about taking such medications.

The report noted that there has been a progressive increase in antidepressant use since 1999, and that during the time of the study, nearly 13% of people over the age of 12 in the US have reported taking antidepressants in the past month.  Women take antidepressants at double the rate of men.  A quarter of those who reported using antidepressants have taken them for at least ten years.

It’s reassuring that those who need to take medication are in good company, but it is important to explore non-medical treatment of depression and anxiety, as the beneficial effects tend to be of a much longer-lasting duration.

Switching Psych Meds Often Doesn’t Help

December 19, 2016

medication changeA recently published meta-analysis of over 3000 studies suggested that switching antidepressants after the first drug doesn’t produce the desired results is not better than staying the course and/or exploring options other than trying a different drug.  This is a very interesting finding as most prescribing clinicians tend to give one antidepressant a “trial” of about 6-12 weeks.  If things aren’t better then often scrap that medication and start another 6-12 week trial of another one.  The authors of this article reviewed 3234 relevant studies and concluded that it is generally wiser to explore alternatives other than a medication change.

Prevalence of Psychiatric Medication Use

December 13, 2016

medication

A recent research letter, published by JAMA, reported that one out of six American adults take at least one psychiatric medication.  As a clinical psychologist I understand the benefits of non-medical treatments for psychiatric illness, but that doesn’t mean I don’t appreciate appropriate use of psychiatric meds.  In fact, I refer a significant number of my patients to their primary care providers or to psychiatrists for medications, and I often make suggestions to the prescribing professionals about which medication I believe would work best for the referred patient.  Nearly every time I do this, however, I have a long discussion with my patient about what it means to be on a psychiatric medication, and what it doesn’t mean.  I almost always say something like, “several of your friends and several of your coworkers are on [psychiatric] meds… but they just haven’t told you,” in an effort to communicate how prevalent they are.  This letter drives that point home really nicely.

But what I really like about the letter is that it also talks about how some medications are not be prescribed appropriately.  Two classes of drugs that are most frequently mis-prescribed are benzodiazapines (e.g., Ativan, Xanax) and sedative/hypnotics (e.g., Ambien), which are supposed to be used short-term, not for months or years at a time.

When Patients Try to Seduce Doctors

October 31, 2016

I was recently interviewed for a Medscape article about maintaining professional boundaries, entitled, When Patients Try to Seduce Doctors.  It’s a relatively short piece and, though I was misquoted a little, it has some good information about the doctor-patient relationship and the importance of establishing and upholding appropriate professional boundaries.  Check it out.

Why Placebos Work

July 19, 2016

A recent article in The Wall Street Journal summarizes some of the explanations about how we think placebos work.  If you read an earlier blog post I wrote about placebos, what I find so fascinating about all this is that even when subjects/patients are told they are receiving a placebo (either in the form of a sub-therapeutic dosage of a real medication or just a sugar pill), they often still show the suggested effects of that “treatment.”  If people expect something to happen when they take a pill, it often does.  For example, this self-confirming bias occurs with medication side effects: you read that horrible insert from the pharmacist that lists every possible side effect that has been reported for the drug and sure enough you start to experience some of the effects… right away, before it’s really physiologically possible for the medication to have caused them.

Though some of my colleagues may not like this, I’d imagine that a nice chunk of what happens in psychotherapy is related to the placebo effect.  We might call it a safe holding environment, positive future orientation or something like that, but the fact of the matter is that when a patient comes into therapy expecting a positive outcome, they typically experience that.  (Similarly, when patients initiate treatment with negative expectations, they often don’t get much from treatment.)  Clearly, a difference between psychotherapy and placebo is that actual treatment is being provided with psychotherapy, but patient expectation, therapist suggestions and patient suggestibility all play a significant role in therapy and should not be underestimated.

Exercise to Argue Better

June 29, 2016

Let’s face it, all couples argue (well, some don’t but they probably don’t communicate much).  Typically when we argue we we try to convince the other person that we are right and they are wrong.  In doing so we tend not to listen much; instead while the other person is speaking we are thinking up a good come back or a verbal zinger to put the other person in his or her place.  Pause for a moment and think about how effective this really has been for you.

Sometimes, along the way, couples escalate and start calling each other names or slinging insults (or even physical objects) at each other.  Again, how well does this work?  Now maybe you win some battles but you (both) lose in the end.  After all, if you care about your partner, and you “win” that means he or she “loses.”  Furthermore, when you sling mud during an argument, that needs to be cleaned up afterward.

Could there be a better way?  Sure!  What people really want when arguing is usually to feel listened to and understood.  Sure, we might want our partner to agree with us and do things the way we want, but most of the time if you truly feel understood by your partner, the heat of the argument fizzles quickly and there’s nothing to apologize about afterward.

So how do you do this?  As with most skills, it’s a good idea to do skill-building exercises and to practice these exercises.  The exercise I’m about to describe is not how people actually talk to each other on a day-to-day basis; it’s an exercise.  It’s kind of like a runner who wants to improve her time will do interval training: instead of just going out for a run as she usually does, she’ll sprint from one utility pole to the next one, then rest/jog to the next utility pole, and then run to the next one.  If she repeats these “intervals” her running times improve.  That said, you’ll never see someone run a marathon alternating between sprinting and walking from utility pole to utility pole.

Oh, another thing about the exercise: it’s frustratingly slow.  You’ll likely hate this at first, but the slowness is part of it’s benefit.  If you have to argue really slowly, you’re less likely to escalate to yelling.

So here’s the recipe:

Start

Person A: Speak to Person B for up to 30-45 seconds making a simple statement, request, argument, etc.

Person B: Paraphrase in your own words Person A’s statement without introducing new information, interpreting, judging or otherwise modifying the statement.

Person A: Either give a thumbs up to acknowledge sufficient accuracy of the paraphrased response or thumbs down so you can offer clarification.

Person A: If thumbs down, don’t judge how or with whom the communication breakdown occurred; instead, simply restate in different words your main point in 30-45 seconds.

Person B: Paraphrase the restatement.

Person A: Thumbs up or thumbs down

Swap Roles

Person B: Speak to Person A for up to 30-45 seconds responding to Person A or making a simple statement, request, argument, etc.

Person A: Paraphrase in your own words Person B’s statement without introducing new information, interpreting, judging or otherwise modifying the statement.

Person B: Either give a thumbs up to acknowledge sufficient accuracy of the paraphrased response or thumbs down so you can offer clarification.

Repeat

Remember, this is not as easy as it seems, and to become a better arguer you’ll need to become a better listener.  The more you listen (and communicate to your partner that you understand him or her), the less you’ll need to argue.

Give it a shot, and like any new exercise routine, don’t give up after one or two tries; instead, commit to practicing this (about real issues, not current events or the weather) for about 10 minutes every day for at least a week straight.

No time to exercise?

May 1, 2016

A really interesting study just came out on PLOS One that should be of particular interest to those of us who say they just don’t have enough time to exercise.  The study took a bunch of sedentary guys and divided them into three groups: regular exercise, interval training and lazy controls.  The guys in the exercise group had to continuously exercise for 50 minutes, the lazy controls did nothing, and the interval training group did three 20-second ‘all-out’ cycle sprints interspersed with two minutes of low speed cycling (just ten minutes of alternating intensities of exercise). 

After twelve weeks the researchers noted “that brief intense interval exercise improved indices of cardiometabolic health to the same extent as traditional endurance training in sedentary men, despite a five-fold lower exercise volume and time commitment.”

It’ll be interesting to see if anyone measures the effects of such brief interval exercise on mood and anxiety disorders (see a 2014 blog post I wrote about the antidepressant effects of exercise).

How to Fall Asleep

March 17, 2016

There are several topics that seem to come up with patient after patient and I find myself making the same suggestions over and over again. One of these topics is sleep hygiene.

Simply stated, sleep hygiene is a way to describe your behaviors and habits related to sleep. There are several types of insomnia including delayed sleep onset, middle insomnia or frequent awakenings, and early morning awakenings. Though improving sleep hygiene can help with all three of these subtypes, change will be most dramatic with delayed onset or trouble falling asleep when you want to.

Sleep hygiene is all about rules, behavior change and “stimulus control.” Though I am rarely directive with my patients, when it comes to sleep hygiene I explain a set of rules they should follow if they want to be able to fall asleep quicker. Here they are:

  • Use your bed for sleep and sex only. Don’t read, do work , play on your phone or watch TV in bed. This is all about stimulus control: you want your body to react to the stimulus of being in bed by getting tired and falling asleep. If you like to read before bedtime, sit in a chair next to your bed or, even better, do so in another room.
  • Set rigid bedtimes and wake-times. Be reasonable and calculate out the number of hours of sleep you do best with. Note: more is not always better; most people tend to function best with approximately 7-8 hours of good quality sleep per night. Set these times and stick with them, even on weekends, at least in the beginning of your sleep hygiene training.
  • Set a rigid pre-bedtime routine. For example, before you fall asleep you probably want to wash your face and brush your teeth. Some people like to take out the next day’s outfit the night before. Make time to include saying your goodnights to your loved ones, engaging in prayer, doing your evening reading or whatever. After you’ve listed all your pre-bedtime activities, write them out in the order you want to do them each night, estimate the start time prior to when you want to fall asleep and then stick with this rigid schedule. Again, this is all about stimulus control.
  • This one is tough: If you’re not asleep within about 20 minutes or so, get out of bed and do something boring. Don’t read a good novel, watch an engaging movie or pay your bills. Instead do something mundane and boring like reading the user manual for your refrigerator. When you’re eyes get tired, get back in bed and start over. Once again, we’re focused on stimulus control: you are trying to get your body used to only sleeping (or having sex) when in bed.
  • If you have tons of thoughts that run through your head as you’re trying to get to sleep, have a notepad and pen (and maybe a small flashlight) next to your bed. Roll over, write down those important thoughts and then let them go; you no longer have to try to remember them because they’re written down.
  • Some people find that over-the-counter Melatonin is helpful if they take it about 30 minutes or so before bedtime. Unlike some other medications, Melatonin is not habit-forming.
  • Taking a very hot soaking bath immediately before getting into bed (i.e., the last pre-bedtime activity) can help “jumpstart” the process of falling asleep. The theory behind this is that a very hot bath will raise your core body temperature a bit. Then, when you get out of the bath and into bed, your core temperature will drop, and this is the jumpstart because when you fall asleep your core body temperature automatically drops a little.
  • No screens before bedtime. Recent research has demonstrated that the frequency of light emitted from televisions, laptops and handheld devices are neurologically stimulating and can make it much harder to relax and fall asleep.
  • Start exercising on a regular basis, but try to do so earlier in the day. Don’t do any strenuous activity within a couple hours of bedtime.
  • Eliminate caffeine from your diet. If you can’t do that, start to cut back by drinking half caffeinated and half decaffeinated drinks. No caffeine at all after lunch time.
  • Don’t have a big dinner and don’t snack after dinner. Eat your bigger meals earlier in the day.
  • Learn to do relaxation training. Now, the point of relaxation training is not generally to get you to sleep, but it surely doesn’t hurt. Most people find that progressive muscle relaxation and guided imagery are the best when they’re trying to fall asleep.
  • Instead of having the television or music on when you’re trying to get to sleep, turn off those stimulating sounds and muffle out distracting sounds with a white noise machine or a regular fan. The “wooshing” sound of the fan masks other sounds and is not stimulating like music or the news.
  • No naps. Though for some people naps can be quite rejuvenating, they alter your sleep-wake cycle and can delay sleep onset significantly. Cut naps out of your routine.
  • Remember that your sleeping difficulties didn’t just start over night; you’ve probably been dealing with them for quite some time. Even if you follow every tip on this list it’ll still probably take a little while before you’re able to get to sleep quickly. With consistent efforts however, you should be able to improve your sleep within a few weeks or sooner.
  • Speak with a psychologist, physician or other healthcare professional if you have questions or additional concerns.

 

Happiness Promotes Health

March 15, 2016

In a recent presentation, US Surgeon General Vivek H. Murthy said, “If there was a factor in your life that could reduce your risk of having a heart attack or a stroke, that could increase your chances of living longer, and would make your children less likely to engage in crime or use drugs, and that would even increase your success with losing weight, what would that factor be?  It turns out, it would be happiness.”

happiness

Happiness is a realistic goal for most people; it is not a luxury and need not be a distant fantasy.  People often have psychological road blocks to achieving true happiness, and psychotherapy can often help knock down or work around these obstacles.

Therapy is Better than Medication

February 10, 2016

The American College of Physicians has released a new clinical guideline on the treatment of depression in the Annals of Internal Medicine.  They suggested that psychotherapy is as effective for treating depression as antidepressants, and “given its relative lack of potential harms, should be strongly considered as the first-line treatment.” This is consistent with the American Psychiatric Association guidelines on major depressive disorder from 2010, which show therapy and antidepressant medications as being similarly effective.

The two issues that I, personally, have with this are: 1) that the guidelines specifically mention CBT and do not adequately discuss the benefits of other modalities of psychotherapy which may lead health care providers and patients to assume that CBT is the only mode of treatment that is so effective, and 2) the suggestion that psychotherapy has a “relative lack of potential harms.”  The word “relative” is key here: psychotherapy has significant fewer potential side effects than medication, but this does not mean that psychotherapy is side effect-free.  Therapy can be difficult for many patients at different times along the course of treatment and patients should be aware of this from the outset.

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Individual Therapy & Counseling

Through individual psychotherapy, I can help you improve your relationships with others in your life, stabilize your moods and cope with anxieties and worries.

Couples & Marital Therapy

If you and your partner are struggling to communicate with each other, having problems with romance and intimacy or even dealing with an affair, by engaging in couples therapy I can help the two of you refocus yourselves back onto improving your relationship.

Why Dr. Heitt?

I bring decades of experience working in a variety of settings and with a variety of people to my clinical practice. In addition to doing therapy with couples and individuals, I specialize in helping people like you deal with work-related problems.