Frequently Asked Questions

Q. When diagnosing depression in a client, how concerned should I be about identifying specific depression subtypes? Do specific subtypes suggest different treatment modalities?

A. For years now, clinicians have attempted to categorize depressions into “subtypes.” A few examples are: typical vs. atypical, reactive vs. biological and psychotic vs. non-psychotic. There are as many as 12 subtypes of Major Depressive Disorder, according to The Diagnostic and Statistical Manual, 4th Edition (DSM-IV).

The important question though is whether labeling a depression by subtype assists the clinician in treating the client more effectively, or whether diagnosing a specific subtype implies that a different treatment modality should be utilized. With few exceptions, the answer is no.

Subtypes generally are poor predictors of treatment response. There are some exceptions however: Seasonal Affective Disorder, for example, may respond to light therapy as well as antidepressants, and psychotic depressions all but always require antidepressant treatment augmented with antipsychotics.

Don’t be overly concerned about subtypes. Pigeonholing depression is short-sighted and undermines what’s most important: Treating the “whole” patient from a bio-psycho-social perspective.

Fish Oil May Deter Schizophrenia

“Fat” is a bad word in our society, but omega-3 fatty acids are one of the superstars when it comes to improving nerve conduction. High levels of omega-3 fatty acids in the brain also reduce neuroinflammation, a factor commonly seen in people with depression. Cell membranes consist partly of omega-3s, which make it easier for the neurotransmitters norepinephrine, serotonin and dopamine to pass through cell membranes. This is an essential fatty acid, which means it is not produced by the body and must be obtained via foodstuffs or through supplementation. Foods high in omega-3 fatty acids include: salmon, tuna, cod, mackerel, sardines, walnuts and flaxseed. One to two grams daily of fish oil as a supplement to a balanced diet is advisable, especially for those susceptible to depression.

A new study suggests that fish oil may also be a possible deterrent to schizophrenia. One theory supporting this hypothesis is that those with schizophrenia don’t process fatty acids properly, leading to damaged brain cells. Omega-3 fatty acids in fish oil could possibly help brain cells to repair and subsequently stabilize.

Researchers are starting a large international study in eight cities with the goal of replicating their findings. These findings appear in this month’s Archives of General Psychiatry.

Antipsychotics and Kids: The Controversy Goes On and On

On December 4, 2009, the FDA approved the use of two more antipsychotic medications — Zyprexa and Seroquel — for treating schizophrenia and bipolar disorder in teens. Risperdal and Abilify are also specifically approved for the same use in this age group.

In association with the approval of Zyprexa and Seroquel, the FDA also stated it wants to know more about the risk of weight gain and diabetes in youth taking these drugs and other antipsychotics as well.

It has been clear for years that weight gain and other endocrine risks are associated with these medications, and their warning labels say so. Some evidence however, suggests that these issues are even more paramount in kids.

A study published in the November, 2009 issue of JAMA ( Journal of the American Medical Association) found that children and adolescents using antipsychotics gained significantly more weight over an 11-week period than comparable kids who weren’t taking the drugs. Those on Zyprexa demonstrated the most weight gain – 19 pounds – although weight gain was also associated with several others of these antipsychotics.

Zyprexa labeling does warn that youth are not only likely to gain weight, but are prone to gain more weight compared to adults taking the drug. But the labels for the other antipsychotics the FDA is investigating – Risperdal, Abilify, Geodon and Seroquel – don’t state whether children and teens are at higher risk than adults for weight gain. Frankly, I believe the reason for this is that Zyprexa clearly produces the most weight gain – regardless of age.

The safety conundrum associated with second-generation antipsychotic use in the treatment of schizophrenia and bipolar disorder in youth will linger until a new, safer generation of compounds is developed. These safer agents aren’t coming soon, as some big Pharma companies are planning to cut billions of dollars in annual research and development spending. When it comes to treating psychotic and bipolar disorders in children, I staunchly agree that the balance needs to favor minimizing risks. However, for children with serious and potentially dangerous behavioral problems such as severe aggression, violent outbursts and out-of-control tantrums, what other viable options are there outside of the use of these drugs? Mood stabilizers such as lithium and Depakote carry similar risks of marked weight gain, in addition to other debilitating side effects. Benzodiazepines are not approved for use in the pediatric population period, and carry the risk of potential abuse and dependence. Lastly, with many states experiencing severe cutbacks in mental health care services, there is a paucity of well trained, experienced behavioral specialists with the requisite skills for managing the above-mentioned behaviors in youth. And even if very capable behaviorists were in adequate supply, how on earth could the management of out-of-control behavior be successfully or even adequately facilitated in the absence of medication augmentation?

The bottom line is this: Don’t look for prescribers of these medications to change their prescription-writing habits anytime soon. Why? Because for children with serious and potentially dangerous behavioral problems associated with schizophrenia, bipolar disorder or other associated syndromes, physicians as a whole continue to conclude that the benefits of medication use typically outweigh the risks.

Frequently Asked Questions

In my next few blogs, I will provide answers to the most frequently asked questions fielded from conferences, seminars, e-mail and telephone contact. So if you’ve wondered about the answers to these questions or have encountered them in your work with clients, please read on! I’m delighted to be of service in this capacity.

Q. How long does it take for Zoloft, Paxil, Effexor and Wellbutrin to take effect?

A. At least 50 percent of those who will eventually respond to the above mentioned antidepressants will begin to demonstrate improvement within one week of treatment initiation. Users most often report an increase in energy and productivity, and a decrease in sensitivity (particularly to inappropriate comments from others), and anger within the first seven days of use.

Remission of mood symptoms is tougher. This may span over an 8-12 week period, because depression is neurotoxic. Depression suppresses levels of a key neural growth hormone known as BDNF (brain-derived neurotrophic factor), leading to the eventual death of neurons in critical memory and reasoning areas of the brain, including the hippocampus and prefrontal cortex. Simply put, depression causes brain damage, and it takes 8-12 weeks for antidepressants to aid in the repair of this neurotoxicity.

Q. Should adults take ADHD drugs?

A. Absolutely adults should take ADHD drugs. Seventy percent of those diagnosed with ADD/ADHD in childhood or adolescence go on to experience symptoms in adulthood. If untreated, these adults will struggle with distractibility and inattention throughout their entire lives. Many adults do, however, “outgrow” the hyperactivity/impulsivity component of this disorder. Adults unable to manage can benefit from any of the medications typically prescribed to youth, such as the dextroamphetamine and methylphenidate psychostimulant preparations, the antidepressant Wellbutrin and the non-stimulant Strattera.