Treatment Resistant Depression

Depression is affects approximately 350 million people worldwide, and approximately 7% of the US population. The primary objective is to treat to remission, and if they do not are considered to be treatment resistant. Resistance is often considered the failure of 2 adequate treatment trials. It is believed that approximately 45% of patients are treatment resistant, according to a major study. Risk factors for treatment resistance include psychiatric comorbidies, medical comorbidies, and genetic preponderance. 

If you are not responding to medication it is imperative to reevaluate diagnosis, complete an adequate trial of at least 4-6 weeks on a medication, and adhere to directions in taking medication. 

Decisions in pregnancy of whether to use an ssri

A recent retrospective review of close to 50,000 women, divided into 3 groups; never exposed to ssri’s and no psychiatric problem, having a psychiatric diagnosis (98% an affective disorder) but not taking an ssri, and having a psychiatric disorder and treating with an ssri..showed that treatment of the psychiatric disorder had a protective effect. The was significant as there was a lower risk of preterm birth and c sections. There however was a higher risk of neonatal problems as reported in prior studies. 

Use of L Methy folate, when can it be helpful and why.

Folate is a vitamin, B9, needed by the body.  L Methyfolate is the active form of the vitamin. It helps to regulate the synthesis of serotonin, dopamine, and norepinephrine. 

A key regulatory enzyme, methylene tetrahydrofolate reductase (MTHFR), converts dietary folate to useable L methylfolate.

L methylfolate assists in the formation of a critical cofactor, known as tetrahydrobiopterin or BH4 which actives the enzymes that produce the neurotransmitters.

People at risk for low folate include abusers of alcohol, pregnant women, those suffering with an eating disorder, those with high homocysteine levels, and patients on lamictal or valproate which interfere with the conversion of dietary folate to L methylfolate. 
Patients on antidepressants that fail to respond, should consider augmentation with L methyfolate, as without it, the key neurotransmitters, which regulate mood, cannot be synthesized. 

Development of fatigue on antidepressants. What does it mean?

Mant patients after a period of time on antidepressants develop considerable fatigue and apathy, described by a lack of motivation, energy and a feeling of  just “wanting to sit on the  couch.” 


What does this mean?


For starters it could represent a side effect of could represent a worsening of symptoms. 

What can be done?

1) decrease the dose to see if apathy or fatigue resolves

2) switch to dose in evening 

3) add a stimulant–bupropion, modafanil

4) change to a TCA not associated with apathy

5) add abilify

6) if insomnia develops with the antidepressant, adding trazodone or remeron for a more restful sleep may help

Antidepressant treatment in pregnancy. brief summary

In review of the several studies, although most are case reports as we do not test medication on pregnant women revealed several areas of consistency.

1) there is a possible effect of antidepressants in precipitating. spontaneous abortion and miscarriage.

2) there is no effect seen associating use of antidepressants with fetal death

3) there is a possible association between paroxetine and cardiac malformations.

4) there is a likely effect of antidepressants on preterm birth.

5) there is a probable effect of antidepressant exposure and development of a neonatal behavioral syndrome.

But, none of the effects are large and serious consequences are rare.

use of antidepressants during pregnancy, is a risk vs. ratio decision. In addition, in reviewing the studies there is no way to avoid bias for depression and the risk of depressive symptoms on pregnancy.

Mental Health awareness in the wake of Robin Williams tragic death

APA Reaches Out in Wake of Robin Williams’ Death



Every day in the United States an average of 108 people die by suicide, a statistic brought into tragic prominence last week as the nation focused on the death of comedian and actor Robin Williams. Williams had publicly acknowledged his struggles with substance abuse and depression. 

The tragedy provided an opportunity to educate the public about mental illness, risks of suicide, and the importance of reaching out for help and seeking treatment. Many news outlets ran stories about mental illness and about its presumed presence in creative people. 

“It’s very important that we stop seeing these illnesses as false and stop blaming patients and see them for what they are—which are medical conditions, genetic conditions, brain disorders that require appropriate diagnosis, treatment, care, and support,” said APA President Paul Summergrad, M.D., in an interview on NBC Nightly News. 

Mental illnesses can be just as fatal as big killers like cancer or heart disease, said Thomas Insel, M.D., director of the National Institute of Mental Health, in his blog. “We must continue to invest in research to develop new and more effective treatments for people with depression and other mental illnesses. The goal must be a future in which no lives are lost as a result of suicide.” 

“It is natural under such circumstances to experience feelings of deep sadness and loss,” noted APA CEO and Medical Director Saul Levin, M.D., M.P.A. “APA continues to provide expert interviews and public education resources on bipolar disorder, depression, suicidality, substance and alcohol use, and their treatments.” 

Antidepressant use during pregnancy

There has been a debate about use of antidepressants during pregnancy, as data is collected retrospectively, and without clear controls. Recent literature points to a small risk of development pulmonary hypertension in the infant, however the risk is small and the disorder quite rare. In addition, there is also a greater risk for pulmonary hypertension in infants born to depressed mothers.
With regard to growth, there was an association with both delayed fetal body and head growth in infants born to mothers treated with SSRI’s, but a delay in head growth in infants born to untreated depressed mothers.
The consensus is, it is better for both mother and infant to treat a woman for depression during pregnancy.

Study shows addition of creatinine from health store hastens response to ssris in women

A study of depressed women treated with Lexapro, published in Am J Psychiatry, shows that augmentation of the SSRI with creatinine from the health food store, hastened the response to the antidepressant and doubled the number of responders at week two of treatment. The study was of a placebo controlled design.

The Canine Psychiatric Assistant is becoming a recognized therapeutic tool.

Walk into psychiatrist Drew Ramsey’s office in Manhattan and you’ll likely be greeted by Gus, a four-year-old shih tzu. After escorting you through the waiting room, he may hop onto the ottoman and go to sleep or sit beside you on the couch.

Therapists use ‘canine assistants’ to comfort and cheer up their patients. WSJ’s Christina Tsuei sees how psychiatrist Drew Ramsey teams up with his four-year-old shih tzu Gus.

Some patients pat Gus while they talk to Dr. Ramsey. A few talk to Gus instead. And if they get emotional, Gus provides physical comfort that therapists can’t offer. “We can’t hug patients, but patients can hug Gus,” says Dr. Ramsey, who began bringing his dog to his office two years ago. Now, he says, “I think about Gus the way a cowboy thinks of his horse—he’s part of the job.”

A small but growing number of psychologists, psychiatrists, social workers and other therapists are bringing their dogs to work in their private practices, where they help calm patients down, cheer them up and offer a happy distraction with a wagging tail. The job is similar to what therapy dogs do when they visit at hospitals or nursing homes, but these “canine therapy-assistants” often work full days and get to know the patients just as well as the doctors.


Mimi Ritzen Crawford for The Wall Street Journal

New York neurologist Gayatri Devi, who specializes in memory disorders, brings Lola, shown, and Wolfie to the office.

Even some medical doctors have put their pups to work. Lacey, part golden retriever, part spaniel, entertains waiting patients at New York plastic surgeon Janis Di Pietro’s office, though she isn’t allowed in the procedure room.

Lola and Wolfie, mutts aged three and 17, put elderly patients at ease for New York neurologist Gayatri Devi, who specializes in memory disorders. “Coming to this office can be unnerving for dementia patients, but when they see a dog, it’s disarming. They feel comforted and safe,” she says.

Research shows that a few minutes of stroking a pet dog decreases cortisol, the stress hormone, in both the human and the dog. It also increases prolactin and oxytocin, hormones that govern nurturing and security, as well as serotonin and norepinephrine, neurotransmitters that boost mood. One study found that five minutes with a dog was as relaxing as a 20-minute break for hospital staffers.

“It’s chemical, not magical,” says Rebecca Johnson, who teaches a popular course in animal-human interaction at the University of Missouri and has conducted much of the research.


Michal Czerwonka for The Wall Street Journal

Child psychologist Aubrey Fine has used animals in his Claremont, Calif., practice for 30 years. Shown are his two golden retrievers, Magic and P.J.

While there are no set requirements for having an animal assistant, most dogs who work with doctors have been trained in obedience and as therapy dogs. The Delta Society offers such courses to human-and-pet pairs nationwide, as do other organizations.

Interacting with a dog can work wonders for some patients. Early in his practice, child psychologist Aubrey Fine treated a 9-year-old girl who was painfully withdrawn and refused to speak until his golden retriever, Puppy, laid her head in the girl’s lap. The girl slowly began patting Puppy, smiled and spoke to her as her astonished parents looked on.

Melinda Beck explains to Simon Constable why a growing number of therapists are incorporating dogs into their practices and why the animals are proving beneficial in treating patients.

For the past 30 years, Dr. Fine, who practices in Claremont, Calif., has used dogs and other animals to help treat children disorders such as autism, attention-deficit/hyperactive disorder and obsessive compulsive disorder. Learning to walk and interact with the pets helps the kids learn to maintain focus, eye contact and communication. “With some children, I use the dog as an external form of biofeedback,” to help them learn to regulate their behavior, says Dr. Fine, who


Mimi Ritzen Crawford for The Wall Street Journal

Psychiatrist Drew Ramsey with his fouryear-old shih tzu, Gus, in his Manhattan office.

“You never have a problem getting a child to go see Dr. Fine—they want to go,” says Velene Lima, whose daughter, Angela, now 24, has been a patient since infancy, when a brain tumor left her with multiple challenges. “She would be bouncing off the wall when she was young, but with Dr. Fine, she’d be calm. Those dogs mean everything to her.”

Some therapists report that their dogs act differently with different patients, depending on their conditions.

“I call them ‘seeing heart dogs’—because they can see into people’s hearts,” says Lois Abrams, a marriage and family therapist in Los Alamitos, Calif., who practices with her two cavalier King Charles spaniels, Duke, 11, and Romeo, eight. Duke lies on the floor next to patients with anxiety disorders and sits on the couch close to those who are depressed.

Once, Duke jumped up and sat next to a patient she hadn’t realized was depressed. “When I asked if she was, suddenly the woman poured out her heart


Sandra Barker

Sandra Barker and High Anxiety (‘Hi’ for short) visit a patient at Virginia Commonwealth University Health System.

How can dogs be that sensitive to human emotions?

Experts speculate that people give off tell-tale scents under certain physical or psychological conditions that only dogs can detect.

That acute sense of smell also enables specially trained service dogs to recognize when seizures, diabetic comas or heart attacks are imminent in humans. Some dogs can even detect the presence of cancer cells in lab specimens—much like detecting traces of contraband or explosives in luggage.

That still doesn’t explain some of the things dogs seem to intuit. Sandra Barker, director of the School of Medicine Center for Human-Animal Interaction at Virginia Commonwealth University, recalls taking a therapy dog to visit a patient who was paralyzed from the neck down. When the patient blinked “yes” to invite the dog on the bed, the dog nestled around his head. “How did that dog know that was the only part of his body that had any feeling?” Dr. Barker marvels.



Erin Morgan

Anita Sacks an assistant professor of psychiatry at New York University’s Langone Medical Center, with her chocolate lab, Deacon.Anita Sacks, an assistant professor of psychiatry at New York University’s Langone Medical Center, “prescribes” dogs for some patients. From a psychoanalytic perspective, dogs offer the kind of unconditional love that some people didn’t get from their mothers, which sets them up for life-long attachment problems, says Ms. Sacks,who practices with her chocolate lab, Deacon.

Dr. Ramsey thinks their appeal is simpler. “Like Freud said about cigars, sometimes a dog in the office is just a dog in the office,” he says. “They’re just nice to have around.”

He also thinks Gus is good for his own mental health. “Much of psychiatry is about loss and depression, so when I get a break, it’s great to have him there to take for a walk.”

What do dogs get out of working with patients?



Herb Abrams

Lois Abrams, a marriage and family therapist, with Duke in a chair and Romeo on her lap.

“Lots of cookies,” says Dr. Barker, whose Lhasa apso, High Anxiety, or Hi for short, helped out in her practice treating trauma survivors for nine years before retiring.

And many dogs seem happiest when they have a job to do—whether it’s herding, guarding, patrolling or engaging in supportive listening. What’s more, patients bring presents. “Gus got a Freud chew toy,” Dr. Ramsey says.

Not every dog is cut out for the health-care profession. Dogs that are highly energetic, territorial or demanding could be disruptive to a practice. Temperament is more important than any particular breed, says Dr. Barker, who says the Virginia Commonwealth program has included pit bulls, Great Danes and everything in between as therapy dogs.

As a rule, dogs are better suited to therapy than other animals. “Cats like relationships on their own terms,” says Dr. Johnson, who is president of the International Association of Human-Animal Interaction Organizations, a nonprofit working to advance the nascent science of understanding between humans and animals.

[HEALTHCOLjp5] Ashley Talbott

Ashley Talbott, a fourth-year medical student at Virginia Commonwealth University’s School of Medicine, with Berkeley.

But other animals can serve other roles. Besides golden retrievers and black labs, Dr. Fine has worked with guinea pigs, bunnies, birds and bearded lizards. He recalls one lizard that had a severed tail and chronic constipation, which helped some children relate to her even more closely. “She was one of the nicest lizards I have ever met,” he says.

Of course, some patients are allergic or frightened around animals. Most doctors who practice with dogs inform patients before the first visit, and put the pup elsewhere for part of the day if necessary. But most find that practicing with a dog is a draw for patients, not a deterrent.

Animal-assisted therapy is still in its infancy. But research is expanding and interest is growing steadily. Some universities now offer undergraduate courses. VCU’s School of Medicine offers a course in human-animal interaction for fourth-year medical students and another for psychiatry residents.

“When you have psychiatrists who say, ‘I want to leave my practice and come and work with you,’ you know it’s an area of great interest,” says Dr. Barker.

Prevalence of General Medical Conditons in patients with bipolar disorder

Increased prevalence of cardiovascular disease, pulmonary conditions, diabetes, Hep C, liver problems, and thyroid disease.

Many pharmacologic treatments are associated with obesity, with only 50% of patients properly monitored. Particular offenders include Zyprexa and Seroquel, both excellent medications and highly efficacious.