Antidepressant Withdrawal is a Worryingly ‘Normal’ (Severely) Abnormal Experience

Finally a systematic review puts paid to the nonsense that ‘withdrawal from antidepressants’ is problematic only for a few, is ‘mild’ & ‘lasts only 1-2 weeks’ with no treatment necessary other than reassurance, which is still being perpetuated by current prescribing guidelines both here and overseas. In fact their review found that 56% of patients experienced problems with stopping antidepressants and the majority of these rated these as ‘severe’.  Back in the good/bad old days when I worked for a  pharmaceutical company who made psych meds the phenomenon of an ‘initiation phase’ during which time suicidal risk was heightened, was acknowledged and freely discussed…in-house at least.  However, the concept of a ‘withdrawal syndrome’ was less clear.  Anyone who has witnessed patients coming off ‘even the cleanest’ SSRIs will speak to a potential myriad of worrisome experiences including…

“Typical AD withdrawal reactions include increased anxiety, flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. Dizziness, electric shock-like sensations, brain zaps, diarrhoea, headaches, muscle spasms and tremors, agitation, hallucinations, confusion, malaise, sweating and irritability are also reported (Warner, Bobo, Warner, Reid, & Rachal, 2006, Healy, 2012). Although the aforementioned symptoms are the most common physical symptoms, there is also evidence that AD withdrawal can induce mania and hypomania, (Goldstein et al., 1999; Naryan & Haddad, 2011) emotional blunting and an inability to cry, (Holguin-Lew & Bell, 2013) long-term or even permanent sexual dysfunction (Csoka & Shipko, 2006).”

Previously termed ‘discontinuation syndrome’ by expert panels – to distinguish these inconvenient effects from the more seriously viewed (read nasty) benzo-associated discontinuation problems –  was an act of smoke and mirrors, according to this scathing and insightful review by Davies and Read, who argue strongly this is a clear cut withdrawal picture and it deserves as much consideration and concern.  In particular they point out that of course, patients can experience these symptoms even without ‘discontinuation’ – but simply as a result of a delayed or skipped dose, an intentional dose reduction etc. And they provide the alarming context that one third of people in the U.K. (and likely similar developed countries) who take antidepressants for more than two years have no evidence-based clinical indications for continuing to take them. But wait..I’m just getting to the worst bit, this is the part that gets me personally…having been a peddler in the past of these meds and in certain patients still spruiking their benefits, I am in no disagreement about them being necessary, helpful & even life-savers in some patients…yes I have seen this too many times to ignore it…BUT…and now this is where I start raising my voice a tad….

Patients need to make informed choices, and having a clear understanding of what you are likely to experience on any given medication has been shown to improve outcomes but according to the 2 largest surveys conducted to date,< 2% of antidepressant users are being told any of this.  Do you know why?  Well, let’s start with the misleading guidelines… if the RACGP says it isn’t so…then can we expect their GP to know or say any differently?

Grrrrrrrr…. yes that’s me…not a wild animal in the room with you.

Because you know what happens in the absence of this?! And let me say I have also seen this too many times to ignore as well, people feel compelled to stay on them & this is truly heartbreaking to witness. The experience of a reduced dose or a period without is so terrifyingly disconcerting to that poor unsuspecting individual, and without explanation, is misinterpreted by them (and according to this review often by their doctor as well!!) as being either a sign of their inherent mental instability and need for ongoing medication, or misdiagnosed as a separate condition. Ok…apologies, this is over a decade of pent up frustration…resurfacing as a result of reading this incredibly important and disturbing review.  I think I need a little lie down now 🙁

Helping patients off anti-depressants is a challenging and important function that must be initiated by the patient with the full support of the prescribing practitioner, however there’s a role for complementary medicine here too. Rachel walks you through a range of strategies and when you might consider each. Listen to the free sample here from the Update in Under 30 from 2013 – Leaving Anti-depressants Behind. Or perhaps you’re interested in all things Mental Health and should find out more about our specialist mentoring group running in 2019.

 

 

Two Pointers for Addiction Management

Forever fascinated by the neurobiology of various mental health presentations, addiction included, two medical news items caught my attention this week.  If you’ve ever heard me speak on addiction, in somewhat simplistic terms, it is very much about the reward centre of the brain and how strongly all recreational drugs hit on this.  Think rats tapping levers with their feet to continually self-administer cocaine…to the exclusion of all else….kind of magnitude of reward hits.  You may have also heard me quote or misquote (!) someone famous who once said something to the effect of….and I am totally paraphrasing poorly here: if we can’t seek pleasure legitimately, we will seek it illegitimately. 

So this story from ABC news about a Newcastle addiction group support program showing some early signs of greater retention and engagement and therefore potential success with addicts…because they incorporate prizes…well that makes so much sense!

The article is important to read in its entirety as it creates the context – especially for many people suffering from addiction who tell tragic stories of lives where the only rewards/prizes and even gifts they’ve ever known, being drug-related – even from a young age.  So to normalise reward to some extent, and give individuals an experience of constructive legitimate versions of this, is actually desperately needed and ground-breaking. 

How can we incorporate some element of this in our interactions with these patients?

The second ABC news item touts ‘a new generation drug that restores balance to the brain’ but is actually just a teaser about…wait for it…cue stage right…a not so old favourite…N-acetyl cysteine!  Although this is effectively a recruitment drive for methamphetamine addicted individuals into a new 12 week trial of NAC, run by the National Drug Research Institute, taking place in Melbourne, Geelong and Wollongong, it gives NAC a great wrap and rationale for being a good adjunct in addiction, of course. Just a reminder folks that naturopaths belong on that multi-modality health care team for people struggling with addiction, and we do have some potent therapies to contribute. 

A couple of years back I was asked to deliver an educational session to a group of hospital based mental health specialists on the merits of NAC.  My favourite question/comment at the end of my detailed presentation from a very experienced psychiatrist was, “Well if N-acetyl cysteine is so good for mental health…why haven’t I heard about it before now?!”

I hope they follow the ABC news 🙂

Want to Get Up Close to N-acetyl Cysteine in Mental Health? Previous ideas regarding the pathophysiology of mental illness have been profoundly challenged in recent times, particularly in light of the limited success of the pharmaceuticals that ‘should have worked better’ had our hypotheses been correct. Novel drivers such as oxidative stress, inflammation and mitochondrial dysfunction are on everyone’s lips and N-acetyl cysteine is in prime position in this new landscape, to be a novel and effective therapy for mental illness. This presentation brings you up to date with the current NAC research in a large number of mental health conditions & translates this into the clinical context.

What’s Eating Gilbert Now?

 

I’ve had my nose in all the research on Gilbert’s Syndrome again..watch this space…in the interim just thought I’d share this image and a couple of important details I may not have been able to convey when you last heard me talk (very fast!) about this important and common polymorphism:

  1. While the incidence is approximately 10% of Caucasian population, rates are heavily influenced by ethnic background and the highest rates (up to 1/4) are seen in Middle Eastern populations
  2. Gone are the days of thinking this condition only effects bilirubin levels and the enzyme responsible for its clearance – more recent research has shown over 3/4 of patients with Gilbert’s Syndrome have multiple SNPs that compromise clusters of enzymes within the glucuronidation pathway – with varying patterns – this goes a good chunk of the way to explaining the variability we see in bilirubin levels and symptom pictures across patients all deemed to have Gilbert’s Syndrome.  This also explains why figures of reduced glucuronidation activity vary anywhere between 10% less to 90% less! It depends on your cluster..but the average reduction is around 50%
  3. UGT enzymes, the ones affected in Gilbert’s, are also expressed all the way down the GIT and constitute important food and drug handling. These UGTs are most active in the small intestines,as you can see above, but may explain why Gilbert’s patients are ‘more sensitive’ to medications than just paracetamol!
  4. And are you still thinking you need to run an $$$ gene test to confirm your Gilbert’s hunch in a client whose bilirubin sits consistently high normal or high? Think again… here’s a great little diagnostic short-cut that even the Royal College of Pathologists Australasia cites as sufficient evidence to confirm the polymorphism:

In the face of elevated total bilirubin levels and in the absence of liver pathology or increased haemolysis to explain this..”If the diagnosis is uncertain the serum bilirubin fasting level can be measured and should exceed the non-fasting level by  >50%.”

Nice.  So that means you only need to demonstrate that the patient’s fasting total bilirubin levels go up by at least 50% compared with their fed levels and BINGO you have your diagnosis. Much easier.  Oh and this image comes from an interesting paper from Tukey & Strassburg 2001 – but is probably not for the faint-hearted 😉

Stay tuned for more 🙂

Just new to this condition and need a soft place to land with understanding Gilbert’s Syndrome?  This previous UU30 is just the thing! Affectionately called Gilbert’s Girls because in particular it details a set of twins with this condition, this short audio explains the basics about this common polymorphism and why we tend to see a lot of patients who have this…even if no one has pointed it out to them yet!  You could be the first to provide them with this important understanding about how genetics is impacting their detox pathways, changing their sex hormone handling and perhaps setting them up for both mental health issues and some serious upset guts! Better still, what to do once we have that diagnosis. 

A Hat Trick Week for Gilbert’s Syndrome… Guys and Gals

Sometimes we wonder who put the invisible sign up out the front of our practice, right? The one that says…absolutely everyone with Condition ‘Z’ come and see me, now!  I’m sure you know what I’m describing.  Well this week I have hit the trifecta, performed a neat little hat-trick and diagnosed 3 patients with Gilbert’s Syndrome who all present in their own individual way but actually each one also with quite a textbook Gilbert’s picture, it almost beggars belief.  Have a little look

70yo Female says: Since childhood she has felt like she has had a rock in her stomach after she eats. This ‘rock’ is there for hours. Her stools are never the same in spite of a regular diet and she has always been uptight and anxious. All her bilirubin results are in the 20s & she reports she’s ‘always’ had high values

55yo Male with severe ‘constitutional anxiety’ and surprisingly high oestrogen and a worrisome profile of oestrogen metabolites. His bilirubin is in the 20s

30yo something Female presents with unexplained severe unwellness for 20yrs that mostly involves nausea, bloating, a functional gut disorder without a real diagnosis, anxiety, depression and poor stress tolerance. Her bilirubin fluctuates between 30 to high 40s. (more…)

The Rachel Arthur Mentorship Program Honour Roll for 2017

Recognise your own name or someone else’s on this list?

Dear 2017 Group Minties aka Mentees.   I have always struggled with the term, ‘mentees’…seems too American or something and this morning when I was out walking, I had a light-bulb moment – I am proposing a re-branding to something much closer to home (!)… I propose we rename you Minties!! Because you are always fresh and you give me & your fellow Minties always something; cases, questions, clinical conundrums, ethical dilemmas,  every month to seriously get our teeth stuck into!  Cheesy but true 😉

Congratulations on completing your full year of group mentoring – and if this is your 2nd, your 3rd even your 4th year then I bow to you even more deeply.

Thank you for including me on your support team and entrusting me with helping you grow & develop as exceptional practitioners.

You should  be celebrated for your commitment to your own learning & your endeavour to always improve your knowledge and skills. (more…)

And not a moment to soon…

Are you hearing me?  Yup, it’s been a BIG year..and to think I don’t even have the ANS technically to blame this year!! How about you?

But listening to myself say this to people, in my wrap-up of the year-that-just-was, I am thinking….Has anyone EVER got to the end of year and exclaimed, “Wow! That was a small one?!” 

Not me, not ever, well not in my living memory! But somehow I forget.  I get to December and I think, ‘Geez, I’ve never felt this spent before!  I need to go on holidays and never come back, retire from work and retreat from the world’, until someone who loves me, and who has a longer memory than a goldfish says, ‘Love, you always feel just like this.’  The upside to this annual amnesia is, it pushes me to make very conscious choices for my holidays. (more…)

It’s Landed At Last! Aka ‘Kids’ Guts Can Be Mental’ [ft. Threadworm] Recording

Standing at the podium, I looked down at my notes & slowly read out the title of my presentation to the hundreds of people attending, ‘Paediatric Digestive Issues & Neurocognitive Abnormalities’ and briefly froze thinking, Holy Heck (!) this is someone else’s presentation!  Seriously. No, this is not one of my work stress dreams.  This happened. I thought…oh my how am I going to deliver this, it sounds very complex and lofty and scary!!

Then I saw my scribbled hand notes on the page, the unofficial name I had affectionately given this presentation as I researched, compiled my case studies and brought it into being, months prior and I instantly relaxed…oh…Kids’ Guts Are Mental…now that I have some serious experience with and something to say about! (more…)

Working on the Edge

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May was the month of teenage girls presenting with severe digestive problems, especially ‘food intolerances’,  leading to avoidance of specific foods and at times significantly reduced food intake overall.  As integrative health practitioners,  validating and creating insight for clients on the nature and source of their food reactions is our bread and butter, right?  Is it wheat?  Dairy? Gluten? FODMAPs? Salicylates? Oxalates?  We are not surprised by how many ‘sick’ patients we see in spite of a theoretically ‘healthy diet’ – healthy for others perhaps but not  for the individual in front of you, right? But what if I told you that each of these teenage girls had a BMI < 18 kg/m2, does that change your opinion about your role?  Would you assess, monitor and manage these teenage girls differently? You should.

Take the example of one of my clients: 14yo female with a BMI 16.3, who had her first confirmed food reaction under 2yo with failure to thrive, which was attributed by a paediatrician & dietitian at the time to severe salicylate sensitivity.  She underwent jejunal biopsy at 3yo for suspected coeliac disease, due to ongoing concerns and a primary relative with CD but it was NAD.  In the 11 years since, there have been a couple of other digestive diagnoses based on solid evidence, such as mainstream stool PCR testing. So surely, the fact that she is underweight & that she skips lunch at school due to digestive discomfort is proportionate and explained by her organic digestive issues. Or is it? (more…)

Pyrroles…I Recant!!!

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This year has been a steep learning curve but this is exactly as I had hoped and planned for.  I strapped myself in for my roller-coaster ride,  a series of intensive upskilling initiatives undertaken with mentors and experts in specialist areas, and I haven’t hurled yet or screamed loud enough to make the operator stop the ride (seriously this happened to me in about 1997 on a Pirate Ship in Rosebud!)…but I have come close 😉 

One of the really big lessons has come from getting more into the science behind pyrroluria and urinary pyrrole testing again.  What motivated me to tackle this spikey beast?  Well, like many people who have been introduced to the concept of pyrrole testing and pyrrole driven mental health presentations – I had a lot of questions that hadn’t been adequately answered.  Those gaps left me with some uncertainty about the validity of this investigation and about the interpretation of the results.  I also have introduced this pyrrole theory to many naturopaths and hence feel a responsibility to polish up my knowledge on this and set the record straight.

Last but not least, in our local area we reputedly have a ‘pyrroluria plague’ at play – every man woman and their dog is getting this diagnosis and it had added not only to my misgivings about testing but also my concern about misdirected & unsafe treatment. (more…)

Did we Leave Oestrogen in the 80s?

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Duck duck GOOSE! Do you know this game?  That’s how I’m feeling with oestrogen – high-high-high-LOW!-of late. Likely similar to your experience, the majority of my female clients battle with oestrogen dominance, therefore I get so used to looking for it, expecting it: the high Cu, the profoundly elevated SHBG, maybe a raised ESR.  So much so that sometimes the low ones can catch you out, especially of course when it happens in women way way before menopause.

We’re so resolved to hear bad press about oestrogen and to be armed ready to saturate our patients with broccoli extracts of the highest order – do we remember the clinical features and markers of an oestrogen deficit and know what to do with those women who simply don’t have enough? (more…)

Are you Listening for the Good News?

Want to start 2017 with some good news?  Sometimes working with patients challenged by mental health I get scared.  A well-known colleague of mine introduced me to the notion of the ‘clinician in crisis’. The practitioner who, in the face of their patient’s extraordinary pain & distress feels overcome by the need to Do Something…Anything.  Over time I have learned to spot, what we call a ‘desperation prescription’, the patient who is on 3+ psych medications all from different drug classes and still remains tragically symptomatic. It is potentially frightening stuff.  I’ve had the same experience with patients using herbs and nutrients.  The patient’s biological drivers may seem straight forward on paper, but they fail to respond as predicted.  Nobody has a 100% success rate…not me, not Ben Lynch, not Kelly Brogan…as much as their marketing machines might make you think otherwise. (more…)

Your Burning Zinc Questions Answered

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Most practitioners are pretty knowledgeable about Zinc and are quick to recognise a deficiency and the opportunities for zinc supplementation as an effective therapy and those same practitioners are often plagued by nagging questions that come up, in spite of loads of clinical experience, like:

  • Are plasma and serum zinc levels interchangeable?
  • What does zinc adequacy look like?  Is it just a single number on a page or do we always have to factor in copper levels and get the ratio right as well?
  • What can I expect from zinc supplementation in terms of changes to the patient’s plasma zinc?
  • What should I do when a patient’s zinc marker is refractory to the intervention?
  • Is there really a significant difference between the different supplemental forms available?

(more…)

Mental Health Assessment for the Integrative Practitioner

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I became interested in working in mental health not entirely of my own free will.  I guess you could say, it had made it’s way into my world via family members and friends as well as my own problems when I was younger. So when I was at uni and I came across any information about mental illness, whether it was pathology or prescription, it was when I undoubtedly resonated most strongly with what I was learning. I’ve had some great opportunities throughout my career to feed my interest, met some wonderful mentors and some other powerful teachers who were often my patients. It’s now become a running joke among my teenage children that all my friends are either psychologists or have some sort of mental health diagnosis, ‘…and what does that say about you?’ they love to add teasingly.  Well it says a lot probably: that I enjoy people who are comfortable talking about the psychology of our lives and ourselves, that I deeply appreciate that to be human is to suffer and we all suffer it’s just a question of degrees and the bravest of us share that with others.  Lastly, I think it tells you that I live in the real world with real people 🙂 (more…)

Are We Setting Patients Up to Fail?

 

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Fresh faced students, new graduates and seasoned practitioners alike, are forever reminding me of the challenge we experience as practitioners when it comes to instigating real change in our patients health related behaviours … the change we KNOW will make a difference to their health and wellbeing.  ‘If only they actually listened to us!?!’ has been screamed by the novice and seasoned practitioner alike. With an overwhelming desire to share our wealth of knowledge, the discovery that information ≠ change can lead us to despair at times.

In a recent interview with Dr. Azita Moradi (Consultant Psychiatrist) as part of our Access the Experts webinar series, I was quite surprised (and pleased) to hear that Azita sometimes spends a whole session with a patient discussing the possibility of change, before even touching on the reality of change. Azita’s discussion surrounding the neuroscience of change and the challenges this may pose in the therapeutic relationship was fascinating, and certainly resonated with the practitioners taking part in the webinar.  Azita’s interview was full of clinical gems reminding us that just as in other settings, if we give a man a fish he eats today but if we teach a man to fish we feed him for life.  Hand and in hand with this, we need to have a strong understanding and appreciation of how to engage clients in making positive changes to their lives, often when it seems most difficult to do, such as in mental health patients.

Knowing how to improve behavioural change in patients generally, is integral to everyday practice, and its value cannot be underestimated. (more…)

A New Mental Health Education Initiative in July!

Listen to the Wave (2)

“Access the Experts with Rachel Arthur” is a month long intensive webinar series focusing on the best of Mental Health Education. Every Thursday night for the month of July, Rachel will be interviewing a hand-picked guest speaker about a particular area of expertise in Mental Health.

Each speaker is a clinician with years of experience (from a psychologist, to a GP, to psychiatrists) who Rachel has worked with and/or been mentored by and she is thrilled that these interviews create an avenue to share their incredible & very practical knowledge with a wider audience.

Rachel’s role as the interviewer will be a feature of the webinar series – ensuring you get the best of each speaker; translating the complex into easy-to-understand concepts and clinically relevant content that you can start applying immediately. (more…)

Emotional Pain…Pop a Paracetamol?

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During a mentoring session this week a practitioner asked me, ‘How could paracetamol relieve anger?’.  After the initial, ‘What the..??.’ reflex, I thought well the placebo response is really a wonderful thing, the potency of which should never be under-estimated. I mean this is just one of many ‘afflictions’ I have been told by patients can be rectified by a popping a Panadol!  But just to ensure I wasn’t missing something I went digging into the scientific literature about the latest understanding of its mechanisms and actions and lo and behold (!!!) several RCTs have shown paracetamol can “blunt emotional pain” and reduce the negative effects of “social rejection” specifically!

 Back to my…’What the…????!!!!’ reaction 🙂  While Michael Berk (ie NAC pioneer) did co-author a huge paper on the potential application of aspirin in a range of mental health conditions https://www.ncbi.nlm.nih.gov/pubmed/23506529 given what we now know about the inflamed brain model of psychiatric illness, this one is easier to grasp than perhaps paracetamol for the pain of emotional interactions & experiences.

  (more…)

Turning the Spotlight on the Low Dopamine Depressive

 

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Low dopamine as an underpinning cause of depression, anxiety and even addiction (illicit drugs, sex, gambling) has been gaining increased recognition in research.  In spite of this there are no antidepressants currently on the Australian market that address dopamine specifically and therefore patients with this pathophysiology often fall through the gaps, failing to get efficacy from pharmaceuticals.  Many of these patients are subsequently diagnosed with ADHD as well, which has disordered dopamine as part of its aetiology, and are prescribed dexamethasone as well.  The dexamethasone, being a stimulant that helps significantly to improve dopamine, is typically the drug that has more of a positive impact than the anti-depressants on these patients however, still fails to really solve the issue and can come with many side effects.

Since the 1990s the term ‘Reward Deficiency Syndrome’ was coined to describe a subset of these individuals whose brains are effectively under-equipped with dopaminergic activity in certain key areas.  This is the result of a less common genotype coding for our D2 receptor in the brain.  Far from being rare, this genotype is reported to be present in 30% of Americans, however, the magnitude of problems associated with it can vary from mild to severe depending on many other genetic and environmental factors.

(more…)

Hold the DHA in Mental Health?

 

About a decade ago there was a lot of excitement about using fish oils in the management of mental health, so much so even the American Psychiatric Association developed recommendations suggesting that people with mood, impulse control & psychotic disorders should all consume 1g EPA + DHA per day… but then what happened?

Ask most health professionals (GPs, psychiatrists, naturopaths & nutritionists alike) today whether fish oils are their first choice in mental health nutritional interventions and you’ll frequently get a, ‘No’ and I include myself in that.

Let’s retrace our steps to find out how we got here.  The epidemiological evidence linking low omega 3 intake to myriad mental health problems in terms of susceptibility, incidence and severity is almost overwhelming. For example, depression rates are 10 times higher in countries with limited seafood intake and post-partum depression 10-50 times higher (Kendall-Tackett, 2010).

Noaghiul & Hibbeln postulated that countries where individuals consumed less than ≈ 450-680g of seafood per person per week demonstrated the highest rates of affective disorders (2003). One study of 33 000 women with low omega-3 intake were found to have an increased risk of psychotic symptoms (Goren & Tewksbury 2011) and it goes on.  Then, we have other evidence also pointing in the direction of fish oils, such as the general consensus that excess unchecked inflammation is evident in many mental health conditions (Maes et al 2013).  Numerous intervention studies using fish oils as stand-alone or adjunctive treatments have been published. Interventions have included high dose omega 3 (no specific EPA/DHA breakdown), EPA alone, ethyl-EPA, high DHA, blends with high DHA:EPA ratio, flaxseed oil etc. etc. (more…)

Avoiding Overwhelm In Clinic

So…a 40 something female walks into your clinic with depression & anxiety…sounds common enough right?  But here’s the twist: she’s already seen another practitioner who ran a range of investigations revealing she has pyrroles, high copper levels & is homozygous for the C677T MTHFR mutation. Her medical history includes significant use of Ecstasy and a partial thyroidectomy due to nodules & she has persistently high TSH.  But wait there’s more!…The first practitioner upon discovering all of this put the patient on 12 different products which included zinc, B6, evening primrose oil, vitamin D, thyroid support etc etc.  And guess what…the patient feels worse!

Frequently our patients are just as complex as this case & sometimes our attempts to narrow the treatment focus through thorough investigation instead leaves us feeling we now have even more things we need to deal with than before! Feeling overwhelmed?? Often! At risk of completely overwhelming the client as well?  Definitely!  And a reflex to throw your whole dispensary at a client never ends well. (more…)

Nutritional Science & Debate in Action

 

Last weekend I attended the Science of Nutrition in Medicine Conference in Melbourne https://nutritionmedicine.org.au/enews/2015-02-06-Program.html and for those of you that didn’t make it I can tell you, it wasn’t your regular CPE event.  I’m not sure if the debate inside the presentations or outside in the breaks was more interesting but I can say that I haven’t seen this much stimulated thought, heated discussion and passion at company run events.  Why? (more…)

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